Studer Group Hospital Case Study

The hospital that I work in uses principles from The Studer Group, which works with hospitals to obtain improved clinical outcomes, to obtain a high reliability organization (Studer Group, 2017). Quarterly, we focus on different safety topics such as support the team, ask questions and focus on the task. Employees complete a computer based lesson each quarter and leaders are to make rounds on staff for validation of practice. We also have Safety Coaches for each department. Their role is to be the spokesperson for their unit to help increase compliance with the high reliability culture. We use bundles, such as ventilator bundles in our ICU to ensure that we do everything evidence based to prevent ventilator associated pneumonia. These steps have resulted in no ventilator acquired pneumonia for the last year. We also try to implement hourly rounding. This unfortunately has become an example of pencil whipping. Nurses have a sheet at the patients door where they are supposed to initial each hour that they have rounded on the patient. Common practice due to poor staffing is that the nurse waits until the end of the shift and just initials all the way down on the sheet at one time. They do this to keep
Anyone can and is encouraged to complete event reports for errors and near misses. It could be more effective than it is currently. Staff tend to feel that an event report is a "write up" even though they do not get disciplinary action from event reports. This can hinder the data collected by underreporting. Data is complied by the risk manager who reports it to the Patient Safety Committee. The data is eventually shared with the Medical Executive Team. My experience with feedback is that once I investigate an event report as a nursing director, the information is entered in the system and nothing else is said about it unless there is major harm to someone or a trend. Then we utilize root cause