Eliminating sentinel events

By Michelle McDade - November 28, 2017

Patients and consumer groups rightly expect the healthcare sector to continue to focus on improving patient safety and quality.

Renowned international leader in this field, Dr Raj Behal visited Pitcher Partners Melbourne recently to share his insights and ideas with some of our colleagues and clients.

Having worked within the healthcare sector for more than 20 years, Dr Behal says the resounding issue in value-based care is achieving the best patient-desired outcomes, at the lowest feasible cost of care.

Dr Behal believes most of the problems leading to less-than-optimal patient safety are due to two main issues: 

  1. the way systems are set up,
  2. and how we approach improvement.

I have been working with Dr Behal over a number of years to develop and introduce these concepts to hospitals in Australia and overseas.

Increasingly, hospitals in Australia are adopting Dr Behal’s SafetySteps framework, designed to reduce harm by focusing on human factors and systems design. SafetySteps applies a ‘100 point plan’ approach to the recommendations from clinical incident reviews. For each recommendation, points are awarded.  This 100 point system involves:

The closer the score to 100 points is, the more effective the reduction of clinical incidents will be. Hospitals with SafetySteps in place have built this framework into their clinical incident review process. One USA based hospital with SafetySteps in place has reported zero never events[1] (similar to sentinel events) for a year, and no perioperative mishaps for over 800 days.

Pitcher Partners will continue to work with Dr Behal to share the beneficial impact of SafetySteps across the Australian healthcare sector. If you would like to know more about the potential of SafetySteps, please contact Michelle McDade or your Pitcher Partners expert.

Michelle McDade is a Client Director in Pitcher Partners Consulting (PPC) Melbourne, and a Lead in PPC healthcare sector practice.


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