A new Lean-inspired system implemented at St. Paul’s Hospital last spring received some Ministerial attention recently.  Don McMorris, the Minister Responsible for Lean, and a representative of the Ministry of Education, visited both Royal University Hospital (RUH) and St. Paul’s Hospital on November 28 to learn more about the Safety Alert System (SAS).

Lean Minister Don McMorris speaks with Victoria Schmid.

Don McMorris, Minister Responsible for Lean, listens as Victoria Schmid describes how the Safety Alert System at St. Paul’s Hospital is working.

The SAS, built and designed using Lean processes and methodologies in December 2013, went live at St. Paul’s Hospital in March 2014. The new call-in reporting system allows patients, families, employees and physicians to call one number to report a safety issue or concern, and it immediately calls a halt to any activity that could cause further harm; in Lean terms, it stops the line.

Anyone can call the Safety Alert System phone number to report anything they know, feel, see, smell or hear that has the potential to cause them, a loved one or employee harm.  It replaces a methodology of reporting safety issues or concerns that didn’t work that well, which was tedious, confusing or time consuming for staff, and was not responsive to anything they did report.

“We knew this needed to be fixed,” said Victoria Schmid, Director of the Safety Alert System.

SAS was rolled out at St. Paul’s Hospital as a trial, and will soon be implemented across Saskatoon Health Region and eventually, the entire province.

“We want everyone to feel comfortable, secure and empowered to call out mistakes or stop the line as soon as possible to protect the safety of patients, providers and our peers,” Schmid stated. “When you make the call, you’ll get the help you need in a timely manner and you can do it without fear of reprimand or punishment.”

McMorris received an update as to how SAS is working so far. Reported incidents, Schmid stated, are far above last year’s numbers, which is a good thing. “Before we had a lot of underreporting,” she noted.

Staff are finding the system easy to deal with as well.

“The staff love it. The physicians really like it. They see things happen,” said Vanesa Vanstone, Kaizen Specialist supporting the SAS. “The nurses are calling, and they like it, too,” she said. “The number of reports is remaining high. The system is sustaining itself because of the culture it has created.”

Most of the incidents being reported are at Level 2, which means the risk of harm is quite low, and most of those have already been dealt with by the time a report about an incident is made, thanks to quick action by staff members. The system has been working for those incidents, as well as those on Levels 3 and 4, where the risk of harm is moderate or severe.

Protocols have been developed for each level of incident, with timeframes and who is responsible for responding clearly indicated. It’s hoped the clearly outlined protocols will make the process of implementing any recommended changes in processes faster.  Already, the time it takes between reporting a Level 3 or 4 incident and putting in the fix, which is usually system-related and quite complicated, has dropped by 91%, Vanstone noted, which means things are getting dealt with more quickly.

Some things have shifted since the SAS was launched. For instance, the levels have been somewhat redefined, and have come to be somewhat based on how soon help is needed to make the situation safe again.

“We’re peeling the layers of the onion,” Schmid said.

Not many patients have made reports to the line yet, but promotion of the line, now that it’s up and running, is next on Schmid’s to-do list.  Pamphlets will be distributed to units within St. Paul’s starting this week.

McMorris had a chance to tour the Safety Centre at RUH, which is manned 24/7, and will accommodate the other facilities when their SASs go online.

“It’s impressive,” said McMorris of the system. “It’s really interesting, all the work that has been done to get to this point. I’m most impressed with the impact this is going to have for patients in the future. It will be a much better patient and staff experience.”