Message from the President – June 2018

Posted on Jun 5, 2018 in President's Message | 0 comments

Medical Staff Leaders recently completed Sutter Safe Care Leadership training. A special thank you is extended to everyone who donated eight hours out of their busy schedule to participate. We learned during the training that Sutter Safe Care is about creating a safe environment for not only our patients, but also for everyone in hospital. Zero harm is our goal.

Sutter Safe Care is about having a preoccupation with failure and safety, and linking this to our decisions to help create a safe environment for all. It’s about addressing potential safety issues before they become problems and cause harm. It’s about speaking up about issues we encounter on a daily basis, and thanking individuals for bringing up their concerns. It’s about actively finding problems and fixing the proximate causes. Also, it’s about changing our culture by creating an environment of trust and cooperation.

A more technical aspect of Sutter Safe Care is changing some of the details of our reporting system to better categorize events that could lead to harm or have caused harm e.g. Intensive Analysis (IAs) and Root Cause Analysis (RCAs). This will help us as an organization better understand patterns of safety events and create solutions within our system to avoid these events from occurring in the future.

Furthermore, there is an emphasis on “Just Culture”, or in other words, having a fair and accountable culture, which is understanding that most events are unintentional. When a safety event occurs, rather than blaming the individual, we take a deep dive into our system and determine how we can prevent future incidents through improving our systems. Also, as physicians and care givers, we hold ourselves accountable to our patients and each other.

The dates, times, and location for the two hour Sutter Safe Care sessions will be emailed soon.

Remember, if you see a problem or potential problem, please report it to your unit manager or to your Medical Staff leader, either your Department Chair or Medical Director. Below is an outline of the Medical Staff leadership reporting structure.

Required two hour training sessions for physicians and staff will occur June through September. Many options will be available at varying times of the day. Specifically, there will be a few grand rounds dedicated to Sutter Safe Care training. Administration will sponsor dinner sessions at both the Summit and Alta Bates Campuses for physicians and allied health professionals. Also, you can join the hospital staff during any of their training sessions. It’s the same training. Please be sure to sign up and sign in to receive participation credit. CME credits are also available. Thank you in advance for participating in the quest toward zero harm!

A special thank you goes out to each and every physician and allied health professional caring for our patients during the unexpected downtime which began the night of May 14th. Around 10:30 p.m., activation of the fire suppression system in the Sacramento data center forced an immediate shut down of all of Sutter’s data systems. All Sutter computer services and systems were down. Our physicians, nurses and staff worked side by side quickly pulling together all available resources during this unfortunate event. While walking through every floor and visiting almost every department, I noticed a strong sense of camaraderie and team work. Adversity brought out the best in everyone despite the challenges we faced. Radiologic studies were read at the bedside. Lab results were both hand delivered and faxed. Physicians heard through the grapevine potential consultations and without being called, came to the patient’s bedside.

Two radiologists deserve recognition: Dr. Phillip Wong and Dr. Chris Lee. The night hawk service was unable to function without computer services, therefore, no teleradiology. Both radiologists came in to care for our patients the night of the outage despite not being on call so studies could be read in real time. Thank you Drs. Lee and Wong.

Sutter is doing a deep dive into the circumstances surrounding the unexpected downtime. They will report their findings to each affiliate and we will report the findings via the medical staff newsletter. Also, we are doing our own debriefing as there is a lot we can learn as this situation simulated a true disaster. Please escalate downtime concerns, or ideas to streamline downtime procedures to your unit manager, Medical Director, or Medical Staff Chair. We can learn from your experience.

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