Revolutionizing Patient Safety through Organizational Certification Anne Arundel Medical Center 1 Anne Arundel Medical Center 1
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 3 Certification Requirements 4 2
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. 5 Certification Process Flow Leadership Baseline Data Select Team Establish Goals Education 6 3
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 7 Base Line Data 8 4
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 9 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 10 5
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 11 Revolutionizing Patient Safety Creating Sustainability Facilitating Discovery Fostering Accountability Revolutionizing Patient Safety Preventing Errors Escalating Performance Improvement Accelerating Change Exploring Solutions 12 6
Education 13 Outcomes Comparison Patient Safety Pre Study vs. Post Study YTD 80.00% 60.00% 40.00% 20.00% 0.00% 20.00% 40.00% Level I Level II Level III Total # Events Reported Unsafe Conditions (included in Total Events) Near Miss Reports (included in Total Events) 60.00% 14 7
Outcomes Continued Positive Outcomes 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% 15 AAMC 2017 Safety Culture Survey Results Composites AAMC 2011 R = 1151 AAMC 2013 R = 823 AAMC 2014 R = 1649 AAMC 2017 R = 1910 AHRQ Bed Size 2016 Teamwork within units 77% 80% 80% 82% 79% Leadership expectations & actions promoting patient safety 70% 77% 73% 76% 76% Management support for patient safety 70% 76% 72% 80% 69% Organizational learning continuous improvement 70% 75% 73% 77% 70% Overall perception of patient safety 60% 68% 64% 81% 61% Feedback & communication about errors 69% 71% 71% 77% 66% Communication openness 65% 66% 63% 73% 61% Frequency of events reported 61% 68% 62% 72% 64% Teamwork across units 53% 60% 60% 70% 57% Staffing 46% 57% 53% 64% 48% Handoffs & transitions 37% 44% 43% 77% 43% Non punitive response to error 42% 45% 41% 72% 41% Recommend AAMC 96% 97% 97% 96% N/A 8
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 17 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 18 9
Unit Safety Liaisons Roles 19 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 20 10
Measuring Success 21 11