May, 2009
Disclosures Courtemanche & Associates Healthcare Synergists is an Approved Provider of continuing nursing education by the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. Continuing Education Contact Hours will be awarded upon full attendance of the program and receipt of the participant course evaluations. There are no influencing financial relationships or commercial support relating to this activity. Participation in an accredited activity does not imply endorsement by the provider or NCNA of any commercial products displayed in conjunction with this activity. Courtemanche & Associates does not discuss any products for use for a purpose other than that for which they were approved by the Food and Drug Association. www.courtemanche assocs.com 2
Session Objectives At the conclusion of this session, learner will be able to: Assist the organization in a focus on patientcentered care Identify strategies to promote safety in the organization www.courtemanche assocs.com 3
TJC Leadership Model TJC in its five column model places leadership as the foundation to an orderly structure supported by five pillars that lead to a successful organization with Care, Treatment and Services as the outcome. The five pillars leading to safe care, treatment and services are: Using Data Planning Communicating Changing Performance Staffing www.courtemanche assocs.com 4
Leadership Structure (The Joint Commission 2009 CAMH) Outcomes Process Structure www.courtemanche assocs.com 5
TJC Leadership Using Data LD.03.01.01 Leaders create and maintain a culture of safety and quality throughout the organization Regular evaluation of culture of safety using a reliable, valid tool Results used to prioritize and implement changes Code of conduct Team approach Education that focuses on safety and quality Create and implement a process to manage disruptive behavior Input from populations served www.courtemanche assocs.com 6
TJC Leadership Using Data LD.03.02.01 Data and information are used to understand variation in performance of processes supporting safety and quality Set expectations for the use of data Processes support systematic data and information use Data and information are used in decision making that supports safety and quality Evaluate effectiveness of data use Handout 1 www.courtemanche assocs.com 7
TJC Leadership Using Data Organization Dashboard Financial status Core Measures Staffing effectiveness Restraint Death Reporting Sentinel Events Medical Record Deficiency www.courtemanche assocs.com 8
TJC Leadership Using Data Results of Pro active risk assessments Safety and security EOC Tours Hazard vulnerability analysis Infection Prevention Medication management risk assessment www.courtemanche assocs.com 9
TJC Leadership Using Data Measure and Assess required activities TOPIC Critical Tests Restraint Deaths Rapid Response Outcomes High Risk Process (18 months) Adverse Privileging decisions Use of Blood and Blood Components Clinical Practice Patterns Sentinel Events TOPIC Deaths Associated with Infections Falls Patient Flow Medical Assessment and Treatment Use of Medications Operative and Invasive Procedures Autopsy Criteria Use Patient Safety Data www.courtemanche assocs.com 10
TJC Leadership Using Data Measure and Assess required activities TOPIC Patient Satisfaction Adverse Events During Sedation Resuscitation and Outcomes Behavior Management and Treatment OPO Conversion Rates Medical Record Delinquency TOPIC Discrepancies in Pre & Post Op Diagnosis Transfusion Reactions Serious ADRs Significant Med Errors Staffing Effectiveness Leadership Identified Projects www.courtemanche assocs.com 11
TJC Leadership Planning Leaders use planning to establish structures and processes that promote safety and quality Safety and quality are the focus of planning activities Planning supports a culture of safety and quality Planning is systematic Effectiveness of planning is evaluated Planning resources are provided by leaders www.courtemanche assocs.com 12
TJC Leadership Communication LD.03.04.01 Information on safety and quality is communicated to staff, LIPs, patients, families and external parties Communication processes foster safety and quality Support a culture of safety and quality Changes are effectively communicated Effectiveness of communication is evaluated www.courtemanche assocs.com 13
TJC Leadership Communication Safety in the Leadership Chapter LD.01.02.02 The governing body establishes a process for decision making when leadership fails LD.01.03.01 The governing body provides: Resources needed to maintain safe, quality care A system for resolving conflict LD.01.07.01 The governing body provides leaders with training and access to information www.courtemanche assocs.com 14
