building a high reliability organization: sustaining

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Connecticut Hospital AssociationLeadership Workshop

© 2014 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.This material is a proprietary document of Healthcare Performance Improvement LLC. Reproducing, copying, publishing, distributing, presenting,or creating derivative work products based on this material without written permission from Healthcare Performance Improvement is prohibited.

Building a High Reliability Organization: Sustaining Reliability and Safety Culture

Slide 2

“Attention is the currency of leadership.”Ronald HeifetzDirector of the Leadership Education ProjectJohn F. Kennedy School of GovernmentHarvard University

“There is no priority higher than patient safety. If there is a conflict between safe practice and speed, efficiency or volume, then safety

wins – hands down.”James M. Anderson

Past President & CEOCincinnati Children’s Hospital Medical


Slide 3

The “ATM” of Safety Culture Leadership

A – AttentionAttention is the currency of leadership.

T – Transparency and TrustTransparency = learning. Trust is the enabler of transparency.

M – Measure, Measure, Measure from Lee Carter, Chairman of the Board – Cincinnati Children’s Hospital Medical Center

Slide 4

Sustainment through Measurement


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…

Typical Improvement Curve

Actual increase due to complacencyor reverting to old habits

Achieved in 1 to 3 years, approximately

Time

Sig

nific

ant E

vent

Rat

e

Start ofCulture Change

Apparent increase due to healthier event/problem reporting culture

80% reduction in serious preventable harmas a result of prevention activities

Long-term improvement through sustained prevention

Hospital X


Slide 7

Best Practice Tips inSafety Event Classification

� Identify a consistent group of people to serve as a “Safety Event Review Panel” to provide expertise, consistency, and integrity in event classification. The group should be a mix of clinicians and methodology experts and senior enough to gain organizational trust.

� When classifying an event, use the SEC algorithm and always ask ALL the questions – e.g. Was there a deviation? Did the deviation reach the patient? What was the level of harm?

� Charge one person with the responsibility for thinking/asking about precedent.

Slide 8

Best Practice Tips inSafety Event Classification

� Keep a record of challenging event classification cases and classification rationale. This record provides a useful reference when assessing similar future cases and enables the group to look at changes in their own perspectives in event classification.

� What happens in the discussions, stays in the discussions. The group speaks with one voice outside the meetings.


Beyond SSER – The SSE+PSER

with permission of Holy Redeemer Health System

The SSE+PSER…� Prevents complacency during

long event-free stretches� Heightens awareness of the

wealth of learning opportunities from “lesser events”

At Holy Redeemer:� The SSER and SSE+PSER is

monitored at the Board and Senior Leader levels.

� The SSE to PSE ratio at this Holy Redeemer division is 1:16. (In a state of optimal reporting health, the ratio likely is 1:100 or more.)

SSE PSE

What It Tells Us How many people did we injury?

How many people received anerror in care with minimal or no harm?

Message We Want To Send Reduce…and eliminate! Freely report and learn

Slide 10

Worker Safety Improvements(5 hospital system – Southern US)

$0

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

CY 07 CY 08 CY 09 CY 10

Workman's Compensation Costs

Over $1, 200,000 savedyear to date!

02468

101214161820

Sep-06O

ct-06N

ov-06D

ec-06Jan-07Feb-07M

ar-07Apr-07M

ay-07Jun-07Jul-07Aug-07Sep-07O

ct-07N

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ec-07Jan-08Feb-08M

ar-08Apr-08M


ct-08N

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ec-08Jan-09Feb-09M

ar-09Apr-09M


ct-09N

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ec-09Jan-10Feb-10M

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ct-10N

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ec-10Jan-11Feb-11M

ar-11Apr-11

Month

Monthly Lost Time ClaimsJuly 06 - April 2011

802 Over 300 Serious Injuries prevented

90% reduction in OSHA IIR


Sentara Safety Dashboard

Leading Indicator• Safety Culture Survey Scores

Real Time Indicators• Safety Behavior Pulse Checks

• Leaders• Staff• Physicians

• Safety Success Stories Received & Communicated• Number of Events Reported

Lagging Indicators• Serious Safety Event Rate (SSER)• # Serious Safety Events• # Precursor Safety Events• #/$ Professional Liability Claims & Suits• OSHA Employee IRR• #/$ Worker’s Comp Injuries

Slide 12

Sustainment through Rigorous Reinforcement of

Safety Habits


Slide 13

Non-Technical Skills

Slide 13

Non-technical skills describe how people interact with technology, environment, and other people. These skills are similar across a wide range of job functions. These skills include attention, information processing, and cognition.

Flin, O’Connor, and CrichtonSafety at the Sharp End

Generic non-technical skills:� Situational awareness� Attention� Communication� repeat backs� call outs� phonetic & numeric clarification� clarifying questions� inquiry, advocacy, assertion

� Critical thinking� Protocol use� Decision-making

Slide 14

Safety Starts with Me

• Self-check using STAR

Mentor Each Other – 200% Accountability • Cross-Check and Coach teammates• Speak up for Safety: ARCC it up – “I have a Concern”

• Repeat Backs / Read Backs with Clarifying Questions • Phonetic and Numeric Clarifications

• SBAR

• Validate and Verify• Stop the Line – “I need clarity!”

Practice and Accept a Questioning Attitude

Communicate Clearly

Handoff Effectively

H

C

H A M

P

Be a safety “CHAMP” for our patients

Attention to Detail


Slide 15

Complementary Strategies


Central LineInfections

HandHygiene

Surgical SiteInfections

Codes Outsidethe ICU

Culture

��

Slide 16

Process Bundle People Bundle

4 for VAP Prevention1. Elevation of the head of the bed to

between 30 and 45 degrees2. Daily “sedation vacation” and daily

assessment of readiness to extubate3. Peptic ulcer disease (PUD)

prophylaxis4. Deep venous thrombosis (DVT)

prophylaxis (unless contraindicated)

Read More: Community Health Network Reduces Deadly Infections ThroughCulture of Reliability, American Society for Quality (June 2008)


More Clever: All in it together – leaders take the quiz, too!

