Patient Safety Fellowship Opportunities & Beyond! Lessons Learned From AHA Health Forum Fellowship &...

Patient Safety Fellowship Opportunities & Beyond!Lessons Learned From AHA Health Forum Fellowship & Beyond!

Techniques & Tools:Effectively Development and Promoting

A Culture of Patient SafetyBy: Patti J. Magyar, RN, MSN, JD; Hospital Counsel

Chelsea Community Hospital – Chelsea, MI

(734) [email protected]

A Culture of Patient Safety

Shared ways of thinking and behaving that work

to meet the primary objective of Patient safety. (Schein)

Be APatient Safety Champion!

Be Realistic: • Some Colleagues are first on the bus • Some need help getting on the bus

• Some Colleagues will board the bus late, possibly kicking and screaming

(and “’pay’ a late fee!”) • Some Colleagues will be left at the

bus stop and won’t even know it: “What ‘was’ that!”

• Some don’t care that there is a bus & may need to be “invited” to leave.

Be a Patient Safety Champion

Assess your current environment:

Informally: Open dialogue at staff meetings

Initial & On-Going Inquiry: How are we doing: NPSF: “The ABC’s of Patient Safety”

- Linkage: PSLF & NPSF! -

How can we make things safer for patients and staff?


Assess your current environment:

Formally:

Cultural Assessment e.g., “Strategies for Leadership-”

VHA, Inc. (Supported by & available through AHA) (2000)

Cultural SurveyCCH A Survey of Hospital Clinical

& Non-Clinical Staff

Be a Patient Safety Champion Integrate Patient SafetyInto Your Hospital’s:

• Strategic goal for Excellence • Climate as a “Learning Environment”

• Formal & Informal Marketing! …

Your Hospital aspiring to be “Great!”Flower, Joe. Good to Great.

Health Forum Journal (July-August)2002, 17-20 (related editorial pp 5-6).

- PSLF Linkage –AHA Summit -


Invite & Facilitate Resolution to:

“Wicked Questions”

- PSLF Meeting #1-

“How can we move patient safety forward given our barrier of skepticism?

… barrier of financial challenge?

… barrier of work overload?

…overlap with QI/RM?

Be Patient Safety Vigilant for:

Patient Safety Risk

Opportunity

Success

Reward



Recognition (verbal/card/letter/sharing of patient success stories), financial (major based on risk minimization and cost savings; minor: meal tickets, gift shop certificate, dinner out with PSO/other, pizza party for department, AmEx certificate; balloons!)


Equipment & Systems Enhancements

Braun Outlook IV Pumps

Midas+ Integrated Systems“Chelsea Community Hospital Partnering in Patient Safety”


Be clear & committed to critical patient safety “values”

~ Error Tolerance ~“…errors will occur in any system, no matterhow well managed, and early identification

and analysis of errors can provide an opportunity for the proactive correction

of conditions that are unsafe.” (Merry p. 127)



~ Interdisciplinary Teaming ~

Patient safety problems cannot be successfully resolved

through traditional management OR traditional healthcare!

• Joint S/PS/RM “Wheelchair Availability to Guests memo

• “FMEA: Medication Administration; Patient Identification”

• Interdisciplinary education (e.g., UMMC Conference @ CCH)

• HiQ Teams: Legibility in the Medical Record (PosterBoard)



“A Just Culture”~ PSLF~

• Accountability v. Blame! • Patient/Visitor Occurrence Reporting Process

• Peer Review (“Real” PE! with input, ensuring competence +/or conduct issues are addressed early to “salvage,” develop and retain

talented physicians!)• Performance Evaluation


Communicate: Evidence, Innovation & News!

Create effective feedback loops regarding latent workplace conditions and latent organizational conditions (Merry, 127)



Latent Workplace Conditions• Undue time pressure• Inadequate maintenance• Inadequate tools• Inadequate training• Understaffing• Unworkable procedures (Merry, 126)



Latent Organizational Conditions • Budgeting • Communication • Norms and Informal Expectations • Planning • Resource Allocation • Senior Level Decisions • Strategic Decisions (Merry, 126)


Communicate:

Transfer Your Expertise!“Scripting”

“I am so sorry you received Valium 5 mg. by mouth for your hip pain instead of the Demerol 50 mg. IV that was ordered; (it was a misreading on my part). Your physician has been made aware, and per the physician’s order I am going to give you the Demerol now for your pain relief. (Have you taken Valium before? – e.g., hx of response?). You should

have no ill effects from the Valium although you may feel … I will be back in 15 minutes to take your vital signs … >”


Communicate:

Transfer Your Expertise!“Scripting”

”Your surgical procedure went well and you are doing very well (minimal blood loss, blood pressure is good …). As I explained

during your office visit, the plastic piece for your knee replacement was fitted into your knee after careful evaluation

during the operation. … Upon my review of your knee film after surgery, I see that a 3 mm larger plastic device would be better

for your knee stability. It will be safe to walk and bear weight on your knee over the next two weeks. Then, if you agree, I would like to do a 15” procedure replacing the smaller with the larger

device …”


Communicate:

Transfer Your Expertise!

