Achieving Results in Safety - FHAAchieving Results in ... Annual Safety Survey Results • Continued...
Transcript of Achieving Results in Safety - FHAAchieving Results in ... Annual Safety Survey Results • Continued...
Achieving Results in Safety
©Copyright Lee Memorial Health System • All rights reserved
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Caring People, Caring for People
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Mission: To meet the health needs and improve the health status of the people of SW Florida. Vision: To be the best patient-centered health system in Florida. Values: Safety, Quality, Service, Compassion and Teamwork.
MAKE HARM VISIBLE
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Changing Behaviors
Set Expectations
Educate & Build Skill
Reinforce & Build
Accountability
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Serious Safety Event •Reaches the patient •Results in moderate to severe harm or death Cause Analysis: RCA Required
Precursor Safety Event •Reaches the patient •Results in minimal harm or no detectable harm Cause Analysis: ACA, possible RCA
Good Catch Safety Event •Does not reach the patient – error is caught by a last strong detection barrier designed to prevent event Cause Analysis: report, no formal review
Precursor Safety Events
Serious Safety Events
Good Catch Near Miss
Safety Event
Monthly Patient Safety Progress Report – New Feature - Safety Coach Corner
Reinforce & Build Accountability
Safety coaches are individuals who have received extra training to provide “just-in-time” peer checking and peer coaching for safety in their department.
Coaches use both formal (documented behavioral observations) and informal (“on the spot”) techniques.
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Slide 7
Influencing Behaviors at the Sharp End
Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994)
Design of Culture
Outcomes
Behaviors of Individuals & Groups
Design of Structure
Design of Technology & Environment
Design of Work
Processes
Design of Policy & Protocol
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
“You have to manage a system. The system doesn't manage itself.”
W. Edwards Deming
"A bad system will DEFEAT a good person every time.“
W. Edwards Deming
The Secret Sauce: Safety Coaches • “Sharp end” is where we have our greatest
opportunity to harm or to heal. • Safety coaches complement and partner with
leaders to help to establish peer accountability. • Safety coaches model a cooperative culture. • Safety Coach program goals:
– Reduce behaviors and practices that could result in harm
– Improve/promote active communication between disciplines
– Identify problems, seek resolution – Share lessons learned
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Reinforce & Build Accountability: Report All Safety Events & Problems
• Encourage reporting of all “near-miss” events. • Remove the “shame” around reporting mistakes. • Re-educate staff on use of Incident Reporting System. • Explore causes to prevent future errors. • Celebrate staff who “raise the safety question”
including physically going to that work unit to personally recognize individual staff members.
• Promote monthly Patient Safety Progress Report.
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How Do We Monitor Safety Journey Effectiveness? Annual Safety Survey Results
• Continued real improvement over past 2 years. • 20/43 questions showed statistically significant
improvement. • Positive increase in 11 out of 12 safety composites. • 5 composites showed statistically significant
improvement: 1. Handoffs and Transitions 2. Teamwork ACROSS units 3. Feedback and Communication about Errors 4. Non-punitive Response to Errors 5. Overall Perceptions of Patient Safety
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What We’ve Learned: • Broad diversity of “spread” team improved the quality of our
output. • Strongly supported Unit-Based Safety Coaches are the “secret
sauce”. • Physician involvement is the “super secret sauce” • Developing new HABITS requires daily surveillance. • Best-Practices are out there– look for them—celebrate them. • Staff responds to “patient safety” exponentially better than
“quality of care”. • It’s critically important to “hang tight and keep paddling” through
the “transparency” white-water debate. • Using creativity, committed people can accomplish amazing
things. 11
“Caring People, Caring For People.”
10/31/2014 12
It’s not our slogan. It’s our promise.