Quiz for Knowledge

Safety Habit Survey – SBH

100 100 100 100 100100 100 100 100 100

0102030405060708090

100

Attention to Detail CommunicateClearly

QuestioningAttitude

Handoff Effectively Wingman

January 2010

February 2010

Percentage of Surveyed Staff Who Could Name the Safety Habits (BBEs)

2010 Goal = 60% surveyed will be able to name all 5 Safety Habits



70

55

20

10 10

60

0

7570

60

9086

7167 67

90

71

8681 81

0102030405060708090

100

STAR RB/RB CQ PhNC SBAR VV STOP 5Ps PCh Pco

January 2010February 2010

STAR – Stop, Think, Act, Review SBAR – Situation, Background, Assessment, Recommendation/Request PCh – Peer Checking

RB/RB – Read Back, Repeat Back VV – Validate and Verify PCo – Peer Coaching

CQ – Clarifying Questions STOP - Stop

PhNC – Phonetic & Numeric Clarification 5Ps – Patient/Project, Plan, Purpose, Problems, Precautions

Percentage of Surveyed Staff Who Could Name the Error Prevention Tools

2010 Goal = 60% surveyed will be able to correctly tie 1 EPT to each Safety Habit


100 100 100 100 100100 100 100 100 100

0102030405060708090

100

Attention toDetail

CommunicateClearly

QuestioningAttitude

HandoffEffectively

Wingman


Percentage of Surveyed Leadership Who Could Name the Safety Habits (BBEs)

2010 Goal = 60% surveyed will be able to name all 5 Safety Habits



70

50

30 30 30

70

0

90

70

60

70 70 70 70 70 70 70 70 70 70

0102030405060708090

100

STAR RB/RB CQ PhNC SBAR VV STOP 5Ps PCh Pco


Percentage of Surveyed Leadership Who Could Name the Error Prevention Tools

STAR – Stop, Think, Act, Review SBAR – Situation, Background, Assessment, Recommendation/Request PCh – Peer Checking

RB/RB – Read Back, Repeat Back VV – Validate and Verify PCo – Peer Coaching

CQ – Clarifying Questions STOP - Stop

PhNC – Phonetic & Numeric Clarification 5Ps – Patient/Project, Plan, Purpose, Problems, Precautions

2010 Goal = 60% surveyed will be able to correctly tie 1 EPT to each Safety Habit


Integration into Annual Performance Reviews

Specific Expectations


HR Integration at Main Line

• Every employee has the goal to demonstrate mastery of EP tools by providing evidence of the use of 4 different tools as they apply to their scope of work.

• The attached document was developed for staff to document their accomplishments to be submitted to their manager (some expect it quarterly). Or they can enter it directly into the electronic system for performance management.

Sustainment through Transparency


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.

Share Safety Success StoriesEnvironmental Services Associate Speaks Up For Safety

While going about her daily duties of cleaning a patient room, Janice, an EnvironmentalServices Associate observed a physician and nurse enter the room and prepare toperform a minor procedure. She knew the hospital’s rule about site verification before aprocedure, yet noticed that the team was about to proceed without the verification. Janicepolitely questioned the physician and nurse, “Shouldn’t we verify the site before theprocedure?” The physician and nurse thanked the Associate and verified the site. Bybeing aware of what was going on around her and being willing to speak up, Janicehelped ensure that the procedure was performed on the correct site.

Slide 28

The HRO DifferenceHarm is visible – Risk is visible


Slide 29

Use SSER to Make Harm Visible…and more importantly, our efforts to eliminate it!

Slide 30

� Held at each site – open to all� “SBAR” presentation of Serious

Safety Event RCAS – Brief description of eventB – Sequence of eventsA – Inappropriate acts and root causesR – Corrective actions to prevent recurrence

� Layman’s language� Discussion about lessons learned

- Link to Safety Behaviors- How could this happen in other places?- How can we apply lessons learned?

Clif Knight, MD – Chief Medical OfficerCommunity Health Network

with permission of Community Health Networkw

Lessons Learned Lunch Series


Slide 31

Sustainment through Structured High Reliability

Leadership

Slide 32

Leadership Method(not micro-management)

“A well-led institution haspredictable leadership…

you can conjecture what its managersare doing and what they

are likely to do next.”Scott Snair

West Point Leadership Lessons


Slide 33

Culture Embedding MechanismsFrom Organizational Culture & Leadership, by Edgar Schein

Primary Embedding MechanismsSecondary Articulation &

Reinforcement Mechanisms• What leaders pay attention to,measure, and control on a regular basis

• How leaders react to critical incidents and organizational crises

• Observed criteria by which leaders allocate scarce resources

• Deliberate role modeling, teaching, and coaching

• Observed criteria by which leaders allocate rewards and status

• Observed criteria by which leaders recruit, select, promote, retire, and excommunicate organizational members

• Organizational design and structure• Organizational systems and procedures

• Organizational rites and rituals• Design of physical space, facades, and buildings

• Stories, legends, and myths about people and events

• Formal statements of organizational philosophy, values, and creed

Culture Embedding MechFrom Organizational Culture & Leadership, by Ed

S d A

Slide 34

Define & Demonstrate Safety Firstat the “blunt end”

Reinforce & Build Accountabilityfor behaviors at the “sharp end”

Find Problems & Fix Causesin systems and processes

Three Roles of HRO Leaders

Set the set point

Manage to prevent, detect, and manage drift



Slide 35Slide 35

CHA High Reliability Leadership Methods

Build and Reinforce AccountabilityLeaders make reliability a reality by building a culture of collegial teamwork where sound practice habits are adopted by all to reduce human error. Leaders reinforce good habits, correct poor ones, never punish honest mistakes, yet are not afraid to hand out fair consequences to those who choose to adopt reckless behaviors.- Rounding to Influence with 5:1 Feedback- Fair and Just Accountability using the Performance Management Decision Guide- Red Rules to Communicate Safety Absolutes- Safety Coaches

Find and Fix System CausesLeaders remove barriers that impede team members from performing effectively and take active steps to find and fix the holes in the Swiss Cheese before they lead to patient or employee harm.- Daily Safety Check-in - Pre-Task and After-Action Huddles- Start the Clock on Safety Critical Issues - Leadership workgroups- Top 10 Lists with Action Plans - Unit Top 2 & Patient Communication Boards

Set the Tone of Safety as a Core ValueLeaders show the way by setting expectations and setting good examples. Leaders model, inspire, train and encourage team members to keep themselves and others safe each and every day.- Safety First in Every Meeting - Thank those who Voice Safety Concerns- Safety First in Decisions – What’s best for the Patient? - Communicate Lessons from Safety Events- Encourage Error, Problem and Event Reporting - Educate for Safety Every Day

Slide 36

Take Away Tool �



Slide 37

Unit-Based Safety Huddles

Slide 38

Start the Clock on Safety-Critical Issues

� Start the Clock sense of urgency� These are the clock ticker issues – issues that pose a significant threat.

