Target Zero at Children’s Colorado: Eliminating Preventable Harm

Author: Dr. Daniel Hyman
Chief Quality and Patient Safety Officer
Children's Hospital Colorado

Our senior management team and Board members routinely describe the Children’s Hospital Colorado Target Zero program as being among the most successful in the 100+ years of our long and proud history. I would describe it as the most rewarding professional opportunity I have had in my career. I appreciate the opportunity to share some of this program’s highlights and key messages and would be happy to provide more information to anyone who is interested.

I am privileged to serve as the Chief Quality and Patient Safety Officer at Children’s Hospital Colorado (Children’s Colorado), a free standing, non-profit hospital in Aurora, Co. We have 17 satellite locations and dozens of outreach clinics in Denver, Colorado Springs, across the front range of Colorado, and extending into the mountain states of our region. Like all of our peer children’s hospitals we provide outstanding care to hundreds of thousands of children each year, and yet we know there are still too many cases where children suffer harm that we could and should have prevented.

Participation in a National Patient Safety Collaborative Network

While we had been working on improving safety and quality for many years, our work accelerated dramatically with our enrollment in Children’s Hospitals' Solutions for Patient Safety (SPS) network in 2012. Funded by a CMMI grant from the federal government, SPS has grown from eight Ohio based organizations to 79 children’s hospitals around the country. SPS’s aspirational mission is nothing short of eliminating preventable harm from all of our hospitals. Our work is grounded in promoting the reliable use of evidence based processes to eliminate specific types of hospital acquired conditions (HACs), while simultaneously advancing our safety culture to eliminate all types of serious safety events. 

What is “Target Zero?”

“Target Zero” is the branding for our patient safety work at Children’s Colorado - we even have a logo that one can see all over the hospital.


Using a curriculum based on work by Healthcare Performance Improvement (HPI) and adopted from SPS, we have trained more than 4000 providers and staff in a set of safety practices designed to make each of us less likely to make errors, and our system more likely to catch an error before it harms a patient. We designed the curriculum with a multidisciplinary group that included physicians, nurses, and administrators and, in an unusual strategic decision, also included leaders from our People Development group within the Human Resources department. By incorporating principles of adult learning we believed we could make small group training sessions more impactful and sustainable, especially with leaders reinforcing these lessons in their areas of responsibility and by training safety peer coaches who would keep the Target Zero practices alive.


Three Commitments - Safety, Questioning Attitude, Communication

We asked all participants to make three commitments - to safety, to promoting a questioning attitude, and to communicating clearly, completely and respectfully. Within each of these commitments are two-three specific tools staff can use to accomplish these goals. In fact, at the end of each training session, every participant chose one safety practice to which they would personally and consistently commit and would model and reinforce among their peers. An illustration of the commitments and safety practices is shown here.


Reliable Practice to Prevent Hospital Acquired Conditions

In addition to training all staff in Target Zero practices, the program depends on active, engaged teams working in a dozen areas of specific types of preventable harm. Infections, falls, pressure injuries, and adverse drug events are among the types of harm these groups are addressing. We have used common approaches to developing and implementing “bundles” of evidence based processes to reduce the incidence of these conditions. We have also used tools in our electronic medical record to identify patients at risk and queue staff in using the bundles. These images reflect some of this effort.


In addition, our patient safety and risk management teams redesigned our approach to cause analysis. Using methods more common in high reliability industries like nuclear power, we significantly strengthened our cause analysis program with training we received with our collaborating SPS hospitals.

Transparency and Family Partnership

Transparency and family engagement have been essential to our success. In addition to posting our results on our intranet, we publish our preventable harm data on our public Internet site (, and in numerous places around the hospital. Pictured here are the central quality and safety wall where we display metrics on a monthly basis and also highlight key elements of the Target Zero program. We make the program visible with white boards in our inpatient areas, and regularly bring a safety buggy around the hospital to engage staff and families in the effort.


Families play roles in numerous ways. One of the videos in our culture of safety training is a family with a child with special needs talking about their experience with preventable harm at our hospital. It is an incredibly impactful video in the educational sessions. Family partners serve on our HAC improvement teams, on our steering committee and one even leads training sessions with staff. We would not have been this successful without their involvement.

What Have We Accomplished?

And what were our results? We achieved a 21 percent reduction in eight types of preventable harm between 2012 and 2013. Although 156 events is still 156 too many, it is 41 fewer children harmed, and represents a substantial initial decrease, getting us started on our road to zero.


People questioned us about calling the program Target Zero - they wondered if zero is possible in a fundamentally human endeavor like providing healthcare. First, “Target some harm” just doesn't resonate. Second, today can be zero, my shift can be zero, this month can be zero for some types of harm. Add it together and eventually we can achieve zero.

We are grateful for the support we have received from our colleagues within SPS, as well as everyone at Children's Colorado who has participated in this effort. We are happy to share with others and continue to learn, together, how to eliminate harm from our hospitals.

Useful Links:

1. Children’s Hospital Colorado - Quality and Patient Safety
2. Children's Hospitals' Solutions for Patient Safety (SPS) - How We Work 
3. Children's Hospitals' Solutions for Patient Safety (SPS) - Hospital Resources 
4. Healthcare Performance Improvement (HPI) - What We Do