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Disclosure

I do not have any affiliations with a commercial organization

SPEAK OUT FOR SAFETY:

COMMUNICATION TOOLS AND SAFETY CULTURE

Adele Harrison

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My Story

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Communication and Patient Outcomes500 Patient Safety &Learning System events/year

32% Patient Care Quality Office events

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Communication, Culture and Safety

CommunicationCulture

Safety

Engaged staff

Patient & Staff Safety

Patient & Staff Safety

“CUS” “I am concerned”“I am uncomfortable”“This is a safety issue”STOPClosed Loop

Communication

Repeating back in your own words

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Speak Out for Safety

Communication Tools

Culture of Safety

Enhanced Patient

Quality & Safety

Improved patient

experience

Safety events

reduced

Potential $41,000

saved/claim

Enhanced Staff

Satisfaction & Safety

Staff sick time

reduced 10%

Staff Injury

Reduced

Potential $24,000 saved/unit/year

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Aim Statement

To improve the patient safety culture by October 2014 as measured by a:

10% reduction in sick time (costs) 10% increase in patient safety event

reporting 10% increase in staff feeling safety

concerns are heard

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Build the team

Develop a vision and strategy

Gain understanding and buy-in

Empower others

Short term wins

The Project

Create a new culture

Create a sense of urgency

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The Teams

Susan Kurucz, Ann Dawkes and the Chemainus Health Care Centre staff, Island Health

Gillian Kozinka and the Victoria Neonatal Intensive Care Unit staff, Island Health

Bart Johnson, Quality and Safety, Island Health

Ann Marie Leijen and the UBC Sauder School of Business Physician Leadership Program

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Safety Climate

strongly

agree; 33%

agree; 40%

neu-tral; 20%

disagree, 7% strongly agree,

11%

agree; 50%

neutral, 28%

disagree; 11%

Do you feel your concerns about patient safety are heard?

Unit A Unit 1

What we Learned

No shortage of enthusiasm Staff looking for solutions to problems Importance of role modelling at all levels

of organization Different emphasis on the 2 tools for

each site Different implementation strategies for

different sites

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Sick time and overtime data: October 2014

2013 (1)

2013 (2)

2013 (3)

2013 (4)

2013 (5)

2013 (6)

2013 (7)

2013 (8)

2013 (9)

2013 (10)

2013 (11)

2013 (12)

2013 (13)

2014 (1)

2014 (2)

2014 (3)

2014 (4)

2014 (5)

2014 (6)

2014 (7)

0

200

400

600

800

1,000

1,200

1,400

1,600

Sick time and Overtime by time period (Unit A)

Overtime Worked Hours Sicktime Hours

Hours

Project start

699 to 425 (39% ↓)228 to 162 (29% ↓)

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Sick time and overtime data: January 2015

2013 (1)

2013 (2)

2013 (3)

2013 (4)

2013 (5)

2013 (6)

2013 (7)

2013 (8)

2013 (9)

2013 (10)

2013 (11)

2013 (12)

2013 (13)

2014 (1)

2014 (2)

2014 (3)

2014 (4)

2014 (5)

2014 (6)

2014 (7)

2014 (8)

2014 (9)

2014 (10)

0

100

200

300

400

500

600

Sick time and Overtime by time period (Unit A)

Overtime Worked Hours Sicktime Hours

Hours

Project start

221 to 178 (19% ↓) 303 to 404 (33%↑)

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Patient Safety Event Reporting

Jan

2010

Mar 2

010

May 2

010

Jul 2

010

Sep

2010

Nov 2

010

Jan

2011

Mar 2

011

May 2

011

Jul 2

011

Sep

2011

Nov 2

011

Jan

2012

Mar 2

012

May 2

012

Jul 2

012

Sep

2012

Nov 2

012

Jan

2013

Mar 2

013

May 2

013

Jul 2

013

Sep

2013

Nov 2

013

Jan

2014

Mar 2

014

May 2

014

Jul 2

014

Sep

2014

Nov 2

014

0

5

10

15

20

25

30

35

40

45

Patient Safety & Learning System Reporting

1 - No harm 2 - Minor harm 3 - Moderate harm 4 - Severe harm

Project start

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Patient Safety Event Reporting

↑ from 62% to 81%

Jun 2011

Jul 2011

Aug 2011

Sep 2011

Oct 2011

Nov 2011

Dec 2011

Jan 2012

Feb 2012

Mar 2012

Apr 2012

May 2012

Jun 2012

Jul 2012

Aug 2012

Sep 2012

Oct 2012

Nov 2012

Dec 2012

Jan 2013

Feb 2013

Mar 2013

Apr 2013

May 2013

Jun 2013

Jul 2013

Aug 2013

Sep 2013

Oct 2013

Nov 2013

Dec 2013

Jan 2014

Feb 2014

Mar 2014

Apr 2014

May 2014

Jun 2014

Jul 2014

Aug 2014

Sep 2014

Oct 2014

Nov 2014

Dec. 2014

0

10

20

30

40

50

60

70

80

90

100

No harm reporting as percentage of total PSLS events

Perc

eent

age

of n

o ha

rm re

porti

ng

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Safety Climate

Excellent40%

Very

good40%

Ac-cepta-ble20%

Excellent20%

Very good60%

Ac-ceptable20%

Please give your unit an overall grade on patient safety

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Safety Climate

strongly

agree;

33%

agree; 40%

neutral; 20%disagree; 7%

strongly agree

80%

neutral20%

Do you feel your concerns about patient safety are heard?

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What did the data mean to you? Did the patient safety culture

improve by October 2014?

10% reduction in sick time (costs)?

10% increase in patient safety event reporting?

10% increase in staff feeling safety concerns are heard?

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Speak Out for Safety

“CUS” “I am concerned”

“I am uncomfortable”

“This is a safety issue”

STOP

Closed Loop Communication