Sentara Healthcare, an integrated health care delivery system serving parts of Virginia and North Carolina, has developed a systematic program to foster a culture of safety throughout its member hospitals, with the aim of reducing the potential for patient harm. During the past five years, Sentara has intensified and expanded the program by engaging the health system’s physician group and other operating units in efforts to: 1) encourage employees to be mindful of the signals of inadequate care and act on those signals; 2) provide leaders with concrete methods of reinforcing employee behaviors that enhance patient safety; 3) reinforce bulwarks against medical error by instituting processes for learning from mistakes; and 4) reward the attainment of high standards of performance. The initiative has helped to reduce the measured rate of serious safety events at Sentara hospitals by 80 percent over seven years.
This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions' experience that will be helpful in their own efforts to become high performers. Even the best-performing organizations may fall short in some areas or make mistakes—emphasizing the need for systematic approaches to improve quality and prevent harm to patients and staff. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case study series is not an endorsement by the Fund for receipt of health care from the institution.