Revolutionizing Patient Safety through Organizational Certification Anne Arundel Medical Center

Transcription

1 Revolutionizing Patient Safety through Organizational Certification Anne Arundel Medical Center Robert Imhoff President and Chief Executive Officer, Maryland Patient Safety Center Anne R. Van Waes, MS, RN, CIC Director, Quality and Regulatory Affairs Anne Arundel Medical Center 1

2 What is Organizational Culture The values and behaviors that contribute to the unique social and psychological environment of an organization. Organizational culture includes an organization s expectations, experiences, philosophy, and values that hold it together and is expressed in its self-image, inner workings, interactions with the outside world and future expectations. It is based on shared attitudes, beliefs, customs, and written and unwritten rules that have been developed over time. Organizational culture is shown through: The ways the organization conducts its business, treats its employees, customers and the wider community; The extent to which freedom is allowed in decision making, developing new ideas and personal expression; How power and information flow through its hierarchy and How committed employees are towards collective objectives. It affects the organization's productivity and performance and provides guidelines on customer care and service, product quality and safety. 2

3 Impacting Organizational Culture 3

4 Change 4

5 Anne Arundel Medical Center

6 Overarching Goal MPSC, in partnership with Courtemanche & Associates, initiated a patient safety certification program that included meeting with leadership, data collection, a risk assessment, formation of a patient safety team, creation of patient safety goals and education 6

7 Learning Objectives Utilized collegial collaboration, classroom instruction and practical application methodology, facilitated by a consulting team with expertise in patient safety, performance improvement and regulatory requirements; Fostered adult learning approaches that emphasize the individual s experience, autonomy and need to contribute to the achievement of organizational goals 7

8 Learning Objectives Established the Patient Safety Officer (PSO) as the focal point and internal coach for coordination of patient safety activities Standardized the process of recognition of past and current successes, communication, action, implementation and resolution for any identified patient safety issues throughout the organization 8

9 Certification Requirements 9

10 Problem Healthcare organizations have been focused on patient safety approaches for more than 15 years, yet, current data demonstrates that there is more to do. Existing patient safety certification models are geared to individual healthcare professionals who serve as change agents for large and complex organizations. While programs of this nature are effective for individuals who can impact change, they are often limited in affecting widespread organizational culture change. 10

11 Certification Process Flow Leadership Baseline Data Select Team Establish Goals Education 11

12 Leadership: Attestation of Organizational Commitment The organization commits to the following: Working collaboratively with the MPSC in planning, coordinating and implementing the scope of service of this program including but not limited to, education and training, facilitated risk assessment, prioritization of initiatives, ongoing coaching, mentorship and support. The leadership triad (governance, administration and medical staff leaders) will support this endeavor through prioritization and championship of identified projects, resource allocation and providing visible presence and support to those directly involved in patient risk/safety activities. Assuring education and coaching is provided on robust performance improvement methodologies. Requiring regular reports to the leadership triad on identified patient safety issues Actions identified Actions taken Ongoing measures to gauge sustainability Barriers to success Creating transparency, through reporting and sharing of lessons learned 12

13 Base Line Data 13

14 Leadership: Lead: Committee: The Team CEO, COO, CFO, CMO, CSO Patient Safety Officer Patient Safety Committee Representatives across the health system to include Ambulatory and Physician Practices (35 Members) Safety Liaisons: 77 Representatives from all departments across the organization 14

15 Establish Goals Utilize innovative approaches, including positive psychology, to enhance collegial collaboration, classroom instruction and practical application methodology, facilitated by a consulting team with expertise in patient safety, performance improvement and regulatory requirements Foster adult learning approaches that emphasize the individual s experience, autonomy and need to contribute to the achievement of organizational goals Establish the Patient Safety Officer (PSO) as the focal point for coordination of patient safety activities Engage and empower the PSO to serve as the organization s internal coach and trainer Facilitate the advancement of the certification process throughout the organization to all departments and services Enable each discipline and organizational department to follow the same process of recognition of past and current successes, communication, action, implementation and resolution for any identified patient safety issues germane to their areas of responsibility 15

16 Methods New Approaches to Identify and Eliminate Serious Safety Events Patient Safety Champions Network & Change Agents Classroom & Practical Applications to include: Strength-based approaches to communication, risk identification and problem solving Appreciative Inquiry Positive Deviance 16

17 Revolutionizing Patient Safety Creating Sustainability Facilitating Discovery Fostering Accountability Revolutionizing Patient Safety Preventing Errors Escalating Performance Improvement Accelerating Change Exploring Solutions 17

18 Education 18

19 Outcomes Comparison Patient Safety Pre Study vs. Post Study YTD 80.00% 60.00% 40.00% 20.00% 0.00% % % Level I Level II Level III Total # Events Reported Unsafe Conditions (included in Total Events) Near Miss Reports (included in Total Events) % 19

20 Positive Outcomes Outcomes Continued Patient safety indicators tracked prior to the study period were compared against data tracked after the study period. This AAMC Event reporting was as follows: Level I (deaths) decreased 10% Level II (medical intervention to prevent death or serious injury) decreased 60% Level III (no harm) increased 3.75% Near-miss reporting increased 42.84% Unsafe-condition reporting increased 72.88% 20

21 Promotion of Organizational Patient Safety Expansion of Patient Safety Committee and Safety Liaison Committee from hospital to system-wide representation Patient Safety Certification Course for Patient Safety Committee (PSC) members First healthcare organization in Maryland to pilot the certification program 35+ members completed training ( six 8-hour sessions=48 hours over Sept-Nov 2014) Upon completion, recognized with a certificate and Safety Through Teamwork pin during celebration led by Tori Bayless Patient Safety dashboard created and used in reporting to MPSC 21

22 Promotion of Organizational Patient Safety Safety Liaison Committee reboot Modified Patient Safety Certification four-hour course, including the concepts from the PSC course, created and presented by representatives from the Patient Safety Committee 51 members completed training Retooled roles and responsibilities of Safety Liaisons Bulletin boards with Dream Statement created by PSC during Pt Safety Certification as well as the posted certificate from Patient Safety Certification course Ensure completion and reporting of Perpetual Readiness Rounds to unit/department leadership Presentation of safety related issues at unit/department meetings Emphasis on near miss and incident reporting to 4PTS Celebration in recognition of Safety Liaisons in cafeteria for Patient Safety Awareness Week 22

23 Unit Safety Liaisons Roles 23

24 Additional Actions Mentorship program being initiated between PSC representatives and Safety Liaisons Introduction of Appreciate Inquiry to Leadership, to go house wide Task force is now developing actions to further commit to a Just Culture framework for quality and patient safety, following a decision to adopt Just Culture by the PSC and be added to Leadership Standard Work Development of orientation materials to onboard new members of Safety Liaison and Patient Safety Committees with essential Patient Safety Certification materials Executive Leadership participation in the High Reliability Self- Assessment Tool (HRST) Pilot Program by the Joint Commission Center for Transforming Healthcare 24

25 Measuring Success 25