Building and Sustaining a Culture of Safety

Transcription

1 Building and Sustaining a Culture of Safety Ann Shimek, MSN, RN, CASC Senior Vice President, Clinical Operations United Surgical Partners International 028

2 Session Objectives q Describe organizational attributes that support a Culture of Safety q Identify actions that contribute to a Culture of Safety q State activities that promote best practice q Explain the relationship between Culture of Safety and Quality 029

3 USPI s Mission USPI s mission is to provide first-class surgical services for the local community in a safe, comfortable and welcoming environment; one in which we would be happy to treat our own families 030

4 Developing a Culture of Safety 031

5 What is a Culture of Safety? q In 1999 the Institute of Medicine came out with report called To Err is Human: Building a Safer Health Care System Reported nearly 98,000 deaths every year related to medical errors in hospitals q Instigated a shift: Risk Management à Performance Improvement 032

6 What is a Culture of Safety? q Healthcare industry was behind the times by creating a punitive response to error which minimizes reporting Change needed to occur to go from Risk Management to open discussions about incidents and errors q Expressed in the beliefs, attitudes and values of all employees in the pursuit of safety Encourages employees to report errors or good catches without fear of retribution 033

7 What is a Culture of Safety? q Acknowledges the certainty of error while proactively seeking potential threats Collaboration across all positions to identify solutions to potential vulnerabilities q Focuses on Good Catches blame processes, not people 034

8 What does a Culture of Safety look like? q Every employee is responsible for patient safety and can speak up at anytime to Stop the Line q Demonstrated willingness to direct resources (including time) to address safety concerns q Identifies errors and potential errors with attribution to process failures, not people q Lessons learned from analysis of errors are shared and communicated to staff as the best known methods to mitigate or prevent future errors 035

9 Right thing is done for the patient every time even when no one else is around Starts at the Top à Leaders completely engaged and willing to invest resources (including physicians!) Atmosphere where anyone can speak freely, without fear of retribution Hold staff managers accountable for process improvement Creating a Culture of Safety Atmosphere that values patient and employee safety everyone is responsible! Supports discussions about errors, lessons learned and how to improve processes Emphasize that errors are breakdowns in process, NOT people 036

10 Non-Punitive response to reporting q We work in a high stress environment and errors are inevitable, as we are all humans Types of Behaviors o Human Error (inadvertent) o Risky Behavior (risk-taker) o Reckless Behavior (with intentional risk-taking) 037

11 Non-Punitive response to reporting q Review the risk incident or event to determine where there was a breakdown in the process, then assess what tools or education the employee needs to avoid future incidents or events 038

12 Celebrate victories EVERYDAY!! Staff Involvement Review incidents COS Team w/ leader Improvement Suggestions Anonymous submissions to improve patient care and outcomes Speak Up! Encourage employees to take action against ALL unacceptable behavior Methods to Improve your Culture of Safety Group Review and Brainstorming Develop solutions and culture Engage physician champions who support the culture Cross- Department Teams Transparent and Collaborative Follow Through w/ Solutions Instills trust between staff & management team 039

13 Actions to take at Your Facility q Create and empower a Culture of Safety Team Culture of Safety Champion o Passionate about quality and strong desire to improve quality o Willing to learn as much as possible about improving the Culture of Safety o Shares passion and enthusiasm with fellow employees 040

14 Actions to take at Your Facility q Culture of Safety Team Cross-functional for all departments and nominate Team Leader who is passionate about patient safety Team members to report to MEC on quarterly basis 041

15 Actions to take at Your Facility q Good Catch is any risk incident or event that is caught prior to reaching the patient Educate all staff members on what a good catch is and how to identify process improvement areas prior to a risk or incident occurring Dedicate monthly staff meeting to Culture of Safety Acknowledge and reward staff members for reporting Good Catches Include Culture of Safety as an agenda item at medical staff meetings 042

16 Actions to take at Your Facility q Designate anonymous reporting process for safety issues and concerns Include concerns and suggestions Regularly review and discuss these with staff 043

17 Actions to take at Your Facility q Review Culture of Safety with Medical Director and report results with MEC/GB Incorporate Culture of Safety reporting to MEC/GB on ongoing basis to encourage physician involvement Encourage COS Team to report progress and when they are addressing concerns Encourage Medical Director to be present at COS Team meetings Develop Physician Champions 044

18 Implement Daily Huddle q Managers/representative from each department q Meet every day at same time (10-15 mins) q Discuss current day s schedule What s going well? What went wrong? q Discuss upcoming schedule Patient concerns from Pre-Admission RN Implants/Equipment needed for specific cases q Discuss staffing issues 045

19 Leadership Rounding q Leaders round every department at least daily q Employees see leadership is easily accessible q Ensure staffing is adequate and that they have tools and resources to be successful q Ask employees about safety concerns they may have q Assess how the employees are working together as a team q Holds employees accountable for doing the right thing every time 046

20 Stop the Line Policy q Ensure every employee knows they are supported through all of management to Stop the Line whenever they question patient safety q Establish direct phrase that all employees and physicians are educated about 047

21 Stop the Line Policy: Phrase Examples q q Stop the Line: I need clarification that this is the correct dosage. Repeat Stop the Line: I need clarification If the process is not immediately discontinued, then: o o Call manager and state, I have a Stop the Line event Manager drops everything to support employee 048

22 Staff Education q Include all employees, physicians, contract and agency personnel q Education upon orientation and annual competency training What adverse events are reported How to report these events The importance of reporting Good Catches q Obtain employee and physician attestation regarding understanding and adhering to policies 049

23 Communication is Vital q Ongoing discussions about adverse events and where the breakdown in process occurred q Performance Improvement from Lessons Learned q Recognition for Good Catches q Resolutions to safety concerns identified by staff q Patient comments and feedback from patient satisfaction reports q Recognize and commend staff for a job well done! 050

24 Most Important to Remember q Never become complacent q Review processes to eliminate frustrations by addressing concerns directly and openly q Speak up and do not accept unacceptable behavior q Encourage staff to monitor each other s behavior q Quality of Care and employee satisfaction will improve q Celebrate victories everyday! 051

25 Barriers to a strong Culture of Safety q Failure to Maintain Structure Leadership has to walk-the-walk, not talk-the-talk Team meetings get skipped Goals and Objectives are unclear q Departmental Silo s Present Departments fail to collaborate with other departments concerning risk incidents to ensure the event does not occur in the future q Lack of standardization of processes to prevent future incidents 052

26 Quality Outcomes q Patients receive high level of care q Teamwork across the facility improves q Communication flows between employees and physicians q Minimizes frustrations and improves workflow q Improved physician and patient satisfaction 053

27 Culture of Safety Implement these COS Improvements And see improvements in quality of care and employee satisfaction!! 054

28 References Kohn, Linda T., Janet Corrigan, and Molla S. Donaldson. To Err is Human: Building a Safer Health System. Institute of Medicine. Washington, D.C.: National Academy Press, Print. Miller, Vivian B.. Creating a Just Culture: A Nurse Leader's Guide. Massachussetts: HCPro, Inc., Print. 055

29 Thank you! Questions and Suggestions? Ann Shimek United Surgical Partners International N. Dallas Parkway, Suite 1600 Addison, TX Phone (972) Fax (972)