Lee Memorial Safety Culture Roadmap
Safety Culture Effectiveness = Plan Effectiveness x Implementation Effectiveness
Task Implementation Engraining & Sustaining
Diagnostic Assessment
Safety Culture Survey
Common Cause Analysis
of Past Events
Diagnostic Interviews
Safety Behaviors for Error Prevention
Education & Training of Leaders, Staff, & Physicians
Red Rules for Safety
Leadership Method for Performance
Excellence
Cause Analysis Program Improvement
Operational Leaders Establish
Safety as Core Value
Leadership Method Application
Behavior Observation &
Coaching
Safety Success Stories
Align Existing Work Processes
Integration with Process
Improvement Methods
Integration with Cause Analysis & Lessons Learned
Board & Senior Leaders Establish
Safety as Core Value
Executive Sponsor
Medical Staff Sponsor
Integration with Vision, Mission, &
Values
Integration with Strategic & Annual
Goals
Integration with Hiring Processes
Integration with Orientation &
Training Processes
Intervention Implementation
Accountability Systems
Process Alignment
Culture Change Preparation
Hardwiring the Change
Safety Culture Lead & Team
Vertical Communication Infrastructure
Alignment with Key Stakeholders &
Programs Safety Coaches Other Diagnostic-
Based Interventions
Results & Interventions Recommendations
Report
Document & Data Review
Integration with Performance Review
Process
Safety Metrics & Control Loops
Complete
In Progress
© 2007 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Next Focus
As of 24 January 2011
Three Drivers of Accountability
Individual • Integrate into hiring criteria
Peers • Safety Success Stories • Safety Coaches • Peer checking & coaching • Integrate into preceptor and
mentoring programs
Leaders • Integrate into vision and mission
• Align goals, metrics, and incentives
• Rounding to observe and coach • Find and fix system problems
Optimal Accountability
Why a Safety Coach Program?
• People at the sharp end have our greatest opportunity to harm or heal
• Safety coaches complement and partner with leaders to help to establish peer accountability
• Safety coaches model a cooperative culture • Goals of a safety coach program:
– Reduce behaviors and practices that could result in harm – Improve/promote active communication between disciplines – Identify problems, seek resolution – Share lessons learned
Safety Coach Roles: • a communicator, ensuring that your co-workers understand
our behavior expectations for preventing infections. • an educator, ensuring that your co-workers have a practical
knowledge of how to practice these behaviors. • a role model, demonstrating and leading the way in our
culture change. • an observer, positively reinforcing, by real time interaction
with co-workers, the expectations for preventing infections • a storyteller, by seeking out every opportunity to share our
patient safety stories with your team members. • a partner with your manager in helping us reach our goal of
no hospital acquired infections for our patients
Roles & Responsibilities
• Primary role is habit formation: • Teach safety behaviors at “bedside” • Provide feedback & reinforcement • May document some observations using a tool
• Secondary roles: • Environment of care monitoring • National Patient Safety Goal monitoring • Communication channel to leaders2staff • Communication channel staff2leaders • Apparent Cause Analysis
Lessons Learned from Other Programs • Leadership commitment is critical to oversee/ support program
and to enable coaches to take time from their normal duties to perform coaching activities.
• Safety coaches need a firm grasp on the tools/techniques used with the safety behaviors (and how/when they are used in their departments)
• Provide continuing education at the monthly meetings • Establish routine check-in for coaches • Ensure meetings are efficient:
– Educational presentations – Share lessons learned and best practices – Role play coaching and feedback – Encourage, reward, recognize, and motivate
Blue Print for Safety Coaches • Each facility should plan their program based on their needs
– Base coach assignments on one (1) per Unit – Share coaches across patient care areas – Focus resources on areas with greatest identified need
• Training & education: – Initial training for safety coaches – Monthly meetings 1hr per month (evidence indicates 15%)
• Plan monthly targets, program focus, & coaching methods • Receive ongoing education and coaching materials
• Duties include: approx. 4 hrs per month per unit per shift
– Rounding (behavior observation) – Environment of care monitoring – Facilitate habit formation – Feedback & reinforcement – Collect concerns from staff
Selecting for Fit
Basic Qualities: • Acts like an Influencer • Belief in Founding Principles and Core Values • Passion for the patient, patient safety, and quality • Has credibility with leaders and staff • Life-long learner
Practical considerations • 60/40 split between clinicians and support • Flexibility in work days (difficult for nurses) • Diversity
Influencer
Make the Undesirable Desirable
Harness Peer Pressure
Design Rewards and
Demand Accountability
Surpass Your Limits
Find Strength In Numbers
Change the Environment
PERSONAL
SOCIAL
STRUCTURAL
MOTIVATION ABILITY Vital Behaviors Use positive deviance to search for vital behaviors. Apply influence so the behaviors become habits
It is not enough to do your best; you must know what to do, and THEN do your best.
