When Zero Means Zero

July 2016

​Target Zero and the Golden Ratio of Relationships 

John Gottman can predict the future. After reviewing 15 minute video segments of 700+ married couples for more than a decade, he could predict—with 94% accuracy—the longevity of a marriage after ten years using what he called “the golden ratio of relationships”: Couples who stay together demonstrated five positive interactions for each negative encounter, balancing criticism with positive, relationship-building behaviors.

How does the golden relationship ratio apply to patient safety and the practice of medicine? According to Children’s Hospital Colorado project manager Jessica Schwartz, (pictured on left) the teams we count on to care for patients can improve their effectiveness by exhibiting respectful and appreciative behaviors. ​

Schwartz manages a component of the hospital’s Target Zero program, an effort that began in 2013 with the goal of eliminating preventable harm. From 2013–2014, all 6,000+ providers and staff at Children’s Hospital Colorado received Target Zero training. Everyone learned the importance of eliminating the typical “silo-ed,” top-down communication and encouraging a questioning attitude. By focusing on pausing to care, having each other’s backs and prioritizing safety over productivity, the hospital experienced incredible outcomes. They saw a 21% reduction of preventable harm from pre-Target Zero 2012 data. After year two, this grew to a 30% reduction.

Yet there’s still more work to be done. Over the last two years, Schwartz and her team have been challenged to keep the work moving forward, without becoming an intrusion into the busy days of hospital team members. 

“Target Zero wasn’t launched to be an initiative that comes and goes. We want to shift who we are as an organization, and how we as individuals show up to work with each other and to work with our patients and families,” said Schwartz. “We knew that a punitive approach to addressing safety concerns wouldn’t work, so we took aim at shifting our culture. Our challenge is to continue making sure what we put out there is meaningful information."

Safety Travels

“Permanent behavior changes don’t happen from sitting through a two hour training class,” said Schwartz. “Our providers and staff don’t have time in their days to come to us, so we invented a portable solution.”

The Safety Buggy is wheeled throughout the hospital, and features educational materials and giveaways. As time allows, Children’s Hospital Colorado employees and families can come spin the buggy’s wheel to win prizes and answer questions that reinforce the “safety bundles” and targeted improvement processes that front line staff follow. (Pictured right to left: Lara Fellows, Trisha Hooker, Darren Riley and Michelle Oslund)

Caught You Being Good 

When you’re on shift and nervous about making a difficult call, who is the first person you go to? “Often, it’s a peer—someone you respect,” explains Schwartz. “These people have the most power to shift culture.” 

Enter the Target Zero Safety Coach program, where front line staff who already serve as informal mentors are given extra support and trained how to reinforce positive behaviors. “They’re not hall monitors—they know to provide constructive criticism whenever necessary—but these coaches are also trained to catch people doing the right things. It’s not a behavior that necessarily comes naturally, but with a little training, our 128 coaches are able to return to the front line and be a real time positive force in delivering patient care.” 

Attitudes at the Top Make the Difference

The role the clinicians at Children’s Hospital Colorado play has been, and will continue to be, essential for sustainability of the culture shift Target Zero aims to bring about. Often, it boils down to clinical leaders to help everyone on their team understand what a questioning attitude looks like, and how it’s safe to display this attitude without fear of retribution. 

“All our providers were trained in safety culture practices including promoting a questioning attitude and being a supportive active listener when questioned by any concerned team member,” said Dan Hyman, MD​, chief quality and patient safety officer at Children’s Hospital Colorado.

“It’s amazing how much it means to the rest of the staff when a physician takes the lead to talk about speaking up,” said Schwartz. “It might sound simple, but our physicians and advanced practice providers seem to understand how hard it can be to speak up to those traditionally seen as being a ‘superior.’ They play a big role in creating an environment that makes this possible.” 

Dr. Hyman believes clinician leadership is essential. 

“Our providers support patient safety both by what they do, for example, modeling proper hand hygiene practices when entering or leaving patient rooms, and by what they say and how they say it,” he said. “The leadership of our providers will be invaluable in ensuring all team members are working collaboratively to achieve our goals.”

The Evolution Continues

“We’re not starting from zero with this work. Many, if not all, departments have an element of quality improvement in their workflows already. What Target Zero has done is given everyone at Children’s Hospital Colorado a shared way of talking about safety,” explains Schwartz. 

She recently assisted with a program developed by pediatric chiefs in partnership with Jenny Reese, MD​. They developed escalation curriculum based on the assumption that being a trainee is tough, from the technical aspects of who to call and when, to exploring the nuances of why making those calls can be difficult. 

Dr. Reese believes the willingness of faculty facilitators to dedicate time to this training demonstrates their commitment to role modeling and teaching optimal communication skills to our residents. 

“Their stories demonstrate that everyone has challenges with escalation at times, and learning these skills in training will pay off in future career roles,” said Dr. Reese. “I think their participation also showed the residents how important this topic is, and maybe even helped break down some of the barriers that trainees face in challenging communication situations.” 

As Target Zero continues to evolve, so will the support the program provides to the units and departments that work hard every day to eliminate harm. 

“Care teams have tested and implemented a number of ways to ensure consistent, targeted assessments of the adherence to relevant prevention bundle elements on many teams across the hospital,” said Dr. Hyman. “Similarly, medical directors in a number of units have assumed new levels of focus on safety systems in their areas of responsibility. Process improvement specialists, HAC team leaders and medical and nursing leaders are partnering in new ways to improve our reliability to prevention bundles and seeing nice reductions in harmful events again in 2016.”