They may be local or global in nature.

� Mobilize those with the expertise to solve the problem and authority to empower action using Condition-Problem-Cause solving� Priority for resolution should be stated (e.g. solved today, solved within

24 hrs); a single-point owner should be identified; the owner should have an action plan; and the issues should be tracked at Daily Check In.

Start the Clock Response to Safety Critical Issuesat Community Health North

For these types of issues, Barb Summers at Community was known to request, “Page me by 3:00 pm today with a status report.” Her rationale was twofold – to demonstrate the sense of urgency and to be made aware of any barriers to resolution that may need to be addressed before close of business.


Slide 39

The Enemy:First Order Problem-Solving

1. “When staff encounter a problem they do what it takes to continue the planned (patient care) task.”– secure the material needed,– don’t probe into what caused the problem to occur– don’t spend time reporting the incident– don’t seek to investigate or change the cause– feel “good” for providing the needed service even though there are

problems with the system

2. “When necessary for continuity of patient care – staff ask for help from people who are socially close rather than from those who were best equipped to correct the problem.”– preserves individual’s reputation regarding their competence– allows avoidance of unpleasant encounters with cantankerous

physicians or managers as long as possible– all but precludes addressing underlying causes that might improve

the system

Adapted from Anita Tucker & Amy Edmondson, Why Hospital’s Don’t Learn From Failures, (UC Berkeley School of Business, 2003

Slide 40

The Solution:Learning from everyday experience...

Condition Solving Extent of Condition Remedial Actions

Problem Solving Communication to Others Compensating Actions

Cause Solving Real-time Cause Analysis

Preventative Actions

Individual encountering problem...

... follow through by Manager or Leader.

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


Slide 41

Wrong medication stocked in Pyxis...


1. Obtain the right medication for my patient.2. Is my medication in the other medication’s Pyxis location?3. Give my patient their medication.

Slide 42


Problem SolvingCommunication to Others

Compensating Actions

1. Notify pharmacy of the condition.2. Suggest possible improvements.3. Report the problem (incident report & manager).4. Warn other caregivers on my shift about the problem.5. Include the issue in my report to the next shift.



Slide 43


Problem SolvingCommunication to Others

Compensating Actions

Cause SolvingReal-time Cause Analysis

Preventative Actions

1. Evaluate extent of condition & remedial actions taken.

2. Perform an apparent or root cause analysis.3. Identify preventative actions (e.g. corrective

actions to prevent recurrence).4. Verify implementation & effectiveness.


Slide 44

Second Order Problem-SolvingAn HRO approach for staff

“When you encounter a problem do what it takes to rectify the condition, continue the planned (patient care) task, and begin problem and cause solving.”

� take immediate remedial actions if necessary� ask where else this condition could exist and take remedial

actions� communicate to the person or department responsible for the

condition� report the problem� share ideas about what caused the situation and how to prevent

recurrence� participate in implementing the needed changes� help verify that the changes have had the desired effect



Slide 45

Second Order Problem-SolvingAn HRO Approach for Leaders

“When you become aware of a problem do what it takes to rectify the condition and solve the cause.”

� be regularly available for al least part of shift(s)� respond in a non-punitive manner – eliminate fear and ridicule� verify remedial actions were appropriate� counteract “time-pressure” by providing assistance for front-line

problem solving efforts� create a psychologically safe environment – admit your own

mistakes� follow through on employee suggestions and provide feedback� “own” cause analysis� verify changes had the desired effect


Slide 46

Lessons Learned inLeadership Method Implementation

� Leader behaviors are the hardest to change!� Top down approach – start with senior leaders first� Start with powerhouse practices first – immediate

impact and whets interest in other HRLM practices� Leaders need implementation structure –

“tight/tight/tight” better than “tight/loose/loose”� Goals and performance measures drive motivate

leader behavior change� Leaders respond to positive reinforcement, too!


Slide 47

BREAK

Slide 48

Sustainment through Physician Engagement


Slide 49

HPI Lessons-Learned

� “Physicians do not make safety transformation happen but they can prevent it from happening.”

� More accurately stated:

“No hospital can achieve a state of highreliability without the full engagement of the

medical staff. True physician leadership, optimally from the outset, is required to achieve and sustain a safe

environment for patients.”

Slide 50

Critical Impact of Physicians onSafety Transformation

� Significant contribution to errors associated with patient injury� Unequaled impact on hospital morale through their

considerable influence on hospital staff and leaders� Strengths may become liabilities – intelligence,

independence, analytical, sense of urgency� Profound impact on long-term hospital culture –

sustained improvements require physician ownership


Slide 51

Common Physician CharacteristicsFrom Barbara Linney, ACPE

� High need for autonomy

� Sensitivity to criticism

� Perfectionistic & compulsive

� Want to direct – resist control

Innate or Nurtured???

Slide 52

The Disruptive PathAttributes

Intelligence

Independence

Objectivity

Analytic Capability

Sense of Urgency

Influence

Liabilities

Elitest

Team averse

Impersonal

Critical

Impatient

Aggressive

Unreliability

Condescending

Abrasive

Belligerent

Blaming

Insensitivity

Sabotage

Derived from Overcoming Your Strengths, by Lois P. Frankel, PhD


Slide 53

The Success PathAttributes

Intelligence

Independence

Objectivity

Analytic Capability

Sense of Urgency

Influence

Strengths

Competence

Confidence

Thinking Critically

Problem Solving

Safety First

Team Building

Reliability

�Preoccupation with failure�Sensitivity to

operations�Reluctance to

simplify�Commitment to

resilience�Deference to

expertise

Slide 54

Sharp End Provider to Blunt End Influencer

Proportion of time by:Residents?Attendings?Division chiefs?Department chairs?CMO?


Slide 55

Vive la Difference

Sharp End Provider� Know and comply with behavior expectations for

error prevention – make them personal work habits� Encourage the practice of behavior expectations

for error prevention in others

Blunt End Leader� Demonstrate in word and actions safety as a core

value that cannot be compromised at any time� Find and fix causes of system and process

problems that challenge safe, high quality care� Reinforce and build accountability for behavior

expectations for error prevention

Slide 56

Medical Staff Stratification forSafety Culture Leadership

Where are our physicians and how can we engage them?

