PATIENT AND EMPLOYEE SAFETY REPORTING SYSTEM PROMOTING A FAIR AND JUST SAFETY CULTURE

Transcription

1 PATIENT AND EMPLOYEE SAFETY REPORTING SYSTEM PROMOTING A FAIR AND JUST SAFETY CULTURE Project Lead: Walter Davis Improvement Coach: Lisa Duda Team Members: James Stewart, Sharon Cary

2 WHY WE DID IT The previous process that was in place to submit a safety report was very difficult to use and very time consuming for staff, resulting in low submission rates and severely delayed reports All Employee Survey Results showed a need for improvement with a Fair and Just Safety Culture Current State GAP Analysis Leadership felt low reporting of incidents and near misses indicated a new system was needed to foster a culture of safety Employee and patient safety were historically separated. Staff felt more emphasis was placed on the safety of the Veteran and not employees Staff were not clear on where to find the reporting tools. Numerous versions existed and there was no central respository There was a perception of punitive actions taken on staff who reported incidents Staff felt that actions taken weren t shared and therefore perceived that there was a lack of intervention

3 THE PROJECT HAD FIVE MAIN GOALS 1. Create a Safety Reporting System that is easy to locate and easy to use 2. Create a system that can be anonymous and foster a fair and just safety culture 3. Create a system that combines Patient Safety and Employee Safety 4. Create a system where the action taken is communicated back to the person reporting 5. Create a system that will increase the number of Safety Incident Reports submitted by staff

4 HOW WE DID IT Using a less-is-more approach, and multiple PDSA cycles, a new process was developed using InfoPath Designer, graphics development tools (GIMP) and workflow management software (SharePoint Designer.) Flow mapping, the 5 why s and Gap Analysis were the main tools used in this process The project measures of success were the total number of submissions, feedback delivered, and patient outcomes (e.gfalls).

5 3 STEP PROCESS STEP 1 CLICK ON THE SAFETY REPORTING ICON LOCATED NEAR THE TOP OF THE MANCHESTER VA MEDICAL CENTER HOMEPAGE

6 Step 2-Complete each field on the Safety Reporting form. Step 3 -Click the submit icon. You're Done J

7 A THANK YOU MESSAGE WILL APPEAR AFTER YOU SUCCESSFULLY SUBMIT YOUR SAFETY REPORT

8 WHAT IS RECEIVED Feedback box (Action Taken) is only visible to the Safety Manager Update will auto generate an response to the submitter only if they included contact information

9 ACTION TAKEN RESPONSE

10 RESULTS Launched on 3/18/15 As of October 23rd 2015, there are 253 submitted safety reports. Compared to FY14, there is a 116% increase in submissions Average time from incident to report = 12 minutes 93% of the staff included there name (Fair and Just Safety Culture) Saw a 73% decrease in inpatient falls since inception Inpatient falls rate of 2.8 (bed days of care included) sustained over 6 months since inception Joint Commission recognized this as a Best Practice Gold standard Patient Safety Cornerstone Award met for first time

11 Incident Type Employee Incident/Fall 3 Employee Unsafe/Unhealthy Work Conditions 8 Inpatient Pressure Ulcer 0 Missing at risk patient 5 Other harm to patient 21 Other safety incident 95 Near safety miss 22 Medication 46 Fall

12 Incident Location Inside 13% Outside 87%

13 Inside by week Incidents by hour Fall Incidents Time of Day

14 LESSONS LEARNED External CBOC locations were not added until after the form launched There is a correlation between the submission icon location on the Manchester Homepage and how many reports are submitted

15 Success of the Safety Reporting System Led to creating an easy to use reporting icon that includes 6 reporting systems.

16 WHAT S NEXT Continue to track and trend data Make improvements as needed