A palpable pulse on organizational culture is imperative for allowing senior leadership to understand the current state and use this as a starting point to measure the gap between the current state and where the organization should be to meet strategic goals related to quality and safety. Knowledge gleaned from causal analysis and coding of safety events provides the organization with that information. Our organization was unknowingly making decisions on a small quantity of coded and classified events, which led to mistakes on our journey to becoming a high-reliability organization.

To remedy this, the Quality and Safety Team improved the user interface of the event reporting system and created standard work for all frontline staff, physicians, area managers and senior leaders. After several interventions, we reduced the time between reported events and documented resolution by 15.28% and increased the quantity of coded and classified safety events tenfold. These changes improved our organization's ability to make better informed decisions and plot a more precise course on the journey to becoming a high-reliability organization.

组织文化的明显脉搏对于让高级领导层了解当前状态并以此为起点来衡量当前状态与组织应达到的质量和安全相关战略目标之间的差距至关重要。从因果分析和安全事件编码中收集的知识为组织提供了该信息。我们的组织在不知不觉中对少量编码和机密事件做出了决策，这导致我们在成为高可靠性组织的过程中犯了错误。

为了解决这个问题，质量和安全团队改进了事件报告系统的用户界面，并为所有一线员工、医生、区域经理和高级领导创建了标准工作。经过多次干预后，我们将报告事件和记录解决之间的时间缩短了 15.28%，并将编码和分类安全事件的数量增加了十倍。这些变化提高了我们组织做出更明智决策的能力，并在成为高可靠性组织的过程中制定更精确的路线。