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Culture of Patient Safety
Todd Salnas Jo Sandersfeld
Debra Miller Mark Knight
Linda Hansen
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Culture of Patient Safety
EMT Proposals: Recap & Approvals (PREVIEW)1. Does EMT agree to continue the Executive Patient Safety Rounds in the
proposed format?2. Does EMT agree to allocate Sonoma Way resources to support NPSG RIE’s?
(or defer to TPOC?)3. Does EMT support the Patient Safety Director Roles & Responsibilities as
defined on the slide?4. Does EMT approve the Cultural Target State as summarized?5. Does EMT agree to the SW Cultural Survey questions and process?6. Does EMT agree with the proposed EMT Chartering process?7. Does EMT agree with overall Roles & Responsibilities for EMT? AMT? Staff?8. Does EMT agree with the revised HML & Performance Evaluations, and feel it
they are reflective of the cultural target state summary?9. Do the 6 Metrics for Patient Safety Culture accurately reflect our desired target
state?
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Patient Safety Culture
Overall Culture
Defining Ideal Culture State
Sonoma Way
RIE Standard Work
Facilitators & RIE Participants ensure
“Cultural” considerations are measured
Sonoma WayCultural Survey
Results
Day-to-Day
Chartering
Projects requiring significant work
approved by EMT
Directors work with EMT to
charter significant projects
EverydayBehaviors
Incorporate Cultural
Principals into everyday behaviors
HML and Performance
Evals
Tangible Improvements In Patient Safety
Prioritization of Safety Goals
Med Reconciliation; HAPU;
High Alert Meds; Critical Results
Patient Safety Director leads A3’s
Failure Rates for each area of
focus
Executive Patient Safety Rounds
Patient Safety Director, EMT;
Follow up with staff
Completed follow up items
Employee Engagement Survey (Summer 2011)
Culture of Patient Safety Survey (Fall 2011)
Focus Areas
Roles & Responsibilities
Measures Of Success
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Culture of Patient Safety
Tangible Improvements in Patient Safety Executive Patient Safety Rounds Follow up
National Patient Safety Goal Improvements
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Tangible Improvements in Patient Safety
Executive Patient Safety Rounds One Rounding Session per month at each hospital Tracking process to ensure feedback loop Immediate follow up after debrief Closure with individual reporting incident Communication Team consists of Executive, Patient Safety
Director, Pharmacy Director, Risk Manager, Physician (SRM)
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Tangible Improvements in Patient Safety Executive Patient Safety Rounds
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Prioritizationof
National Patient Safety Goals
Tangible Improvements in Patient Safety
8 Increasing Difficulty/Complexity in Improving
01.01.01•2 Pt. Identifiers
•05.01.01•Suicide Risk Assessment
•LASA Meds
•03.09.01•Labeling Meds
•01.03.01•Blood Administration
•07.##.01•Infection Control; Hand Hygiene
•Universal ProtocolProcedures
•03.05.07•Anti-Coag’s
•08.##.01•Med Rec
•High Alert Meds
•Patient Falls
•HAPU’s•HAC’s: (other than falls or wounds)
•02.03.01•Critical Results
Group: ToddE.J.JoanieLarryKenBradJillKimGary M.JaneLinda H.
Capacity: 3 RIE’s rolling out over 3-4 Months|--20 hrs prep--| |--40 hrs RIE Event--| Monitoring/report outs: |--20 hrs --|--10 hrs--|--10 hrs--|
Tangible Improvements in Patient Safety
•Patient Handoffs, Unit to Unit
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Priority NPSG Initiative SRM PVH Total
1 14. Medication Reconciliation (might be IT project- Todd to check) 7 3 10
2 5. Critical Results Communications 6 3 9
3 12. High Alert Meds (including Anti-Coagulants) 4 3 7a
4 11. HAPU's (Hospital Acquired Pressure Ulcers) 5 2 7b
5 10. Patient Falls 4 1 5
6 9. Patient Handoffs, Unit to Unit (not shift-to-shift) 2 1 3
7 7. Infection Control/Hand Hygiene 1 1 2
8 8. Universal Protocol (&Crew Training Expectations/ Budget) 2 2
9 13. Hospital Acquired Conditions, excluding HAPU's & FALLS 1 1
10 2. Suicide/Safety (Just do it? Education?) 1 1
11 4. Labeling of Medications 1 1
12 1. Two Patient Identifiers
13 3. Blood Administration
14 6. Look Alike, Sound Alike Medications -LASA (Just do it? Education?)
