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Marcie Hopkins, U of U Health.
Creating Safety Through Learning
What does it mean to take a system approach to problems? The discipline to learn as a team, patience to wade through hundreds of cases, and a diversity of perspectives. Utah’s Critical Care Senior Nursing Director Colleen Connelly, System Quality, Patient Safety, and Value Senior Director Sandi Gulbransen, and Associate Chief Medical Quality Officer Kencee Graves reflect on what they’ve learned by studying system problems with an interdisciplinary team.

A systems approach to safety


magine you’re sitting in your mom’s hospital room and you’re holding her hand. She begins breathing rapidly. How long can you sit at the bedside, before you’re out in the hall trying to get help? Anything beyond that is an opportunity for improvement, according to a hospitalist at Mayo Clinic, Dr. Jeanne Huddleston. The standard of care is the kind of care you’d want your loved one to receive.

15 years ago, Huddleston and Mayo’s patient safety team created the Safety Learning System, or SLS, to study mortality issues at Mayo. They wondered how they could learn lessons about their processes using deaths in the hospital as a convenient sample. The team decided to bring clarity to complexity by developing a multidisciplinary, team-based system review process. The process identified pre-defined (commonly occurring) opportunities for improvement, as well as opportunities to identify what has gone well in the course of care.

We had heard Dr. Huddleston speak and were very interested in bringing the work to the University of Utah. The rigor and discipline of the data review process was exciting. We knew based on feedback from our Vizient benchmark that we had opportunity to improve around mortality. We were excited to work closely together—a physician leader (Kencee), a nursing leader (Colleen), and a quality and safety leader (Sandi).

About a year after we first learned of SLS, we joined the collaborative and started to review.

The review begins

Beginning in June 2018, we collected the cases that would become our own review sample. We started with cases of patients who had died in the hospital. Whether or not there were process failures,  there are still opportunities to learn from these patients’ stay in our hospital 

We randomly selected cases and then assigned them to a practicing nurse and a practicing physician to conduct the reviews. Based on that review, the nurse and physician pick an opportunity for improvement from a list of possible improvements derived from the SLS collaborative. 

At a monthly meeting, the reviewing nurse and physician present their conclusions to the a 20-person multidisciplinary team made up of other reviewers. The ad-hoc reviewers include clinicians from pharmacy, respiratory therapy, physical therapy, patient safety, and transfer center. We were the first SLS collaborative member site to add this type of ad hoc reviewer team to review every case, in addition to the nurse/physician reviewer dyad. The team then collaboratively decides opportunities for improvement and gratitude. To date, over 200 cases have been reviewed. 

How does it work? A step-by-step approach:

Charts are assigned to review teams, a practicing nurse and physician, who use a standard process to review the chart. Once the review is done, the dyad presents their findings to a multidisciplinary team that is made of other reviewers. The committee deploys several rules, like the Chatham House Rules, to make sure the conversation is frank and open. Decisions are made by consensus. What if there is no consensus? Then more information is requested to help the group make a decision. After a decision is reached, the case is closed with the identified opportunities. Once we have reviewed 100 cases, we aggregate the data in a Pareto chart and deploy improvement teams as appropriate. Each nurse/physician dyad only reviews one every month so the workload doesn’t overwhelm. We also get the benefit of having different reviewers at every meeting who bring different perspectives that enrich the discussion.

In any large, complex system, there are ample opportunities for improvement. We don’t review charts out of a belief that a particular patient should not have died. Instead, we see opportunities for improvement to make the process smoother for patients and families, staff, and providers, whether or not the patient would have lived. This effort is different from how we’ve approached problems in the past. 

Previously, fixes were one-offs. Something really bad happened, and we tried to fix that one problem. The system process was the issue. 

Clinical lessons from 200 cases 

In real medicine, things go well and things go wrong in the very same case. The SLS system has a place to document both what went well—what we call opportunities for gratitude—as well as what did not go well—opportunities for improvement. 

We recently had a case reviewed where an older gentleman went to surgery and then did not do well. In reviewing the chart, we saw so much that went right. For example, when the doctor first met the patient, they talked about the goals of care, what was important to the patient, and whether or not he would want certain things during the course of his care.

Improvement opportunities generally cluster around four main areas: end-of-life care, documentation opportunities, deteriorating patients (when the clinical team doesn’t recognize when a patient is getting sicker), and care transitions.

In real medicine, things go well and things go wrong in the very same case. The SLS system has a place to document both what went well—what we call opportunities for gratitude—as well as what did not go well—opportunities for improvement. 

In our first 100 cases, we identified 51 opportunities for gratitude and 323 opportunities for improvement. We delved deeply into our pareto of opportunities for improvement.

Sometimes the problems identified have easy fixes. Some problems can go to a standing committee, such as critical care committee, or a fix. Other problems with more system-wide implications are handed off to improvement teams.

We’re about to start our 3rd cohort of cases. Our first cohort studied mortalities, our second cohort studied transfer-in mortalities, and our third will study readmissions. This framework isn’t just for mortalities, it is a powerful tool to understand the system opportunities for improvement in any area of interest.

Leadership principles learned

1. The power of gratitude. Kencee sends an email to members of the team identified in an opportunity for gratitude, and includes their direct supervisor, chief and/or department chair. We started sending gratitude to organizations outside of our hospital. For example, there was a doctor in the Four Corners area who did a tremendous job making sure the patient’s goals of care were clear before transferring the patient to the University of Utah. We’ve been amazed at the impact of gratitude. People don’t get thanked very often.

2. Trust your team by cultivating a common language. All our reviewers are trained in the exact same way. That training has in-person, where a case is actually reviewed together, and video-based components. When cases are taken to the community, people have an opportunity to see each other present, which further builds that shared language that says we are all on the same team.

3. Respect the power of process. This project has been successful because we are taking a step back and looking at system failures, not people failures. We ask: Where did our processes fail our patients, providers, or staff? By focusing on the process, people don’t feel attacked, and it allows us to see issues for what they really are, system problems that we can overcome by working together. Instead of feeling a sense of anxiety, this process has been collaborative and supportive.

4. Learning together is powerful. We have been surprised by how much our reviewers love the process! We’re asking already busy nurses and doctors to dedicate time, and they are willingly doing it. Our physician and nurse reviewers are engaged because they are asked to bring their expertise to address system problems. Their expertise is respected and valued. It has been a leadership opportunity for nurses to stretch in new ways. Their voices are heard, and they see us move the needle. The SLS showcases what happens when nurses and physicians learn together.


Kencee Graves

Hospitalist, Associate Chief Medical Quality Officer, University of Utah Health

Sandi Gulbransen

Chief Quality Officer, University of Utah Health

Colleen Connelly

Senior Director, Nursing Services, University of Utah Health

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