0 engagement and empowerment of frontline staff to promote a culture of safety: a safety champion...
TRANSCRIPT
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Engagement and Empowerment of Frontline Staff to Promote a Culture
of Safety: A Safety Champion Program
Jeanette Tanafranca, MSN, RN-BC
Safety Champion
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Why do we need a Safety Champion program?
During this 20 minute presentation:• 5 – 7 patients across the U.S. will
die due to medical error or infections
• 85 – 113 patients will be hurt• 21 – 29 employees will
experience a needle-stick injury
Improving Healthcare Using Toyota Lean Production Methods R. Chalice, 2007Levinson, D. R. (2008). Adverse events in hospitals: overview of key issues. Department of Health and Human Services, Office of Inspector General. Retrieved at: http://oig.hhs.gov/oei/reports/oei-06-07-00470.pdfIOM (1999). To err is human: building a safer health system. Retrieved at: http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdfKohn, L.T., Corrigan, J.M., and Donaldson, M.S. (Eds). (2000). To err is human: building a safer health system. Committee on Quality of Healthcare in America. Washington, DC: National Academy Press.
Health care is not safe.
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1. Identify Top Causes of Harm
2. Enhance our Culture of Safety
3. Improve the Quality and Clarity of Clinical Communications
4. Redesign Care To Eliminate Harm
HARM
50%
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No Harm Campaign Extended 3 more years
Combined Harm Rate HFHS Hospitals by Hospital
20
30
40
50
60
70
80
Jan-
08
Mar
-08
May
-08
Jul-0
8
Sep-
08
Nov-
08
Jan-
09
Mar
-09
May
-09
Jul-0
9
Sep-
09
Nov-
09
Jan-
10
Mar
-10
May
-10
Jul-1
0
Sep-
10
Nov-
10
Jan-
11
Mar
-11
May
-11
Jul-1
1
Rate
per
100
0 Da
ys
HFH Clinton Twshp Warren West Bloomfield Wyandotte All
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Establish a Common Language
Create Safe Environments
Build Local Structure
Formal
Team Training
HFHS Culture of Safety Building Blocks
Safety Champions
Safety Culture Global Indicators
• Organizational commitment• Management Involvement• Employee Empowerment• Reward Systems (Just Culture)• Reporting Systems
HFHS Added:• Partnerships with Patients and
Families
Wiegmann, D.A., Zhang, H., von Thaden, T., Sharma, G. and Mitchell, A. (2002). A synthesis of safety culture and safety climate research (Technical Report ARL-02-3/FAA-02-2). Savoy, IL: Aviation Research Lab Institute of Aviation.
Enhancing our Culture of Safety
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Impact of Safety Champion Program
2006 - 2010 Comparison of Percent Favorable: (4 - Agree and 5 - Strongly Agree)
76
62 59
34
81 82
68
8379
70
58
7774
53
65
7473
80
0
10
20
30
40
50
60
70
80
90
100
Mgt actionsshow safety is
a priority
We areencouraged to
speak up
I would feelsafe as a
patient here
Lots of nursedoctor
teamwork
Clinicaldisagreementsresolved well
Communicationbreakdown
leading to caredelays rareCulture of Safety Question
%
2006 2008 2010 AHRQ 75th Percentile 2010 AHRQ 90th Percentile 2010
N=15,767 N=15,683 N=16,566 N=10,407 N=10,994 N=10,994
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Safety Champ vs. No Safety ChampCOS & Engagement Scores
Units with Safety Champions showed improvement for all
safety questions and engagement questions compared to units
without safety champions.
0.090.14 0.22
0.190.14
0.3
-0.1-0.05
00.050.1
0.150.2
0.250.3
0.35
Man
agem
ent
Act
ions
Enc
our
aged
to S
pea
k U
p
Fee
l Saf
e as
a P
atie
nt
at H
FH
S f
acili
ty
Lots
of
team
wo
rk
bet
wee
n nu
rses
and
d
oct
ors
Dis
agre
emen
ts
reso
lved
wel
l
Co
mm
unic
atio
n b
reak
do
wns
un
com
mo
n
C05 C06 C07 C08 C09 C10
Dif
fere
nce
Bet
wee
n 2
010
and
200
8 M
ean
S
core
s
COS Question
Safety Champion vs. No Safety Champion (Clinical Units)Improvement 2010 vs. 2008
NO Safety Champ
Safety Champ
Engagement Scores Improvement 2010 vs. 2008Safety Champ vs. No Safety Champ (Clinical Units)
0.08
0.15
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
Q12 GMEAN
12 Engagement Questions GMEAN
Diff
eren
ce B
etw
een
2010
and
20
08 G
ME
AN
Sco
res
No Safety Champion
Safety Champion
0.1 improvement = meaningful0.2 improvement = statistically significant
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Safety Champion Program
“Coming together is a beginning;
Keeping together is progress;
Working together is success.”
