2021 Award Winner Rural Hospital Member


Peterson Health, Kerrville

Project: Zero Harm

In 2018, the Leadership Team and Quality Council of Peterson Health reviewed the publication Leading a Culture of Safety: A Blueprint for Success. This publication prompted Peterson Health’s ZERO Harm and Just Culture journey, and their first safety vision was created and approved by Peterson Health Leadership and medical staff.
The team identified the following goals for the project:

  1. Implement an evidence-based approach to identify systems issues that lead individuals to engage in unsafe behaviors;
  2. Maintain individual accountability by establishing zero tolerance for reckless behavior;
  3. Focus on correcting system imperfections; and
  4. Analyze each event to distinguish between human error, at-risk behavior and reckless behavior.

Within Peterson Health’s Just Culture, all workforce (clinical and nonclinical) are empowered and unafraid to voice concerns about threats to patient safety and workforce safety. While everyone is held accountable for actively disregarding protocols and procedures, the reporting of errors, lapses, near misses, and adverse events is not only encouraged, it is expected.

Peterson Health’s Quality Services Team, from left to right: Barbara Stehling, RN, Director of Quality Services; Elaine Ivy, RN, Patient Safety/Accreditation Coordinator; and Pam Burton, RN, Infection Prevention Supervisor.

Their online event reporting system was revised to include an option for directors to select which behavior they identified in response to the event. This is done with the staff member to help them feel supported and held accountable at the same time.

The Zero Harm and Just Culture journey for Peterson Health has been effective in demonstrating both a reduction in harm and improved Culture of Safety. Their Culture of Safety survey results over the last several years have demonstrated a significant trend of improvement. When their journey began in 2018, their positive response rate related to a non-punitive response to error was at 60%. Improvement trended over the next three years to an all-time high of 90% in their FY 2021 survey results.

Patient Harm, as measured by the AHRQ PSI 90 measure, has also trended positively over the last three years. Harm rate per 1,000 discharges has decreased from 4.8 in FY 2019 to 1.3 in FY 2021. To this day, the entire organization continues to put Zero Harm and Just Culture at the forefront of everything they do.