TJC Leadership Communication LD.02.01.01 The Governing body, medical staff leaders and senior managers create the mission, vision and values of the organization and use these to guide their actions. Handout 1 www.courtemanche assocs.com 15
TJC Leadership Communication LD.02.03.01 Leaders discuss issues that affect the hospital and the populations served in relation to: Performance improvement Safety and quality issues Proposed solutions and impact on resources Key quality measures and safety indicators Input from populations served LD.02.04.01 The organization manages conflict between leadership groups www.courtemanche assocs.com 16
TJC Leadership Changing Performance LD.03.05.01 Leaders implement changes in processes to improve performance Structures for managing change and performance improvements exist that promote patient safety and quality The approach to PI fosters safety and quality The effectiveness of the approach is evaluated www.courtemanche assocs.com 17
TJC Leadership Staffing/Culture LD.03.06.01 Those who work in the hospital are focused on improving safety and quality Design of work flow processes support focus Staffing number and mix support focus Competency of staff supports processes Medication administration Staff adapt to changes in the environment Change acceptance Effectiveness of staff ability to promote safety and quality is evaluated www.courtemanche assocs.com 18
Staffing and Safety LD.04.01.05 Qualified professionals or LIPs oversee departments and programs LD.04.01.11 Space and equipment are available as needed LD.04.03.09 Care provided through contractual arrangements is safe and effective www.courtemanche assocs.com 19
National Patient Safety Goals Adherence = Safe Culture Two Identifiers Communication Effectiveness Medication safety Infection Prevention Medication Reconciliation Fall Program Patient involvement in their care Suicide Risk Universal Protocol www.courtemanche assocs.com 20
Patient Partnering for The Diamond of Healthcare Administration Medical Staff Governance Patient www.courtemanche assocs.com 21
TJC Leadership and Culture Patient = 45 in the Leadership chapter Partner = 2 in entire manual (domestic abuse) www.courtemanche assocs.com 22
TJC Leadership and Culture National Patient Safety Goals Environment of Care Infection Control Life Safety Medication Management Rights and Ethics Transplant Services Waived Testing www.courtemanche assocs.com 23
Developing the Culture of Safety and Quality Mission, Vision and Values Leaders, Governance and Medical Staff Organizational Goals Staff awareness and buy-in Community/Patient input, awareness and buy-in www.courtemanche assocs.com 24
Developing the Culture of Safety and Quality Live the TJC Manual Road map to safety and quality Educate Educate Educate Include the patient as the fourth partner in the provision of safe quality patient care Focus all systems and processes on the patient safety and quality Hold staff, LIPs, accountable for safety and quality www.courtemanche assocs.com 25
Synergy Enhancement Supporting Leadership Through Cultural Change www.courtemanche assocs.com 26
Basic Premise Risks are often revealed at the operational level due to process gaps that are not supported by the structural foundation. www.courtemanche assocs.com 27
www.courtemanche assocs.com 28 Synergy Enhancement Model Leadership Financial Performance Decision Making Accreditation & Regulatory Success Patients Patient Outcomes Staff & Physician Satisfaction Patient Satisfaction Patient Safety
Using Synergy to Assess Risk Encourages organizations to look at their entity as a living system Engages a collaborative approach to organizational analysis Fosters collective generation of tactical solutions Launches innovative structures to reduce risk www.courtemanche assocs.com 29
Synergy Enhancement Synthesizing relationships to change and sustain positive performance through effective leadership Collaborative communication to reduce organizational risk through planning and ethical decision making Driving patient centered care through unique process improvements and measurement Engaging effective numbers of competent staff in driving excellence in patient care www.courtemanche assocs.com 30
How to Create & Sustain the Energy Leaders work through people Set goals, develop strategies & expectations Coach for achievement Facilitate development Provide feedback & reinforcement Achieve the goal www.courtemanche assocs.com 31
Resources The Joint Commission Comprehensive Manual for Hospital Accreditation http://edition.jcrinc.com A Quick Reference for Hospital Accreditation and Regulatory Requirements 2nd Edition www.courtemanche assocs.com www.courtemanche assocs.com 32
Info@courtemanche assocs.com (704) 573 4535