- W. Edwards Deming
Safety Coach Curriculum • Fundamentals (safety, systems thinking, human error)
• Behavior super-users (error prevention techniques)
• Feedback & reinforcement skills (5:1 feedback)
• Observation skills (observable standards, observation tool)
Continuing education • Current events in patient safety & quality • Lessons-learned from cases (external + Lee) • Patient safety results and areas of emphasis Plan a four (4) hour orientation for new coaches
Provides uniform schedule Forces leaders to take on tough
passages – not just the easy messages Aids in sharing resources and insights
while preparing to influence
Cycle Safety Coach Topic 1 Speak Up for Safety Using CUS 2 Reporting of Safety Events, Errors, & Unsafe Conditions 3 Safety Practice: Time outs 4 Cross Monitoring 5 Red Rule: Patient Identification
6 Communicating Clearly by Asking & Encouraging Clarify Questions
7 Hand Hygiene for HAI Prevention 8 Staffing Shortages: Crisis or Chronic?
Safety Behavior Habit Scale
1 2 3 4 5 6 7 8 9 10
Our Safety Behaviors are just how we do things around here! We do it when we
know someone’s watching
Safety Behaviors? What are they?
No one else is doing it, so I feel
out of place
I do it most of the time, but when I get
busy, I forget
What Makes a Great Story Great??? Everyday excellence – not just the great saves Language we can all understand Name names to recognize Link to a behavior expectation
More Clever: Use the number of published safety success stories as
a real-time metric.
Environmental Services Associate Speaks Up For Safety While going about her daily duties of cleaning a patient room, Janice, an Environmental Services Associate observed a physician and nurse enter the room and prepare to perform a minor procedure. She knew the hospital’s rule about site verification before a procedure, yet noticed that the team was about to proceed without the verification. Janice politely questioned the physician and nurse, “Shouldn’t we verify the site before the procedure?” The physician and nurse thanked the Associate and verified the site. By being aware of what was going on around her and being willing to speak up, Janice helped ensure that the procedure was performed on the correct site.
Share Safety Success Stories
Consensus Scale (encourages all to express their thought)
3 4 5 2 1
Thinking and feeling reasons in favor of the
proposal
Thinking and feeling reasons against the
proposal
Consensus is achieved when the group is greater than 4 and no one is a 1.
Objectives of Observation & Coaching
Reinforce the use of our Safety Behaviors – convert them to our work habits 1
Reveal symptoms of problems before they become events that result in harm 2
Provide data from observations so we can track how we’re doing 3
How We Want to Provide Feedback Be Proactive... Stop an unsafe act or behavior that could lead to harm.
Be Discrete... Provide feedback in a private manner – giving feedback in front of patients and
peers only leads to embarrassment and is not effective. Be Helpful... The goal of behavior observation is to improve individual and team performance
by recognizing good behaviors and correcting unsafe, unproductive behaviors – not to catch someone doing something wrong.
Good Habits for Coaching 5:1 feedback • Based on observation and fact • No sandwich approach • Immediate feedback, yet pick
appropriate time and location • “Lightest touch” possible to get the
desired results • Ask for commitment to change
behavior
Delivering the Message Invitation: “May I point something out…”
Observation: “I could tell that you were struggling in your phone conversation with Dr. Smith about your patient.”