Characteristics Actions to Engage in Safety Culture Leadership

Level 3Blunt End Leader for the Common Best

Influences changes in systems and processes to improve the sharp end condition in the interest of all providers and patients

�Crystallize role of blunt end leaders�Actively engage as leaders and as

influences of Level 2 and Level 3 physicians

Level 2Blunt End Leader for My Own Good

Influences changes in systems and processes to improve the sharp end condition for their own benefit

� Educate about blunt end role and expectations

� Develop strategies to:-Move the willing and able to Level 3-Moderate the unmovable-Manage disruptors

Level 1Sharp End Provider

Functions primarily as a care provider, delivering care and service to patients or supports the delivery of care and service

�Encourage accountability for individual and team behaviors for safe, productive practice



Slide 57

Assessing the Medical StaffLeadership Function

1. Who are our Level 3 leaders?

2. What do we expect of our Level 3 leaders in leading our safety culture transformation?

3. How will we engage our Level 3 leaders?

4. Who are our “willing and able” Level 2 leaders?

5. What strategies can we use to move our Level 2 leaders to Level 3?


Slide 58

Physician Safety Champions

Concept—select a respected, influential group of physician leaders to mold a high-reliability medical staffculture, beginning with patient safety

� Not necessary to influence everyone to tilt the culture, only a segment equivalent to the square root of the number of participants—Edwards Deming, Ph D


Slide 59

Physician Champions� Additional initial education on concepts/ theory� Potential roles:

- Attend daily huddle periodically- Round with operations colleague periodically- Assist with education of other physicians- Meet periodically as a group of physician champions for

additional skill building and feedback- Serve as a resource to other committees and members

of their own group- Participate in strategic safety/ reliability planning

Slide 60

Implementation Considerations� Initial Design Group:

- Willing, interested volunteers from core specialties� Members of the formal medical staff leadership� Informal leaders of the medical staff� Representatives from hospital safety behaviors task force

� Physicians teaching physicians� Storytelling� Clear hospital support of the physician initiative� Mandatory vs. voluntary education� Developing and supporting physician champions� Building consistency with peer review and other

processes- Just culture


Slide 61

Slide 62

Sustainment through Tight Accountability Systems


Slide 63

Three Sources of Accountability

LeadersVertical

Accountability

PeersHorizontal

Accountability

IndividualIntrinsic

Accountability

OptimalAccountability

Accountab

I di id lid l


Slide 64

Fr

Accountability: Where Are We Today?


L

I P

Free for All

L

I P

Leader Centric

L

I P

Team SurvivalCharacteristics:� Significant blunt-end/sharp-

end disconnect.� Leader not aware of status

of operations at the front line.� Individual standards thrive.�Workers work around each

other, not with each other.

Characteristics:� At worst, accountability is

top-down driven and punitive; breeds fear.� At best, L/I relationship

reflects balanced feedback and trust. Yet condition is leader-dependent and, over time, exhausting for the Leader.

Characteristics:� Leader is disconnected, yet

high degree of teamwork and cross monitoring to get the work done.� At best, good results can

mask lack of leadership involvement.� At worst, practice may

differ sharply from – or, over time, deviate from –best-practice expectations.

Characteristics:� Individuals “hired for fit” –

high degree of motivation to do the right thing.� High degree of teamwork

and cross-monitoring, focused on best-practice standards.� Leader provides real-time,

5:1 feedback; finds and fixes system problems.� Strength in I and P

accountability results in lesser relative L effort.

Optimal

PI

L


Slide 65

Fr

The Path to Optimal Accountability


L

I P

Free for All

L

I P

Leader Centric

L

I P

Team Survival

Optimal

PI

L

Team Building

PI

L

Standard Setting

PI

L

Slide 66Slide 66

CHA High Reliability Leadership Methods

Build and Reinforce AccountabilityLeaders make reliability a reality by building a culture of collegial teamwork where sound practice habits are adopted by all to reduce human error. Leaders reinforce good habits, correct poor ones, never punish honest mistakes, yet are not afraid to hand out fair consequences to those who choose to adopt reckless behaviors.- Rounding to Influence with 5:1 Feedback- Fair and Just Accountability using the Performance Management Decision Guide- Red Rules to Communicate Safety Absolutes- Safety Coaches


Slide 67

Reinforcing and Building AccountabilityRounding to Influence

5:1 FeedbackRed Rules

Fair and Just CultureSafety Coaches

Slide 68

The RTI Conversation…

Connect to a core value

Assess knowledge and reinforce thespecific behavior expectations

Identify problems impacting abilityto follow the behavior expectations

Ask about commitment actions

�

♥

�

�


Slide 69

RTI Script – Prepare to Influence

Core Value� Relate to our core value of safety protecting patients

and employees from harm� Tell a story or share facts

Can Do’s � Review practice expectations and share facts

Concerns � Ask, “What makes this hard to do?”

Commitment

� Questions to foster commitment actions:� What will you do to make this your habit?� How will you help others do it?� STOP if you see a safety risk.�

Greeting Hello! Do you have a few minutes for a brief conversation about ___________”

Slide 70





Slide 71

Rapid Cycle FeedbackLearning is “doing” with “feedback”


Do

Feedback

TraditionalFeedback Cycle

OptimalFeedback Cycle

Time

Per

form

ance

Slide 72

5:1 Feedback5 positive bits of feedback for every

1 bit of negative feedback

• Based on observation and facts

• As close in time as possible to the act

• No sandwich approach

• Lightest touch possible to get the desired result


Slide 73




Slide 74

� Red Rules are a Communication program for leaders- “SO IMPORTANT, we do it each and every time”

- Should reduce “unintended” non-compliance

� Should be used to encourage peers to speak up

- That’s a Red Rule – we need to do it – I’ll help you”

� Red: the highest priority for exact compliance- Compliance must come before any other consideration,

including revenue, speed or personal desire

� There can still be unintended Red Rules violations or Red Rule errors driven by system problems

Red Rules are NOT a discipline program


Slide 75




Slide 76

Performance Management Decision GuideAdapted from James Reason’s Decision Tree for Determining the Culpability of Unsafe Acts and

the Incident Decision Tree of the National Patient Safety Agency (United Kingdom National Health Service)

Did the individual intend the act?

Would individuals in the same profession and with comparable knowledge, skills, and experience act the same under similar circumstances?

Did the individualdepart from policies,

procedures, protocols, or generally accepted

performance expectations?

Is there evidence of ill healthor substance abuse?