“Scripting”

INVITE SHARING OF CONCERNS

“…Do you have any questions or concerns at this time?”

“Please let us know at the earliest point possible if you have concerns or ideas about how we can improve the

care you are receiving..”



(e.g., P & T Newsletter or Quality/Safety Newsletter or

Patient Safety/Risk Management Newsletter)

• Automatic Stop Orders and Renewals Policy • Alternative Medication Policy Revisions• New Products Added to Formulary • The “Do Not Use!” Abbreviations• Patient Fall Assessment: Who & Why!


Communicate Evidence, Innovation & News!Dynamic In-person Updates:

Self or Other PS Champions

• Administrative Staff• BOT • Hospital Staff (Dept. Mtgs., Directors[Hospital “Forums”]) • Medical Staff (MEC v Services v Entire) • Volunteers (Annual Mtg)(Leadership)


• Written Communication with clinicians• e.g., Memo: “Morphine Sulphate Unit Dosage

Nation-wide Backorder Shortage (January 23, 2003)

• e.g., Reminders of f/u process when illegible entries are found & remind of commitment!

• Judicious use of e-mails

Transfer your expertise:

Scripting

“I am sorry you received Valium 5 mgs. by mouth for your hip pain

instead of the Demerol 50 mg. IV that was ordered. You are not

allergic to Valium – correct? Your physician has been made aware

and per the physician’s order I am going to give you the Demerol

50 mg for your pain relief. (Have you ever taken Valium

before?) You should have no ill effects from the Valium although you

may feel … I will be back in 15 minutes to check on you (+/or take

your vital signs) …”



Transfer your expertise:

Scripting: Hospital Orientation & Beyond

1. Patient/Visitor Occurrence Initial Apology

2. Guidelines for Explaining the Facts when Error occurs in a complex procedure

3. Any/all staff in effective listening to a patient/family member sharing a complaint

Attract & CultivatePatient Safety Co-Champions!

Personally Exude “Service Excellence!”“How Can I Be of Help?”

Acknowledge others’ capabilities

Co-Present and Share Ideas & ResourcesInternally

Attract & CultivatePatient Safety Co-Champions!

• Nurture relationships with prospective co-champions (e.g., orthopedic surgeon, internal medicine specialist, Directors, staff)

• Put others in the spotlight as often as possible! (e.g., I want to thank and recognize Kim for … in PS)

• Involve physician as (co)/speakers, nurses & other clinicians as FMEA leaders +/or team members)

• Celebrate patient safety achievements! (Literally Celebrate: party … shared summary!)

Collaborate Internally & Externally!

Collaborate

• Join Forces !

• Team Up !!

• Work in Partnership !!!

• Pool Resources !!!!

Collaborate!

Collaborate Internally

• Department Directors• Directors of Nursing, Pharmacy, Quality, Recipient

Rights, Risk Management and Safety

• Chief of Staff and VPMA/Service Chiefs/InformalMedical Staff Leaders

• Nurse Director Group & Informal Nurse Leaders• Patients & Families!!! (e.g., Pulse; Advisory Committee)


Executive Rounds (Great for Administrative Buy-In to

Patient Safety, after buying into rounding!) • “Have you seen or experienced any patient safety concerns during your stay?” • “Have you seen your care providers wash their hands just before providing care to you?” • “Do your nurses introduce themselves to you?” • “Do nurses look at your patient identification band just before they give you medication?”


*Patient Safety Roundsvia

Patient Safety InterviewsBy

Diverse Staff Committed to Patient Safety

*See: Attachment

Collaborate Internally & Externally

“Align legal counsel activity

with the patient safety agenda,

ensuring accountability,

while concurrently

protecting the organization.” (Wilson, 33)

Collaborate Externally

Use the plethora of patient safety resourceswith wild abandon but share them very

strategically!

See Attached List: Patient Safety Resources

Collaborate Externally

Brainstorm with others:Your organization’s

Greatest patient safety knowledge or resource Challenge &Potential Solutions

(e.g., Human Error Factors Analysis,“Internal Neutral,” Patient/Family Inclusion in PS …)

Do a (Formal or Informal) Cost:Benefit Analysis!

A Culture of Patient Safety

• Be a Patient Safety Champion

• Attract & Cultivate Co-Champions

• Collaborate Internally

• Collaborate Externally

~ In Summary ~A Culture of Patient Safety (shared ways of thinking

and behaving) will evolve based on our underlying organizational culture, via a

Process of Evolution over

time

A Culture of Patient Safety …

Moving Hospitals and Healthcare to Greatness!

Thank You AHA Health Forum PSLF!!!

Questions & DiscussionLeadership, Disclosure, Tools & Techniques

+/or PSLF!

AHA Health Forum

Patient Safety Leadership Fellowship #1

2002-2003

http://www.hospitalconnect.com/healthforum/hfeducation/

Co-sponsored by:

AHA-HRET, AONE, ASHRM, NPSF

Patient Safety Fellowship Opportunities & Beyond! Lessons Learned From AHA Health Forum Fellowship &...

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