Case Study: WellSpan Health 2023 Achievement Award

Systemwide Implementation of Real Time Problem Solving to Decrease Serious Events 
In Safe Hands - Large Division

The Goal

WellSpan Health aimed to infuse lean improvement science into the daily work of an evolving, complex health care delivery system at every level and to reduce harm to patients and employees. Specific to patient safety, the goal included providing higher quality, safer care as evidenced by increased reporting and a reduction in overall serious events reported to the Pennsylvania Patient Safety Reporting System.

Intervention

During the spring of 2021, the WellSpan Health’s senior leadership launched real time problem solving (RTPS), rooted in lean methodology. The RTPS approach leveraged the health system’s tiered huddle reporting process where safety issues are discussed daily, beginning with a “tier 1” huddle with frontline staff and escalating all the way to the system CEO (“tier 6”).

In support of RTPS and optimizing tiered huddles, 4C (concern – cause – countermeasure – check) was deployed to front line users and leaders. Insights from these 4Cs were collated in a “system-to-share” dashboard accessible by all employees. During May 2022, the 4C tool was integrated into the event reporting system to streamline reporting and provide broader visibility in a PowerBI dashboard.

Results

Since the implementation of RTPS, more than 5,685 4Cs have been documented by health system team members—representing significant improvement work initiated by frontline teams. This resulted in a decrease in the number of serious events from 387 during FY20, to 212 in FY22 (45.22%). During the same time period, the health system enhanced its culture of reporting—increasing the total number of safety event entries from 20,419 during FY20 to more than 40,000 during FY22 (97% increase).

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Topics: Quality Initiatives

Revision Date: 2/28/2023

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