At Banfield Pet Hospital, we’ve long had processes in place to help ensure our hospitals have the tools to practice high-quality medicine. In 2014, we embarked on a new phase in our continuous quality journey with the goal of strengthening our hospital systems to help our veterinarians provide great care for every pet, even on chaotic days. We knew embracing a culture focused on quality and safety was imperative, as was creating systems and processes that made the right thing to do the easy thing to do.
We gathered learnings from human healthcare, including insights from high-profile cases involving system failures, and adopted the “Swiss Cheese Model” to analyze safety incidents. The model illustrates how a particular hazard penetrates multiple barriers and safeguards to result in a safety event. Each slice of cheese represents a system or process that acts as a safeguard to prevent an event from occurring. The holes in the cheese represent areas for improvement in the process. If the slices are organized a certain way, and the holes line up, a safety event may occur. In this way, the Swiss Cheese Model analysis helps to identify risk factors for safety events. This information can then be used to improve systems to prevent harm.
We began to actively foster an environment of openness and transparency without blame across our practice, a step essential to creating a Culture of Safety.
In January 2016, Banfield rolled out a Patient Safety Event reporting system to enable associates to report quality and safety concerns without fear of reprisal. We encouraged reporting on near misses and cases where harm occurred, given that both offer insights on how to continually enhance safeguards.
As we develop strategies to reduce risk, we continue to use the Swiss Cheese Model as a tool to develop changes that minimize risk and improve outcomes. We encourage you to share experiences and use the patient safety event exercise tool to work through events in your own practice.