Mission Possible

University Hospitals, Rainbow Babies and Children’s Hospital


Dr. Anne Lyren
Strategic Advisory, Quality & Safety

UH Rainbow Babies & Children’s Hospital

Associate Professor of Pediatrics & Bioethics

Case Western Reserve University School of Medicine

Co-Clinical Director, Children’s Hospitals’ Solutions for Patient Safety

Joyce Deptola, RN

Director of Quality and Patient Safety

UH Rainbow Babies and Children’s and MacDonald Women’s Hospitals

Nurse Consultant, Children’s Hospitals’ Solutions for Patient Safety


At our hospital, we take very seriously the principle of high reliability organizations that emphasizes a focus on failures and shortcomings. These efforts are ongoing as we have yet to create a perfectly safe experience for every child who enters into our care. However, as summer ends and we begin our plans for 2015 in earnest, we pause to consider the accomplishments of our quality and safety program and the factors that have contributed to our success over the last few years.

In our work to enhance our safety culture, our entire staff has adopted three behavioral expectations for all of our employees; these include teamwork, clear and complete communication, and support of a questioning attitude. In a matter of three years, we have seen an 80% decrease in the rate of serious safety events across our organization, and we believe that the ready adoption of these critical safety behaviors has been crucial to our excellent progress toward eliminating preventable harm in our organization. However, we still have serious harm that happens in our hospital. Without a doubt, continued effort to reinforce and automatize these safety behaviors is critical to our goal of eliminating preventable serious harm to children in our hospital.

In addition, the opportunity to collaborate with other children’s hospitals that share our mission has been a critical factor to our program’s growth and development. As an Ohio children’s hospital, we have the privilege of participating in two key collaboratives. The eight Ohio children’s hospitals have been working together for ten years and have achieved harm reduction in many key areas such as surgical site infections, adverse drug events, preventable codes outside the intensive care unit and, more recently, have achieved more than 60% reduction in serious safety events. The group is now addressing a couple of tough topics that have been perennial challenges for all of our organizations – employee safety and situational awareness. Having the support as well as ingenuity of colleagues from other children’s hospitals has helped us achieve more than we ever could alone. Similarly, the Children’s Hospitals’ Solutions for Patient Safety (SPS) that sprang from the Ohio collaborative has provided tremendous inspiration, structure, and content to our work. With the partnership of eighty other children’s hospitals from across the United States, we have organized our teams to address our most commonly occurring types of serious harm; and it’s working! Rainbow has reduced our sum of serious harm by 22% over the last 3 years. Clearly, our collaboration with other hospitals intent on eliminating harm must continue.

Often, the perspective of an outsider is helpful when considering the factors that are influencing success. During a recent visit by
The Joint Commission, we were reminded of an intrinsic characteristic that is absolutely invaluable in our efforts to improve quality and make patients safer in our hospital. At the end of our Joint Commission accreditation survey, the visiting surveyors were impressed by our culture of high reliability and specifically attributed our success to a strong “DNA,” that is, a strong relationship between “Doctors, Nurses, and Administration.”

Rainbow Babies and Children’s Hospital has experienced a long legacy of strong collaboration between our physicians, nurses, and administration. Over the last twenty years, we have had both doctors and nurses as chief executive and other senior leadership positions such as COO and director of quality and safety. These top leaders have succeeded in establishing a culture in which doctors and nurses are both peers and partners. The structures of our macro, meso, and microsystems are based on physician and nurse leader partnerships. From our CMO and CNO to our Medical Directors and Clinical Nurse Managers at the unit level, we rely on relationships built on mutual respect and trust as the foundation of our safety culture. As leaders model this culture day to day, they drive the behaviors of our team members throughout the organization; and we see the impact of our strong collaborative culture in the outcomes for our patients and families.

We have many examples of the positive impact of those relationships on our quality and safety outcomes. One critical to eliminating preventable harm began in 2004 as we created our pediatric rapid response team with leadership from our Pediatric Intensive Care (PICU) Medical Director along with two PICU nurses who co-chaired our resuscitation committee. Together, they worked to develop our rapid response team, which is supported by our PICU physicians, nurses, and respiratory therapists who then educated teams within the hospital to assure appropriate utilization of the team. As a result of that project, we achieved more than 800 days between preventable codes on our medical/surgical divisions!

Every unit in Rainbow is led by a physician/nurse dyad who are expected to partner in the leadership of the unit on everything from safety to patient satisfaction to budgetary issues. In the face of the innumerable challenges of running a patient care unit, these dyads work diligently to assure that patient safety is the top priority through their words and actions. By modeling safety behaviors in their own clinical care, identifying staff practicing these behaviors, holding staff accountable, sharing data with patients and family regarding key safety initiatives, and showing genuine support and respect for each other, these dyads reinforce a culture where everyone plays a valuable role in keeping patients safe.

We plan for 2015 with hope and enthusiasm as we strongly feel that our efforts to establish a culture of safety are beginning to pay off for our patients. We are indebted to the wisdom, passion, and support we have and will continue to receive from our colleagues in other children’s hospitals. We will always welcome others’ insights into the power of strong collaboration and interdisciplinary relationships as we work to eliminate harm.

Related Links:
1. A Multicenter Collaborative Approach to Reducing Pediatric Codes Outside the ICU (by Dr. Leslie Hayes et al.)

2. ACS National Surgical Quality Improvement Program (NSQIP) Pediatric

3. CareTrack Kids (Australia)

4. Children's Hospitals' Solutions for Patient Safety (SPS) - How We Work

5. Children's Hospitals' Solutions for Patient Safety - Hospital Resources

6. Cincinnati Children's - Reduce Employee Injury Rates

7. Health Foundation - "Closing the Gap in Paediatric Safety: Using Clinical Huddle to Improve Situational Awareness with an Emphasis on Communication" (UK)

8. Healthcare Performance Improvement (HPI) - Resources

9. Huddling for High Reliability and Situation Awareness (by Dr. Linda Goldenhar et al.)

10. IHI - WIHI: Situational Awareness and Patient Safety

11. Improving Situation Awareness to Reduce Unrecognized Clinical Deterioration and Serious Safety Events (by Dr. Patrick Brady et al.)

12. Joint Commission - Improving Patient and Worker Safety

13. Joint Commission - Patient Safety

14. Making it Safer Together (MiST) Paediatric Patient Safety Collaborative (UK)

15. NPSF - "Lucian Leape Institute at NPSF Endorses OSHA Programs on Health Care Worker Safety"

16. NPSF - "Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care"

17. Partnership for Patients (PfP) Resource Centre - Pediatric Safety

18. Target Zero at Children’s Colorado: Eliminating Preventable Harm (by Dr. Daniel Hyman)

19. Who Guards the Guardians? (by Dr. David Vaughan)