Did the individual act with malicious intent

(i.e. to cause individual harm or other damage)?

Were there deficienciesin related training, experience,

or supervision?

Were the policies, procedures, protocols, or performance expectations available, understandable,

workable, and in routine use?

Did the individual have a known medical condition?

Were there significant mitigating circumstances?

Is there evidence that the individual chose to take an

unacceptable risk OR has a trend in poor performance or

decision making?

(Consult Human Resources)� Disciplinary action� Report to professional group

or regulatory body� Law enforcement referral

Identify Contributing System Factors

(Consult Human Resources)� Disciplinary action� Job-fit consideration


(Consult Human Resources)� Console� Coaching� Mentor assignment� Increased supervision� Performance improvement

plan� Adjustment of duties


(Consult Human Resources)� Occupational health referral� Adjustment of duties� Leave of absenceIf substance abuse:� Substance abuse testing� Disciplinary action


Yes

Yes

YesYes

NoNo

Deliberate Act Test Incapacity Test Compliance Test Substitution Test

Yes

No

No

No

NoNoNo

No

Console and/or Coach the

Individual ANDFind & Fix Process

Problems

Start

Yes

Revision 3, April 2009© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Yes

Yes

No

Yes

Medical Condition and/or Substance Abuse

Possible Reckless or Negligent Behavior

Possible UnintendedHuman Error

Possible System Induced Error

Malevolent or Willful Misconduct

Yes

D1

D2

I1

I2

C1

C3

C2

C4

S1

S2


Slide 77

Fair and Just� When you hear about an event, count to 5 before responding

� Stop & Think before you speak!

� Say, “Thank you” when someone reports an event or error. � Then say, “Let’s understand how that happened…”

� Ask your direct reports to let you know when one of their employees reports an event or error – go thank that person

� Ask about events and errors during Daily Check-In� Train all your leaders on the effective use of the PMDG

� Ask managers if they applied the PMDG when responding to specific events

� Assign HR as the process owner for PMDG implementation� However, ensure all leaders understand Fair and Just is owned by Operations� Ensure the PMDG is officially referenced in HR policies

� Round-To-Influence on the importance of reporting and learning from errors and events� Emphasize the approach you are taking to Fair and Just

� “We don’t punish unintended human error, but there has to be fair consequences when people choose not to comply”

Slide 78





Slide 79

Keys to Safety Coach Program Success

� Executive Sponsorship (and expectations)

� Engaged lead coach = engaged coaches

� Effective Communication and agendas

� Manager support - Get them to the monthly meetings!- Explain to your entire staff what they are all about- Reward and recognize them whenever possible- Meet with coaches monthly to discuss goods and

others

� Recruit individuals who are well respected by their peers, good communicators and passionate about safety

Slide 80

Sustainment through Best Practice Cause Analysis


Slide 81

Best-Practice Cause Analysis

� Cause analysts trained in enhanced techniques� Executive Sponsor & Operational Leader ownership� Charter for event investigation� 1:1 fact finding interviews� Use of appropriate analytical cause tool

- RCA, ECFC, ACA, CCA� Knowledge of failure mode taxonomies� Transportability review� Corrective Actions to Prevent Recurrence with

single person accountability & operational ownership

Slide 82

Five Effectiveness Categories

AnalysisyDoes our cause analysis structure support effective evaluation of event

Do we effectively use evidenced based methods for cause analysis

ScreeningDo we correctly classify events Do we escalate / de-escalate the analysis as

more information is available

gInitiationHow do we hear about an event How effectively to we set ourselves up for a

successful analysis

MonitoringMonitoringDo we evaluate corrective action effectiveness

Do we regularly look for common themes from our events

ImplementationImplementationAre executive leaders accountable for implementation success & completion Do operational leaders own the action plan


Slide 83

The RCA Advisory Group

PurposeProvide oversight and operational ownership

of the cause analysis program andorganizational learning from events

Typical Members- Chief Operating Officer- Chief Nursing Officer- Vice President of Medical Affairs- Patient Safety Officer- Director of Quality- Director of Risk Management

Slide 84

Role & Responsibilities

� Know what “good root cause” looks like� Establish a sense of urgency for root cause

identification and root cause correction� Ask questions to drive effective cause analysis and to

determine if effective cause analysis has been conducted

� Keep board and senior leadership informed� Promote organizational learning – we are hostages of

each other � Measure and communicate performance� Monitor for fair and just response


Slide 85

RCA Advisory Group Metrics ReportSafety Event Metrics1. Event Counts

- # of safety events – SSE, PSE, NME

- # of JC sentinel events

- # of state reportable events

2. SSER

3. Days Since Last SSE- Point in time days since last

- Record run (longest days since last stretch)

4. Ratio of SSE to SSE+PSE (indicator of degree of harm)

5. # of SSE Discovered Through External Means

Cause Analysis Metrics1. Total Events Reported2. Cause Analysis Counts

- # RCA- # ACA

3. RCA Cycle Time (average days to complete an RCA)

4. CATPR Status & Effectiveness- # CATPR past due- % of actions still in place (of those

audited)5. Organizational Learning

- Lessons Learned communicated- % Required Responses received

Slide 86

RCA Executive SponsorA senior leader who “owns” the quality of the

overall RCA outcomes - to assure correct root cause and corrective actions to prevent

recurrence.

Responsibilities� Acts to stabilize the situation� Charters the RCA Team� Meets with RCA Team to discuss and agree on

investigation scope and objectives� Establishes priority and allocates resources� Communicates investigation status� Ultimately responsible for the root solution and

implementation of corrective actions� Addresses any issues team has with finalizing

project� Provides reports to hospital committees and other

reporting groups

People Involved in the Event

RCA Team Sponsor

RCA Analyst Leader/Coordinator

Stakeholders & Subject Matter

Experts

RCA Analysts


Slide 87

Team Charter

� A clear, careful, and specific problem statement created by team sponsor for RCA Project Team members

� Charter should indicate:- Members of the team- Subject experts to be involved- Leadership to be involved- Timeframe for project to be

completed- Expectations regarding updates

on project status- Other related issues from

previous events to incorporate into analysis

Root Cause Analysis Investigation

RCA Team Charter Date: [Insert date] To: [Insert name]

Root Cause Analysis Team Leader From: [Insert name]

Root Cause Analysis Executive Sponsor Subject: Root Cause Analysis Team Charter for

[insert title] Thank you for agreeing to lead an interdisciplinary team to investigate the event [insert description] on [insert date] on [insert location]. I am asking that you conduct a formal root cause analysis of the described incident. You and the Root Cause Analysis Team Members [insert names of Analyst Team] are:

expected to make this investigation one of the top three priority actions of the day relieved of all other duties until the investigation is complete.

