Take ACTION: A Collaborative Approach to Creating a Culture of Safety Heidi Boehm, MSN, RN-BC, Unit Educator Steven P. Kellar, BSN, RN, Unit Educator Joann L. Moore, RPh, Medication Safety Coordinator
Objectives Discuss ways to incorporate actual patient safety issues into an effective education program. Explore an interdisciplinary approach to establishing a culture of safety in a unique healthcare setting.
Background: Culture of Safety Survey 2010 Participants (972): Nursing 48.5%, 471 Laboratory 5.6%, 54 Pharmacy 9.2%, 89 Physicians 4.6%, 45 Other (open response) 23.0%, 224 Clerical/Medical Records 4.4%, 43 Admitting/Registration 4.1%, 40 Communications/Marketing/Finance 1.8%, 18
Employee Survey Example of Survey Questions: (Strongly agree/agree/disagree/strongly disagree) I feel patient safety is a priority When I am busy, I sometimes take shortcuts It is my responsibility to speak up if I observe a practice that compromises patient safety I feel comfortable holding others accountable I have reported an incident or error using the online reporting tool (YES/NO) If I am involved in an error, I feel my manager holds it against me I am aware of process improvements based on reports in my area. 4
Our Vision 5
Educational Components Survey results First, Do No Harm 1 video & discussion Event Reporting How? Why? When? Every employee s responsibility Accountability Communication Strategies ( S.T.A.T.E your path method) 2 Holding each other accountable Components of a Culture of Safety Hospital Policy 1 First Do No Harm. Harvard Medical Institute. www.p4ps.org 2 Patterson K, Grenny J, McMillan R, Switzler A. Crucial Conversations: Tools for talking when stakes are high. New York: McGraw-Hill; 2002. 6
Curriculum First, Do No Harm from Partnership for Patient Safety (p4ps) http://www.p4ps.net/previews/preview1_d rama.html http://www.p4ps.net/previews/preview3_d rama.html
Video Discussion Part 1: A Case Study of Systems Failures 1. What were some of the systems issues or failures that you identified while watching the video? 2. Do you think any of these could happen at our hospital? 3. List one problem you saw you could personally do something about? Part 2: Taking the Lead 1. What would you like to hear from the hospital if you were the patient/family member in this case? 2. How do you feel our hospital would react? Part 3: Healing Lives, Changing Cultures 1. What are the most common communication breakdowns? 2. What does it mean when we say safety is everyone s responsibility? 8
Take A.C.T.I.O.N. A ccountability C ommunication with respect T eamwork I mproving the system O penness/transparency N ear Miss/Event Reporting
Results of the Perfect Storm Hospital Acquired Infections Transfusion Reactions Pressure Ulcers Medication Errors Misidentified specimen or patient
Employee Reaction I expected a redundant offering the presentation was a surprise. Great video, great content, excellent presentation. It has shown me the importance of creating just a few minutes from my busy shift to make everything I do right and do everything correctly It s exciting to work in a place where upper level administrators support a culture of safety Great videos I have never seen a room so quiet and engaged! Thank you! We need to hear this message. I was not aware of the absolute importance of providing patients a safe environment. This really hit home. Really appreciate the patient-centered approach and how each team member is equally valued not just the ones at the top. I am leaving with a renewed desire to be more accountable and be more aware of the safety and care that I am responsible to give to the patients 13
John Nance, JD Why Hospitals Should Fly "As individuals we can never achieve perfection. But, as teams we can catch each others errors and keep them from ever reaching our patients.
Culture of Safety training Incorporated into New Employee Orientation 3 hour interactive class Required for all employees with patient contact New Medical Resident Training Condensed version CMO is one of the presenters 15
Opportunities to Build Patient safety Communication Peer accountability Respect
Content Modification Revised goals Empower staff to speak up when safety issues arise Review the principles of a culture of safety within the context of the operative setting Provide a forum for staff to openly and safely discuss patient safety concerns
Content Modification 4 Part Series (mandatory) Problem identification and reporting Communication, Accountability, Teamwork Mindfulness and Employee Resources Physician communication Three sessions provided by RN and Pharmacist Final session provided by the Chief Medical Officer
Session 1 Watched Part 1 of First, Do No Harm Inspire and empower participants to Take ACTION to promote safe patient care. Identify systems issues and opportunities to improve patient safety. Define the process for reporting near misses and incidents. Provide an example of how reported information is used to improve patient safety.
Empowering the Audience Created a safe environment for open discussion Video promoted discussion and audience participation Leadership presence encouraged communication and teamwork
Shared Our Stories Discussed examples of system changes made as a result of reported events or near misses Positive bone cultures are treated as a Critical Value X-ray field was broadened if counts were off X-ray results treated as a critical value requiring MD to MD communication
Session 2 Viewed Part 2 of First, Do No Harm. Describe how respectful communication within a culture of accountability can impact patient safety in a diverse healthcare culture. Discussed communication strategies to professionally handle inappropriate staff behavior.
Accountability What does that mean to me?
