Culture Change: The Patient as the Priority Rush Memorial Hospitals Patient Safety Journey Linda...
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Transcript of Culture Change: The Patient as the Priority Rush Memorial Hospitals Patient Safety Journey Linda...
Culture Change:The Patient as the Priority
Rush Memorial Hospital’s Patient Safety Journey
Linda Noble, CPUR, CRM and Deborah Hummel, RN, CNA, BC
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Rush Memorial Hospital
Critical Access Hospital status in August 2000
250 full-time, part-time and PRN team members
25-bed Medical/Surgical Department houses all acute care, swingbed, and observation patients
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The Patient Safety Culture
SurveyProcess
And so it begins . . .
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Hospital Survey on Patient Safety Culture – Agency for Healthcare Research and Quality (AHRQ)
Rush Memorial partnered with Health Care Excel to administer survey in April 2006
Participants evaluated statements on a 5-point Likert Scale
This was considered baseline survey and will resurvey the same population in 2008
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110 employees directly involved in patient care processes were invited to participate in the survey process
81% response rate
No incentive was offered other than the opportunity to identify issues that affect the patients and their own work environment
Patient Care Departments ONLY
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Who Participated?
Medical/Surgical Home Health Emergency Surgical Services Cardiology Services Oncology/Hematology Pharmacy
Rehabilitation Therapy
Respiratory Therapy Laboratory Imaging Primary Care
Physician Practices
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Survey Results and Key Findings
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Solid Foundation
Over 90% of the respondents strongly agreed with the statement
“Hospital management provides a work climate that
promotes patient safety”
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Over 90% of the respondents strongly agreed with the statement
“When a lot of work needs to be done quickly, we work
together as a team to get the work done”
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However . . .
87% agreed “staff will freely speak up if they see something that may negatively affect
patient care”
32% agreed “staff worry mistakes they make are kept in their employee files”
27% agreed “problems often occur in the exchange of information across hospital
departments”
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Opportunities Identified
Non-punitive work environment Frequency of patient safety event reporting Hospital handoffs and transitions Encouraging employees to speak up Improving teamwork across the hospital
In other words...addressing the CULTURE!
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“The Plan”
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Crafting the Document
All patient care department managers attended planning sessions to develop a simple 2-page document to be used as a guideline
Managers were charged with the responsibility to discuss the plan and reinforce with teams
Administration supported the efforts of the team and allocated resources necessary to implement
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Part 1
Continue to develop a work environment that is non-punitive in nature Survey results revealed employee concerns about
the extent in which our work environment is non-punitive
Corporate Compliance Officer Linda Noble and Human Resource Director Pam Rennekamp distributed a hospital-wide policy which includes the elements of a non-punitive work environment
Department Managers are coached to reinforce the non-punitive work environment elements in their departments in partnership with their employees
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Part 2
Increase the frequency of patient safety event reporting to include both actual “misses” and “near misses” Survey results indicated “misses” and “near misses”
are occurring, but were not all reported within the established system
A review of the current event reporting system and associated documentation for possible improvements was completed – a Risk Variance Reporting Tool was created to capture “near misses”
All employees receive training and education regarding proper use of the event reporting system
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Part 3
Improve hospital handoffs and transitions and associated communication
Patient care department managers participated in a 3-part seminar on handoff communication utilizing the SBAR system
Managers coached employees on appropriate handoff and transition communication expectations
A universal documentation form for the “top 3” invasive procedures performed in all clinical care areas was put in place (urinary catheterizations, peripheral IV initiation and blood collection/IV access via ports)
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Part 4
Encourage employees to speak up and develop ways managers can encourage and support their employees when questions arise Survey results indicated department managers
support patient safety efforts and the work of their employees – however, some employees don’t necessarily feel comfortable questioning decisions made by those in authority
Department managers encourage employees to speak up and question during informal (day-to-day interactions) and formal (staff meetings) settings within their departments
Department Managers develop department-specific strategies in partnership with employees to address this issue
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Part 5
Improve teamwork across departments The CQI Team which included managers of the
departments with our largest patient volumes was the “pilot group” for teamwork initiatives
The Human Resource Department has the responsibility for the creation and implementation of a hospital-wide teamwork program – R.U.S.H. – which stands for “Respect and Unity Start Here”
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Meanwhile . . .
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The Patient as the Priority
Key patient care managerswere challenged to put in writing
how their departmentdemonstrates their patients and
their patients’ safety are the#1 priority
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Other Initiatives
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Banding Together for Patient Safety
This patient safety program uses different colored bands worn by the patient to communicate a patient’s special needs to our multidisciplinary hospital team members
DNR (BLUE) - Patient has a documented DNR order while a patient of Medical/Surgical Department
Latex Allergy (PINK) - patient has a suspected or known latex allergy or sensitivity
Fall Risk (YELLOW) - patient has been identified as having high potential for falls
“Go” for Surgery (GREEN) - will be used in surgical services department only
Allergy (RED) - patient allergies will be written directly on the band Patient Identification (WHITE or CLEAR)
paper (outpatients) plastic (MS and surgery patients)
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Medication Administration Error Reporting Survey1. In the last 6 months, have you witnessed an error in the administration of a medication, adult
immunization, contrast and other diagnostic substance to a patient in your department?_____ Yes _____ No
An error would include any of the following: the wrong medication, contrast, serum or substance was given the wrong dose was given the wrong route was used when given it was given to the wrong patient it was given at the wrong time the substance was “missed” and was not given the substance was given and there was no order for it to be given
2. If you answered “Yes” to question #1, please circle the choice that applies:The administration error(s) I have witnessed in my department within the last 6 months have been reported on Incident Reports ___ % of the time.
a. 90-100% b. 80-89% c. 70-79% d. 60-69% e. 50-59% f. < 50%3. In the last 6 months, have you witnessed any “near misses” in your department where an error
could have occurred, but action was taken before the error reached the patient?_____ Yes _____ No
4. If you answered “Yes” to question #3, please answer the following: Did you ever discuss how the “near miss” could be avoided in the future with your co-workers?
_____ Yes _____ NoDid you ever discuss how the “near miss” could be avoided in the future with your manager?
_____ Yes _____ NoHave changes been made in your department to help avoid similar “near misses” in the future?
_____ Yes _____ No5. The following is a potential/actual patient safety problem in my department and should be
addressed (use other side if necessary):
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R.U.S.H. Initiative
A position was created in Human Resource Department to assume responsibilities for sustaining the initiative – also coordinates hospital volunteer efforts, AHA Programs and performs other HR duties
Begins with mandatory 1.5 hour introductory session for all employees
Employee Entrance being renovated to include R.U.S.H. elements
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SBAR Communication
S – Situation B – Background A – Assessment R – Recommendation Q – Questions?
All patient care departments are included in the communication expectations – not just nursing departments
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Patient Safety Committee
Membership now includes Patient Safety Officer (Chief Nursing Officer) Corporate Compliance Officer (Risk
Management) Health Information Director Admissions Manager Pharmacy Director Medical/Surgical Manager Chief Executive Officer
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Leadership Development
Includes communication skills review of administrative policies incorporation of shared governance elements implementation of peer review processes in
the patient units
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Additional Changes
Ancillary staff members speak directly to patient’s nurse – no messages
Staffing adjustments in the Medical/Surgical department
Goal development Developing consistency in all direct and
indirect patient care processes from person-to-person and shift-to-shift
New shift report system in both Respiratory Therapy and Medical/Surgical Departments
Monthly Patient Care Roundtable
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Where do we go from here?
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Questions?
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We wish you success with your patient safety and culture initiatives
Thank you!