Executive Summary

Virginia Commonwealth University Medical Center’s Safety First Every Day initiative has resulted in a 50% reduction in serious safety events, declines in falls with injuries and infections in intensive care units, and an increase in safety occurrence reporting.

• All employees go through a four-hour safety training program that focuses on creating safety awareness all day, every day.

• Employees who report safety breaches and work to correct them receive a gold pin awarded by the hospital’s chief executive officer, who presents the pin at the employee’s work site.

• The hospital has developed an Early Warning System which combines clinical expertise and technology to identify patients whose condition is deteriorating before they become worse.


Since the Virginia Commonwealth University Medical Center began its Safety First Every Day initiative in 2008, the 1,125-bed health system has achieved a 50% reduction in serious safety events, an 83% decline in falls with injury, an 88% reduction in infections overall in intensive care units, and a 35% increase in safety occurrence reporting.

The hospital was awarded the American Hospital Association-McKesson Quest for Quality Prize for 2014 in recognition of its comprehensive patient safety and quality program.

“Patient safety is part of our culture. It’s in the fabric of everything we do. We consistently stop and think about what we are doing and whether what we are setting up is safe,” says Ryan Raisig, MHA, director of care coordination at the Richmond, VA, hospital.

Among the numerous patient safety initiatives are a four-hour safety training program for all employees, recognition of employees who report safety breaches, and an Early Warning System to alert clinicians when patients’ conditions are deteriorated, he says.

The hospital has cut the rate of serious safety events and they continue to decline, says Dale Harvey, MS, RN, director of performance improvement. “We are constantly raising the bar to get better. Our goal is for all 14,000 team members to be looking out for patient safety issues and to intervene proactively,” she adds.

The patient safety program was developed by a multidisciplinary team with guidance from experts in higher reliability science, Harvey says. “We completed a diagnostic assessment of our culture, what it was like then and what we wanted it to be. This included interviewing everyone from physicians and frontline staff to executive leaders and board members. Then we developed key strategies that include putting safety first on every agenda, a daily safety check-in, and discussing safety at every meeting,” she says.

Working with high reliability experts, the team developed a four-hour safety training program called Behavior Expectation for Error Prevention (BEEP) that focuses on incorporating safety awareness into every staff member’s work day.

The program includes teaching employees, called team members, how the brain functions so they can understand human fallibility, Harvey says. “We teach behavior that helps minimize mistakes and changes the way people think. Instead of blaming someone when things go wrong, we look at how to improve the system,” she says.

The BEEP program aims to teach all team members safe behaviors such as paying attention to details and using the STAR (Stop, Think, Act, Review) approach to prevent things from going wrong. “These are simple tools but they are practical and easy to use in everyday work,” Harvey says.

As part of its efforts to create a culture where people can talk about errors without assigning blame, the team started with stories of safety breaches in other institutions, then moved to a discussion of errors in their own hospital.

“We worked to create a culture where people talk about errors without naming names and look for ways to avoid them. We’re not focused on the individuals involved in safety breaches. This is about systems and processes and how we work together. That’s really a key strategy for engaging people and helping them understand why an error occurred,” she says.

During BEEP training, the staff learn to point out patient safety errors to the person making the error when they observe them, using another safe behavior called “cross-check,” Harvey says.

“Reporting a safety breach after the fact using patient safety event reports isn’t very useful when you have an opportunity to correct the error in the moment. Our team members cross-check each other routinely to ensure adherence to the highest safety and quality standards. We find that the vast majority of people are not making the error intentionally and thank their colleague for pointing it out,” Harvey says.

To reinforce the importance of pointing out errors, the hospital developed the Safety Star program in 2008 to recognize front-line team members who find an error and work collaboratively to prevent it from happening again. The chief executive officer comes to the employee’s work area and gives him or her a gold pin to wear. “This is an example of how we reinforce the behavior we want to see,” Harvey says.

The hospital developed its own copyrighted performance management decision tree to help the management team distinguish between an unintended human error and a disregard for a safety practice.

“We want to balance individual accountability with organizational and system accountability and to protect people when they make unintended mistakes. It’s the difference between doing the best thing you can under the circumstances, or knowing a safety process and intentionally ignoring it,” she says.

For instance, if someone doesn’t sanitize their hands before going into a patient room, it could be that they were in a hurry and forgot. Or it could be that they have not been educated on how to properly wash their hands, she says.

“We want to make sure that we are not going after the individual if the system hasn’t taught them what they need to know,” she says.

It’s become part of the hospital culture to cross-check everything, Rasig says. “The idea of cross-checking has made its way into non-vital areas. For instance, we’ll be talking about a meeting at 1:00 tomorrow and someone will ask to cross-check the time because her calendar said it was at 2:00,” he says.

Harvey tells of an occasion when she was talking to a case manager outside Harvey’s mother’s room in an intensive care unit. “The nutrition care assistant approached with a lunch tray for my mother. The case manager stopped her and said ‘let’s cross-check and make sure she is supposed to eat.’ It was OK, but it was a good thing for the case manager to do even though she was in the middle of an intense conversation with me. This shows me that safety behaviors have become such a part of how we do our work that they are reflexive,” she says.

As part of their patient safety initiatives, the case management department developed a care transition bundle of 10 things that should happen for every patient. “We understand that the items will be different for a newborn and a transplant patient, for instance. But this is an innovative way to measure how often the items happen and make changes to ensure that every patient gets what they need,” Rasig says.

The case management department is using the safety principles in their relationships with post-acute providers. “When something unexpected happens, like the patient is readmitted from a skilled nursing facility, or the home health services didn’t show up, we do the same thing we do when there is an internal breach,” he says.

A team from the hospital meets with leadership and anyone involved with the patient at the community provider. They analyze what happened, why it occurred, and look at ways to improve the system so the same problem won’t occur in the future, he says.

“We tell them that the meeting isn’t about whether somebody did something wrong. It’s an attempt to identify trends and figure out if we could have done something different that would result in a better outcome. Sometimes the answer is ‘yes’ and sometimes, it’s ‘no,’” Rasig says.

The performance improvement team is heavily involved in the case management initiatives, he says. “They are taking the same principles and applying them across the board. The performance improvement makes sure we are doing things in a structured way and helps us learn from what is happening in the rest of the institution,” he says.