A 'straight-A' hospital's safety playbook

Endeavor Health Elmhurst (Ill.) Hospital is one of only 12 U.S. hospitals to achieve consecutive "A" ratings from Leapfrog since 2012, when the organization began biannual safety rankings. Becker's found out why. 

During orientation, all new employees — from housekeeping to nursing, from respiratory therapy to food services — are immersed into the organization's safety culture, according to Elmhurst president Kimberley Darey, MD. Dr. Darey has served the system since 2010 and became CEO in early 2023. 

If several workers in one department are on paid time-off, the whole "house" needs to know, she said. To air safety concerns or potential risks, the hospital holds a daily safety huddle with every department represented. 

"We do not have a hierarchy when it comes to taking care of patients," Dr. Darey said. "Everyone knows that they have the right to say, 'I have a safety concern,' regardless of their position in our organization, and that they have a chain of command to be able to share that information with if they feel that there's a safety issue."

This culture of safety and high reliability contributes to Elmhurst's constant "A" rating, even after undergoing a merger in 2022, which combined NorthShore University HealthSystem, Edward-Elmhurst Health, Swedish Hospital and Northwest Community Healthcare into a new brand, Endeavor Health. 

Six of the health system's nine hospitals received an "A" rating from Leapfrog; two are ineligible since they are specialty hospitals and another received a "C."

Lakshmi Halasyamani, MD, chief clinical officer of Evanston, Ill.-based Endeavor, said another aspect of patient safety wins is voicing these achievements. It's what she calls "data with a soul."

"Oftentimes, you know, days are filled with lots of things that people have to get done, and we don't always have an opportunity to connect what we do to purpose and to impact," Dr. Halasyamani said. "Being able to share stories around how following these evidence-based protocols has positively impacted our patients has been a very important way for us to sustain our efforts."

All meetings begin with a safety story, including the recognition of coworkers who provide exceptional, safe care. Every month, a peer-nominated physician is awarded for contributing to patient safety goals. 

"One of the ingredients to a safe hospital is engaged staff," Dr. Darey said. "If you have a team that's checked out, then guess what? Safety quality may start showing some downward trends. So I think it's critical that you have an engaged staff that knows that they're accountable and that they're important."

Patient satisfaction is also crucial to delivering safe care, Dr. Darey told Becker's. With shared decision-making among patients, families and hospital employees, communication improves and errors are avoided. 

Thanks to these efforts, Endeavor achieved a 22% decrease in healthcare-association infections between the second and third quarters of 2024.

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