In addition to your RCA team members, the members of the Root Cause Analysis Project Group should also include:

[Name, Title] (department representative) [Name, Title] (subject matter expert) [Name, Title] [Name, Title]

Please add other expertise to the project team if you find it necessary. In your root cause analysis investigation, I am requesting a complete assessment of what happened, how it happened, and why it happened. Your report should include root causes and contributing factors, especially any failed system barriers and/or management barriers. Your report should address any generic implications of this occurrence to all other high-risk areas. Let me know as soon as possible if you identify any issues that need to be quickly communicated outside the department, even if you have not yet completed your analysis. Please provide me with regular progress briefings. I would like a detailed examination of internal and external operating experience. (For example: What opportunities did we fail to make use of to prevent this event? What lessons-learned did we overlook?) In particular, since this case addresses the broader issue of [insert details as appropriate], I would like you to address any recommendations that are relevant from a system perspective. When your analysis is completed, I request that you provide a briefing to senior leadership. Please notify me of any emergent issues associated with the investigation. I would like a final report including an action plan within 30 days. I will be responsible for communicating with the leadership team and to all external agencies. You and the Root Cause Analysis Project Team will be responsible for updating the department(s) involved. This charter may be revised by our mutual agreement. [Insert names of analysts], thank you for agreeing to participate in this activity and helping us to identify processes that will result in improved patient outcomes.

Slide 88

RCA Team - Three Meeting ModelOperations Owns – Quality Supports

SOE = Sequence of Events CATPR = Corrective Actions to Prevent Recurrence

Investigate occurrence to

determine SOE & proximate causes

Determine failure scenario including

individual and system causal

factors for each inappropriate act

Establish root causes and

conceptualize CATPR

Meeting #1 (Facts)

• Review Charter • Confirm scope of event • Identify & coordinate

interviews & data gathering

Meeting #2 (Causes)

• Agree on facts & proximate causes

• Build consensus for possible root causes

RCA Sponsor, Stakeholders & Subject Matter Experts

RCA Analyst Team

• Stabilize situation

• Control evidence

Meeting #3 (Corrections)

• Consensus on root causes

• Finalize Corrective Action plan

RCA Team


Slide 89

Summary and Wrap Up

Slide 90

What Does It Take?Safety exists as an explicit core value, not an

implicit assumption within the organization.

Vital behaviors for human error prevention that are prescriptive and concrete, not abstract.

The organization rigorously reinforces behavior expectations as work habit and finds and fixes system problems that influence behavior.



Slide 91

What Do I Need to Do?Hospital President, CEO, VP’s

� Set the tone

� Relentless Drumbeat

� Personal Involvement

� Put a Face on Safety

Daily� Measure, teach, reinforce, role model and inspire staff to make safety a

core value – “Attention is the currency of leadership.”- Start meetings with Safety Moments- Thank those who voice safety concerns- Put Safety First in decision making

� Practice 5:1 Feedback� Lead a Daily Safety Huddle with Directors and/or Managers

� review significant activities in past 24 hours, � anticipated activities in next 24 hours, � identify priorities, problems, and precautions

Slide 92

What Do I Need to Do?Daily� Measure, teach, reinforce, role model and inspire staff to make safety a

core value – “Attention is the currency of leadership.”- Start meetings with Safety Moments- Thank those who voice safety concerns- Put Safety First in decision making

� Practice 5:1 Feedback� Lead a Daily Safety Huddle with Directors and/or Managers

Weekly� Conduct Executive Leadership Meeting (C-Suite)

� Status of Top Problems List and Level 1 & 2 Action Plans (Ask: Do you have a Level 1 and 2 Action Plan and are you on track)

� Discuss recent Safety Success Stories� Discuss recent Serious Safety Events, status of investigations/resolutions, trends

� Conduct “scripted” Executive Rounds (Rounds to Influence)� Can you name the error prevention techniques that are part of our expected

safety habits?� Have you made any great catches or seen or heard about a coworker making a

great catch? Were one of our safety habits or tools used?� What conditions make you most concerned that you’re going to experience an

unintended error or mistake that could result in harm to a patient or employee?� Can you think of any “close calls” that almost resulted in harm to a patient or

employee? What can we do to prevent that type of close call in the future?

Hospital President, CEO, VP’s

� Set the tone





Slide 93

What Do I Need to Do?Monthly� Lead the “Patient Safety Workgroup” or “RCA Advisory Group” meeting

� Receive update on latest SSER and days since last event� Review outstanding RCAs (including action plans and status)� Review progress on process indicators and action plan that support

safety and quality transformation� Review safety trends, e.g. red-rule performance, safety coach

observations, etc.� Safety Success Stories – select a Safety Success Story of the month� Status of Top Problems List - successes, escalation needs

Hospital President, CEO, VP’s

� Set the tone




Slide 94

What Do I Need to Do?Monthly� Lead the “Patient Safety Workgroup” or “RCA Advisory Group” meeting

� Receive update on latest SSER and days since last event� Review outstanding RCAs (including action plans and status)� Review progress on process indicators and action plan that support safety and

quality transformation� Review safety trends, e.g. red-rule performance, safety coach observations, etc.� Safety Success Stories – select a Safety Success Story of the month� Status of Top Problems List - successes, escalation needs

� Deliver a safety message through electronic or other means (newsletter) to all associates

Hospital President or CEO

� Set the tone





Slide 95

What Do I Need to Do?Monthly� Lead the “Patient Safety Workgroup” meeting

� Receive update on latest SSER and days since last event� Review outstanding RCAs (including action plans and status)� Review progress on process indicators and action plan that support safety and

quality transformation� Review safety trends, e.g. red-rule performance, safety coach observations, etc.� Safety Success Stories – select a Safety Success Story of the month� Status of Top Problems List - successes, escalation needs

� Deliver a safety message through electronic or other means (newsletter) to all associates

Yearly� Propose Safety and Quality Aims “Aim High, Aim Wide, take Dead Aim”

for approval by the Board - for example: We will reduce preventable safety events (SSEs) by 80% across the entire institution

in the next three years ending on by July 1st, 2014. (i.e. (25% reduction first year, 25% second year, 30% reduction third year)

� Develop and Approve Safety and Quality Improvement Plan to achieve Aim

Hospital President or CEO

� Set the tone




Slide 96

"Good ideas are not adopted automatically. They must be driven into practice with courageous impatience. Once implemented they can be easily overturned or subverted through apathy or lack of follow-up, so a continuous effort is required."

