SPS Resources & Tools
Utilizing Quality Improvement Science & High Reliability Concepts to Drive Change
To guide our work, SPS is moving each pediatric hospital acquired condition (HAC) that the network focuses on through a series of phases that allow hospitals to learn from peer institutions through an “all teach, all learn” approach, while implementing evidence-based pediatric process bundles for care and formalizing pediatric prevention standards that will be made available to all hospitals who care for children nationwide.
Transforming Hospital Culture to Reduce Harm
In order to achieve breakthrough safety results, SPS network hospitals are employing the cultural transformation strategies of other high reliability industries to significantly reduce harm—measured by Serious Safety Events (SSEs)—in their institutions. These include sensitivity to operations, preoccupation with failure, and reluctance to simplify. SPS and Child Health Patient Safety Organization (Child Health PSO) collaborate to align curriculum and methodology on these principles. SPS members who participate in the Child Health PSO benefit from learning about national safety themes and trends and share SSEs with federal privilege and confidentiality protections to accelerate reduction of preventable harm in their hospitals. Focusing on high reliability requires in-depth evaluation and change in communication, team dynamics, and leadership.
Culture transformation must happen at all levels of an institution. Therefore, boards of trustees and senior leaders at SPS network hospitals are challenged to transform their organizational culture and set the expectation of personal accountability for safety from all levels of staff within their institutions.
The current work of SPS falls into the seven categories below. Click each square to learn more about the work SPS is conducting in each category, as well as explore published resources.
Change Packages
Fifteen years after the Institute of Medicine brought public attention to the issue of medical errors and adverse events, patient safety concerns remain a serious public health issue that must be tackled with a more pervasive response. With a grant from AIG, the National Patient Safety Foundation (NPSF) convened an expert panel in February 2015 to assess the state of the patient safety field and set the stage for the next 15 years of work. The resulting report (endorsed by SPS) calls for the establishment of a total systems approach and a culture of safety, and calls for action by government, regulators, health professionals, and others to place higher priority on patient safety science and implementation.
Videos
The videos below cover the SPS disclosure process and how to utilize k-cards. For additional videos related to a specific HAC, check out the CLABSI, UE, and Additional HAC pages.