Expectation: “Using SBAR is a Safety Behavior expectation at Memorial Hermann. It helps us frame the conversation when communicating about a situation that requires a decision or action.”
Facilitation: “Let’s do one together. Why don’t we talk through your patient case using SBAR.”
Commitment: “Next time you communicate with someone about a decision that has to be made, will you use SBAR?”
The Question Behind the Question
How are you going to participate in improving the situation?
How can you be a good Peer Coach
for your team member?
How Would You Respond?
“It takes too much time.”
“I’ve never had a problem before.”
“I use the Safety Behaviors when it’s important.”
“No one else is doing it.”
“Who are you to tell me what to do?”
Self-Checking Using STAR
Expectation
• We focus our attention to think before we act when performing familiar, routine acts.
• We use STAR ALWAYS before performing an irrevocable act that could impact safety.
Observable Standards
(What You See)
• They pause, to put head before hands. • They don’t engage in unrelated conversation with others. • When interrupted, they resist (“please wait – I’m doing something
important”). • They use their finger to point to important information that needs
to be checked or should match.
Coaching Tips (What You Say)
• Make it a habit • Visualize the act • Self talk
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Let’s Practice!
• Read the safety situation aloud. • Then C.U.S. with a partner to make the situation safe.
CUS When It’s Critical!
Questioning Attitude
Expectation • We apply a strong Questioning Attitude when considering
direction we are given, information that we receive, and making choices as to how to proceed.
Observable Standards
(What You See)
• They pause to reflect before acting. • They ask Clarifying Questions. • They consider both the source (Qualification) and the information
(Validation).
Coaching Tips (What You Say)
• Good care providers ask when unsure. • Good care providers also ask just to be sure. • Questioning Attitude is not just asking questions, it is questioning
the answers. • Curse of Knowledge – common sense is not always that
common, and the obvious is not always so obvious
Implement Red Rules • An act that has the highest level of
risk or consequence to patient or employee safety if not performed exactly each and every time.
• “Red" designates the rule as a safety absolute with the highest priority for exact compliance.
• if conditions cannot be met.
PATIENT SAFETY WORK PRODUCT—Created as part of LPSES - the LMHS Patient Safety Evaluation System 36
(Insert “It takes Two” Video)
Red Rules
Expectation • We apply a strong, intelligent compliance when performing patient
care governed by Red Rules. If we cannot comply, we stop patient care.
Observable Standards
(What You See)
• Patient Identification: have answer in hand, touch ID bands, and inquire patient name.
• Time Out: all participate; led by physician; verify patient name, procedure, and location; verbal concurrence by all.
• Checks: at bedside, independent, full scope.
Coaching Tips (What You Say)
• Inquire name, “could you tell me your name again, please, for the purpose of identification.”
• Verbal concurrence, “I concur (or yes)” • Location is laterality or level of spine or multiple structures • Say “correct” not “right” (right goes with left) • Independent means that the checker has the same scope as the
doer.
Clear Communication Bundle
Expectation • The Sender and Receiver use 3-Way Repeat Backs, 3-Way
Read Backs, Clarifying Questions, and Phonetic & Numeric Clarifications when communicating.
Observable Standards
(What You See)
• They do a 3-Way Repeat Backs when exchanging information that could affect safety and quality.
• They do a 3-Way Read Backs when communicating telephone orders and critical values.
• They ask Clarifying Questions when critical information is exchanged and when information is high risk, incomplete, incorrect, or ambiguous.
• They use Phonetic and Numeric Clarifications for sound alike letters, words, and numbers.
Coaching Tips (What You Say)
• Use our safety phrases: –“Let me repeat that back.” –“I’d like to ask a clarifying question.”
“The world is not a dangerous place because of those who do harm, but because of those who look on and do nothing.”
Albert Einstein
LMHS Safety Coaches