Admiral Hyman G. Rickover 1900-1986


Slide 97

Healthcare Performance Improvement5041 Corporate Woods Drive, Suite 180

Virginia Beach, VA 23462Phone: (757) 226-7479 • www.hpiresults.com

Steve Kreiser, CDR (USN, Ret.), MBA, MSMSenior [email protected]

Desired

Direction

Baseline

PriorYear

JanFeb

Mar

Apr

May

JunJul

Aug

Sep O

ctN

ovD

ecYTD

Goal

AH

RQ

Com

positesO

verall Perception of Safety�

Managem

ent Support for Safety�

Supervisor Support for Safety�

Teamw

ork Across U

nits�

Non-punitive R

esponse to Error�

% of leaders w

ho have completed error prevention

education�

% of staff/associates w

ho have completed error

prevention education�

% of m

edical staff who have com

pleted error prevention education

�N

umber of Safety Success Stories shared

�Practice of Leader M

ethods (see Tab Two)

Effectiveness of Message on M

ission (Safety First)�

Effectiveness of House-w

ide Daily C

heck-in/Safety Huddle

�Effectiveness of D

epartment-based D

aily Check-in/Safety

Huddle

�Effectiveness of R

ounding to Influence�

Effectiveness of Fair Culture

�

Practice of Safety Behaviors/Error Prevention Tools

Team C

hecking�

Team C

oaching�

Speak Up for Safety

�Validate and Verify

�S.T.A

.R.

�H

andoffs�

SBA

R�

Com

munication C

larifiers�

Num

ber of Safety Coaches

�N

umber of Safety C

oach Observations

�R

ed Rule Violations

�

Serious Safety Event Rate (SSER

)�

Total Serious Safety Events�

Total Precursor Safety Events�

Total Near M

iss Events�

Overall Event R

eporting�

Employee Injury and Illness R

ate�

Employee D

ays Aw

ay Restricted and Transferred

�N

umber of Professional Liability C

laims/Law

suits�

$ of Liability Claim

s and Settlements

�

Organization N

ame

Reliability &

Safety Transformation M

etricsC

onfidentiality Statem

ent

Outcom

e (Lagging) Metrics

Predictive (Leading) Metrics

Process (Real-tim

e) Metrics

Physician�&�Provider�Patient�Safety�Champions�Program

Operational Details

Qualifications• Passion�for�patient/team�member�safety• Willing�volunteer�for�a�minimum�of�1�year�

commitment• Medical�staff�member�in�good�standing• Demonstrates�a�personal�commitment�to�the�RCD• Knows,�practices�and�uses�as�personal�work�habits�

the�five�safety�behaviors�and�associated��tool�kits• Willing�to�lead�though�actionsImplementation• Identify�and�recruit�provider�champions• Identify�facility�lead�physician�Safety�Champions�

and�health�system�executive�sponsors• Provide�Team�up�for�Safety�orientation�for�Provider�

Safety�Champions• Begin�Safety�Champion�duties�as�soon�as�possible�

after�training�• Establish�schedule�for�monthly�work�groupsNumbers• Approximately�one�to�two�Physician/Provider�

Safety�Champions�for�every�20�active�medical�staff�members�(8%)

Training�Program• Team�up�for�Safety�orientation• Cause�analysis�training• Training�focuses�on:

– building�subject�matter�experts�in�safety�and�reliability�principles�at�the�medical�staff�level

– learning��behavior�observation�and�feedback�techniques

– practicing�performance�coaching�of�peers�and�other�team�members

Training�Content• HPI�and�RHS�supported;�co�facilitated�with�facility�

lead�Physician�Safety�Champion• Review�of�human�performance�concepts�and�error�

prevention• Coaching�best�practices�and�tactics• Recommended�reading:

– The�Influencer– Managing�the�Unexpected– Crucial�Accountability

Sustainability• Monthly�discussion�sessions�lead�by�facility�lead�

Physician�Safety�Champion

Role Description

Definition• Provider�Safety�Champions�are�physicians�

and�advanced�practice�providers�who�are��passionate�to�influence�their�peers��to�participate�and�be�engaged��in�the�Riverside�Care�Difference�(RCD)�program

• Champions�use�informal�(just�in�time�intervention)�techniques�to�forward�the�acceptance�and�use�of�the�specific�Safety,�Quality,�and�Service�behaviors�and�tools�by�members�of�the�medical�staff�and�other�team�members�with�whom�they�collaborate�on�patient�care.

Responsibilities• Build�habits�for�Riverside’s�safety�behaviors�

using�5:1�Feedback�to�peers�and�team�members

• Communicate�vital�safety�and�RCD�information�(mission,�vision,�values,�beliefs,�policy,�protocol,�metrics�and�lessons�learned)�to�peers�and�team�members�during�meetings,�informal�observations�and�special�events.

• Communicate�patient�safety�concerns�to�administration�through�established�channels

• Know�and�use�the�Team�up�for�Safety�behaviors�and�tools�in�every�day�work

• Provide�peer�checking�and�peer�coaching�for�safety, reliability,�quality�and�service

• Share�safety�stories�with�colleagues• Support,�mentor,�and�partner�with�staff�

safety�coachesAccountability• Attend�orientation�and�training• Participate�in�at�least�six�monthly�safety�

coach�meetings�per�year• Model�Team�Up�for�Safety�behaviors�for�error�

prevention�for�peers�and�team�members• Participate�in�leadership�rounds�at�least�four�

times�per�year• Attend�safety�huddle�one�time�per�month• Attend�monthly�work�group�sessions�lead�by�

lead�Physician�Safety�ChampionReporting• Convey�observations�during�monthly�work�

group�sessionsTime�commitment• One�year�active�commitment• One�to�two�hours�per�month

Performance Appraisal

Dept # Department name7300XX Registered NurseJob code Job title

Empl ID # Employee name

FYE Appraiser name

1 - Does Not Meet2 - Marginally Effective3 - Fully Effective4 - Highly Effective5 - Exemplary

Any competency performance rating of 1, 2 or 5 requires comment completion.