Tangible Improvements in Patient Safety
10 *Med Rec may be handled as IT Project
Tangible Improvements in Patient Safety
Focus Area Metric
NPSG PrioritiesFailure Rate
Reduction
Executive Patient Safety Rounds
Closure of Follow up Items
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Area Patient Safety Director
1. Managing Monitoring Process Manage / train others Personal observations Reviewing data & developing plans,
presenting data2. Facilitating NPSG Sonoma Way Teams
RIE / A3 / PDCA3. Patient Family / Engagement Models – Year 2
(post #1-2 &post patient satisfaction hard-wiring)4. Executive Safety Rounds
Rounds, Debriefs Follow-up
5. Communication / Publication of Activities6. Personal Follow-up
1. Policy revisions2. Process changes3. Patient Safety Officer role and plan4. PPR / Survey Follow-up
* #6, beyond time
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Culture of Patient Safety
Overall Culture Development
Sonoma Way Initiatives
Day to Day Activities
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Overall Culture Development
See Exhibit # 1
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Overall Culture Development
See Exhibit # 1
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Overall Culture Development
Sonoma Way Standard Work Cultural Vision Survey template developed [See exhibit # 2] 1 -2 critical items monitored throughout VSA/RIE
Process by means of an Online Survey Tool Survey aimed at staff involved in change process Survey results reviewed at Monthly Operating Result
Review Survey results communicated at RIE Report Outs
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Overall Culture Development
Day to Day: EMT Chartering of InitiativesProposal: Approves high cost, high complexity, resource
intensive projects [See exhibit # 3]
Ensures Cultural Vision is considered– Identify key stakeholder involvement– Clear metrics, accountability and ownership– Resource availability– Capacity of organization to implement and sustain project
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Overall Culture Development
Day to Day: AMT and Staff Roles & Responsibilities [See Exhibit # 4]
Active participation in improvement activities Alignment of departmental activities with strategic
initiatives Transparent communication and opportunities for input
and education around standard work Clear expectations about feedback cycle for
improvement Daily monitoring and refining of new processes
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Culture of Patient Safety
Day to Day: Measures of Success[See Exhibit # 5]
Proposal: Revise HML to include success in demonstrating
Cultural Attributes
Map Cultural Attributes to Performance Evaluations – Leadership Competencies
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Culture of Patient Safety
Metric RecapTangible Patient Safety Improvements Failure Rates for Patient Safety Priorities Executive Rounds Follow upOverall Culture Development Sonoma Way Culture Survey Results HML, Performance Evaluation ScoresBoth: Employee Engagement Survey Results Culture of Patient Safety Survey Results
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Culture of Patient Safety
EMT Proposals: Recap & Approvals1. Does EMT agree to continue the Executive Patient Safety
Rounds in the proposed format?
2. Does EMT agree to allocate Sonoma Way resources to support NPSG RIE’s? (or defer to TPOC?)
3. Does EMT support the Patient Safety Director Roles & Responsibilities as defined on the slide?
4. Does EMT approve the Cultural Target State as summarized?Continued on next page--
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Culture of Patient Safety
EMT Proposals: Recap & Approvals (continued)
5. Does EMT agree to the SW Cultural Survey questions and process?
6. Does EMT agree with the proposed EMT Chartering process?
7. Does EMT agree with overall Roles & Responsibilities for EMT? AMT? Staff?
8. Does EMT agree with the revised HML & Performance evals, and feel it is reflective of the cultural target state summary?
9. Do the 6 Metrics for Patient Safety Culture accurately reflect our desired target state?
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Culture of Patient Safety
Questions?
Comments?
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