ProMedica Culture of Safety

June 11, 2014

Linda Yielding RN, BS, MBA

2

Welcome to ProMedica Flower Hospital

Leadership Safety Strategies

Training - Physician, staff, and leadership *

On-line event reporting system *

Transparency*

• SSER*

• Days since last SSE*

• Employee injury rates

• Put a face on safety*

• Scorecards (HACs, AHRQ PSI)

Safe patient handling program*

Communication

• JoE boards*

• Excellence Boards*

• On line newsletters

• Home screen message

* Examples to follow 3

TRAINING

4

5

6

Serious Safety Event • Reaches the patient

• Results in moderate to severe harm or death

Precursor Safety Event • Reaches the patient

• Results in minimal harm or no detectable harm

Near Miss Safety Event • Does not reach the patient

• Error is caught by a detection barrier

or by chance

Precursor Safety Events

Serious Safety Events

Near Miss Safety Event

© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

A deviation from generally accepted

performance standards (GAPS) that…

Safety Structure

8

System Board

Hospital Board

Quality Steering

HRO Team

Safety Events

Team

System Safety

Steering

Hospital Safety

Committee

Sub

Sub

On-line Event Reporting

Manual (2013) Electronic (2014)

0

200

400

600

800

1000

1200

1400

February March

2013

2014

9

Transparency: Faces of Safety RD

2 years Delay in treatment

12/2/2013 EH

9 months

Failure to Rescue

6/22/2013

IZ

11 months

Delay in treatment

10/21/2013

FL 7 day old

Accidental extubation 11/18/2013

LB 17 years

Delay in Tx/SSI 12/8/2013

DB

9 years

CLABSI

12/18/13

LT

16 years

Procedural

Comp. 3 CT’s

3/3/2014

BT

5 months

Care Management

3/1/2014

MC 15 years

SSI 9/17/2013

AS 11 years

Critical airway obstruction 7/8/2013

Transparency: SSER and Days Since Last

Event

11

• 89 days since last confirmed SSE (as of 5/30/2014)

• Approximately 36 days between events

over 12 months

Transparency : CLABSI

12

• NICU – 415 days (1 year, 1 month)

• Hematology-Oncology– 167 days

• Pediatrics –1167days (3 years, 2 month)

• PICU – 597 days (1 year, 7 months)

Last Catheter-Associated Blood Stream

Infections (as of May 30, 2014)

Safe Patient Handling Program

13

2013 – 73% a reduction from

2012!

Employee Injuries Due To Moving Patients

32 20 20 18 15 9 10 15 4 0

10

20

30

40

2005 2006 2007 2008 2009 2010 2011 2012 2013

2013 – a 73% reduction from 2012!

COMMUNICATION

14

15

Journey of Excellence (JoE Boards)

17 CATEGORY

Add’l. Leadership Safety Strategies

Safety huddles

Board involvement

Accountability

• Rounding

Recognition

18

19

Thank You