A Short Story: An Environment without Accountability There was an important job to be done and Everybody was asked to do it. Everybody was sure Somebody would do it. Anybody could have done it, but Nobody did it. Somebody got angry about that because it was Everybody's job. Everybody thought Anybody could do it, but Nobody realized that Everybody wouldn't do it. It ended that Everybody blamed Somebody when Nobody did what Anybody could have done. Author Unknown
To Establish Accountability Expectations are clear to employees They know what they need to do Feedback is provided regarding performance Expectations are perceived as achievable Work is consistent with stated priorities Resources are available to meet expectations
Accountability at the Core Safety Requirements A Culture of Safety Culture; Attitudes & Behaviors
Errors are Inevitable EVERY voluntary human action is subject to error The key is ELIMINATING factors that contribute to human error Watch out for each other and SPEAK UP when you see hazardous behavior
Communication Strategy S.T.A.T.E. Your Path S hare your facts T ell your story A sk for other s paths T alk tentatively E ncourage testing
Our lives begin to end the day we become silent about the things that matter. Martin Luther King, Jr
Session 3 Watch Part 3 and Epilogue of First, Do No Harm. Discuss mindfulness in professional practice. Describe the relationship between mindfulness and patient safety. Reviewed strategies for having difficult conversations. Provided resources available for staff.
Mindfulness Scenario The scrub nurse notices that another staff member is texting during the case and is needed to place an item on the sterile field. The scrub nurse breaks scrub after the second request to get the item.
Reflection Questions Did the scrub nurse make the correct decision in breaking scrub to obtain the requested item? Should the scrub nurse communicate her concerns to the circulating nurse at the end of the case? Should the scenario be reported?
Mindfulness Scenario The surgeon requests the circulating RN to open up Facebook during a surgical procedure because he/she wants to show a picture to those individuals in the operating room suite. The circulating RN does not feel comfortable doing this because it is a distraction from taking care of the patient. She is also not comfortable communicating this to the surgeon.
Reflection Questions What should the circulating RN do? Should leadership intervene? Should this scenario be reported?
Class Results Received 62 class evaluation forms 35 RNs 20 Surgical Techs 3 S3 s 4 Leadership/Management 1 Other Experience in the OR ranged from less than 1 year to greater than 21 years 23 staff < 1 year 20 staff 2-5 years 8 staff 6-10 years 3 staff 10-15 years 2 staff 15-20 years 4 staff > 21 years Forwarded the evaluations to the CMO and area leadership prior to Session 4
Evaluation of Course Objectives PLEASE RATE THE FOLLOWING BY PLACING A CHECK IN THE APPROPRIATE BOX: Strongly Agree Agree Somewhat Agree Disagree Strongly Disagree As a result of this series, I can define the process for reporting Near Misses and incidents and can provide an example of how that information is used to improve patient safety. 4.37 25 35 2 0 0 I can describe how respectful communication within a culture of Accountability can impact patient safety in a diverse healthcare culture. 4.42 I can describe the relationship between Mindfulness and patient safety. 4.47 Using the communication strategies described in this series, I feel more comfortable holding a coworker accountable if I witness a patient safety issue. 4.03 I am aware of process changes that occur in my area as a result of reporting. 3.91 27 34 1 0 0 30 31 1 0 0 18 30 12 1 1 18 24 17 3 0
Evaluation: Sharing Good Catches How can we improve communication about changes made because of PSN reports? Email out any instance of a good catch so that others can be mindful. Also same for changes because of PSN. Post on bulletin Board, emails like friendly Friday reminders Weekly emails of anonymous instances as a review of how to handle situations, right/wrong actions, standards in the OR. Discuss PSN anonymously together and openly. Group awareness and discussion. Combination of staff meetings and email and possibly a bulletin board for communication.
Evaluation: Practice Change What is one thing you will do differently as a result of this series? Be a little more confident in talking with a peer about a safety issue. Fill out more PSN s Communicate with co-workers and resolve the issue instead of complaining and doing nothing about it. Be more aware of what is going on around me that concerns the patient directly and indirectly so I can catch anything that may contribute to undesirable results. Be more assertive and don t back down if I feel strongly about something I believe is wrong. Even in stressful situations, take a step back, look at the situation, ask for help if needed or if necessary ask excess people in room to leave.
Evaluation: Reporting Practices As a result of this series, have you reported an issue using PSN or directly to a manager? 14 YES 47 No 2 unanswered If NO, why not? 32 Have witnessed no issues 7 Don t think it will make a difference 2 Takes too much time 1 Forgot to submit 1 Don t want to get someone in trouble 1 Afraid of retaliation Other reasons why not: I have prior to this class I report on PSNs but I'm discouraged to do so because it seems as though nothing changes as a result Just started last week Others have reported it
Evaluation: Ongoing Concerns What are ongoing concerns in your area that you would like to see addressed? Everyone focusing on patient care, safety. Improved communication about practice changes. Changing cultures of the past make a difference by example. Better communication between OR staff, surgeon staff and anesthesia staff; Effective communication among healthcare members Computer, cell phone use during surgery, lack of accountability, letting others clean up after you rather than do it yourself Waste- so much waste. Pathology specimens and the lack of an effective delivery system. Assignment communication, changes, locating staff for shift change, informing the OR room of REO after ; overall teamwork with free staff, put supplies away and check RN in rooms to help and assist.
Session 4 OR Management team dismissed to allow staff opportunity to discuss issues openly Physician Facilitator representation from Human Resources Physician behavior vs. staff behavior Culture of Safety
Making it Happen Staff meetings Webinars
Future Plans This approach can be used when addressing culture of safety issues in specialized units Scenarios can be modified to reflect current opportunities on the unit
Any Questions or Concerns?
References Assessing Nursing Quality In America s Hospitals, 2006 Advisory Board Company Berwick, D (2005). My right knee. Ann Intern Med. 142: 121 125. McCauley, K and Irwin, R (2006). Changing the work environment in intensive care units to achieve patient-focused care: the time has come. AJCC 15(6) 541 549.