Total Weight

*Overall Average

100

Job Criteria Weight Rating

ANA Standard 1: Assessment - Collects comprehensive data pertinent to the healthcare consumer’s health and/or the situation 4

Comments: DO TO AO DR

ANA Standard 2: Diagnosis - Analyzes the assessment data to determine the diagnoses or issues 4

Comments: DO TO AO DR

ANA Standard 3: Outcomes Identification - Identifies expected outcomes for a plan individualized to the healthcare consumer or the situation 4

Comments: DO AO DR

ANA Standard 4: Planning - Develops a plan that prescribes strategies and alternatives to attain expected outcomes 4

Comments: DO CF TO AO DR

ANA Standard 5: Implementation - Implements the identified plan: a). Coordinates care delivery; b). Employs strategies to promote health and a safe environment

4

Comments: DO CF AO DR

ANA Standard 6: Evaluation - Evaluates progress toward attainment of outcomes 4

Comments: DO CF TO AO DR

ANA Standard 7: Ethics - Practices ethically 3

Job Criteria ScoreLegend

Page 1 of 6


FYE Appraiser name

Comments: DO CF TO AO

ANA Standard 11 - Communication - Communicates effectively in all areas of practice 3

Comments: DO CF

ANA Standard 12: Leadership - Demonstrates leadership in the professional practice setting and the profession 3

Comments: DO CF

ANA Standard 13: Collaboration - Collaborates with healthcare consumer, family and others in the conduct of nursing practice 3

Comments: DO CF AO

ANA Standard 15: Resource Utilization - Utilizes appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible

3

Comments: DO CF DR

ANA Standard 8: Education - Attains knowledge and competency that reflects current nursing practice 3

Comments: DO TO T DR

ANA Standard 9: Evidence-Based Practice and Research - Integrates evidence and research finding into practice 2

Comments: DO TO AO T DR

ANA Standard 10: Quality of Practice - Contributes to quality nursing practice 2

Comments: DO CF TO AO T DR

ANA Standard 14: Professional Practice Evaluation - Evaluates her or his own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations

2

Comments: DO AO

ANA Standard 16: Environmental Health - Practices in an environmentally safe and health manner 2

Comments: DO CF0

Total weights of job criteria (should equal 50) : 50

Page 2 of 6


FYE Appraiser name

Page 3 of 6


FYE Appraiser name

Commitments are weighted at 10% each of total appraisal. 1 - Never Performance Improvement Plan (PIP) required for a score of "2" on 2 - Sometimes safety commitment (Always keep you safe). 3 - Usually

4 - Majority 5 - Always

Commitments Rating

Always keep you safe. -Pay attention to detail -Communicate clearly -Have a questioning attitude -Hand off effectively -Never leave my wingman

Comments:

PEER RATING = DO CF AO

Always treat you with dignity, respect, and compassion.-Greet customers immediately with a smile -Introduce myself and explain my role -Protect the privacy of my customers-Listen to customer ideas and thoughts without interruption-Ask, “Is there anything else I can do, while I’m here?

Comments:


Always listen and respond to you.-Make eye contact with my customers -Be sensitive to body language-Quickly attend to the needs of my customers-Take responsibility to acknowledge, address, and champion concerns-Thank my customers for sharing their concerns with me

Comments:


Always keep you informed and involved.-Welcome the questions of my customers-Partner with my customers in decisions that affect them-Explain things in a way that is easy for my customers to understand-Anticipate the needs of my customers for information and provide it frequently

Comments:


Commitments Score Legend

Page 4 of 6


FYE Appraiser name

Always work together as a team to provide you quality healthcare.-Introduce team members and explain their role to my customers-Respect the work and skills of others -Make our communication visible to my customers-Acknowledge information about my customers received from team members -Take responsibility for keeping other team members informed and safe

Comments:


Accomplishments:

Areas for Improvement:

Goals:Meet or exceed goals for quality (RLGL & readmissions), safety (hourly rounds, falls, caudi, BSI, etc), and customer service (75.5%) Volunteer as a staff member working on a project or team within 2BExhibit the Sentara Commitments every day with every patient or staff interactionAssist in meeting budget by arriving to and leaving work on time; good steward of supplies; etc.Attend atleast 6 critical thinking sessions offered in 2013Become a part of a professional organization and obtain med surg specialty certification when eligible

Employee Comments:

*The Overall Rating Average at the top of this page is a weighted average of all ratings. However, the Final Performance Appraisal Score is this employee's final rating. If this score differs from the Overall Score Average above, please review comments below:

Comments:

This employee meets the competencies required of this position:

The signing of this form means that you have reviewed the information contained herein.

Final Performance Appraisal Score

0

NO

Page 5 of 6


FYE Appraiser name

Manager signature Date

Employee signature Date

Page 6 of 6

Error Prevention Tool Quarterly Report

Name Date Select the quarter of submission:

��First Quarter ��Second Quarter ��Third Quarter � �Fourth Quarter 2013

A different example must be used for each quarter

Select the Error Prevention Tool and explain how you specifically used the tool:

� Attention to detail – We focus our attention to always think before we act, especially in high risk situations. Self checking using STAR.

StopThink Act Review

� Communicate Clearly – We’re responsible for professional, clear, and complete verbal and written communication.

3 way Repeat Back & Read Back Phonetic and Numeric Clarifications Clarifying Questions

� Handoff Effectively – We provide effective handoffs of patient, tasks, and materials by taking the time to give appropriate information and ensuring understanding and ownership.

SituationBackground Assessment Recommendation

� Speak up for Safety – We use good judgment at all times to ensure our actions are the best. We use an assertion and escalation technique to act on a responsibility to protect patients & co-workers in a manner of mutual respect.

Question & Confirm Use ARCC to escalate safety concerns � Ask a Question � Make a Request � Voice a Concern � Use Chain of Command Stop the Line

� Got your Back! – We make reliability by building our own sound practice habits and in our co-workers. We’re accountable not just for our own actions by for our teammates’ as well.

Peer Checking Peer Coaching

Utilize the space below to explain how you utilized the error prevention tool….

� Every employee has the goal to demonstrate mastery of EP tools by providing evidence of the use of 4 different tools as they apply to their scope of work.

� The attached document was developed for staff to document their accomplishments to be submitted to their manager (some expect it quarterly, others just want 4/yr). Or they can enter it directly into the electronic system for performance management.

� All of the Recruiters ask at least one Patient Safety question of all applicants: “Tell me about a time when you observed a situation where a patient could have been harmed. What did you do? What was the result?”

building a high reliability organization: sustaining

Documents