Henry Ford
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Program Objectives
• To develop a network of multidisciplinary front-line safety experts
• Create ‘error wisdom’ at the front line
• Support HFHS core values for patient safety and the No Harm Campaign – build a culture of safety
First Safety Champions 6/2008
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Who are Safety Champions?
• Front line, multidisciplinary employees that act as a “Voice” and “Face” of Safety.
– Have a genuine interest in safety– Model safe practices– Model HFHS Core Values for Patient Safety– Respected by peers– Are willing and able to communicate information (i.e. patient safety goals,
personal safe practices, reporting) at department meetings/briefings/huddles
– Are willing to embrace a leadership opportunity– Create a ripple effect
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Conceptual Framework
Adapted from Dr. Patricia Benner’s Stages of Clinical Competence
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Safety Champion Program
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Core CoursesPatient Safety 101
Introduction to the Safety Champion Role
-Human Factors
CommunicationMonthly Toolkits
Bi-Monthly Newsletters/Great Catch
Process Improvement
Reporting
Strategies
Projects
Sharing
LearningQuarterly Forums
2 Minute Tutorials
Professional DevelopmentIHI Open School
Conferences
Program Start: June, 2008
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Human factors research has shown that even highly skilled, motivated professionals are vulnerable to error due to
inherent human limitations – really ‘good’ people will make mistakes
Core CoursesI. Patient Safety 101
II. Introduction to the Safety Champion Role
(Human Factors)
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Which is the One Cent U.S. Coin?
A Simple Example of the Limits of Memory
Memory- we generally store only partial descriptions of things to be remembered, descriptions that are sufficiently precise to work at the time something is learned but may not work later on when new experiences are encountered.
Image Source:http://www.dcity.org/braingames/pennies/
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Safety Champion Program
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Core CoursesPatient Safety 101
Introduction to the Safety Champion Role
-Human Factors
CommunicationMonthly Toolkits
Bi-Monthly Newsletters/Great Catch
Process Improvement
Reporting
Strategies
Projects
Sharing
LearningQuarterly Forums
2 Minute Tutorials
Professional DevelopmentIHI Open School
Conferences
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Safety Champion Program
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Core CoursesPatient Safety 101
Introduction to the Safety Champion Role
-Human Factors
CommunicationMonthly Toolkits
Bi-Monthly Newsletters/Great Catch
Process Improvement
Reporting
Strategies
Projects
Sharing
LearningQuarterly Forums
2 Minute Tutorials
Professional DevelopmentIHI Open School
Conferences
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Sharing & Learning
• Quarterly Forums: Identify top causes of harm, Culture of Safety, Just Culture,Error Reporting & Error Prevention, Speak Up, Speak Out: Creating Safe Environments, Getting LEAN with Hand Hygiene, Healthcare Equity and Culturally Competent care, Emergency Preparedness and Patient Safety….
• 2 Minute Tutorials: “How To’s”
• Great Catch Stories
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Safety Champion Program
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Core CoursesPatient Safety 101
Introduction to the Safety Champion Role
-Human Factors
CommunicationMonthly Toolkits
Bi-Monthly Newsletters/Great Catch
Process Improvement
Reporting
Strategies
Projects
Sharing
LearningQuarterly Forums
2 Minute Tutorials
Professional DevelopmentIHI Open School
Conferences
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Process Improvement
• Accurate and Voluntary reporting through our reporting system.
• Project survey.
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•2 patient identifier projects•Revised SBAR form for patient hand-offs•Selecting equipment for hospital•Post-fall management program•Handicapped parking assistance•Bladder health and collaborative project•Handwashing projects•Medication review process•Mammogram process review•Medication dispensing projects•A3s-Needlestick prevention•More…..
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• Safety Champions reviewed employee injury data and identified that lift injuries are in the top 3 (2010-2011).– Conducted a survey that employees
stated that lifts were a number one concern of what injury they felt would happen in their area.
• Conducted A3s on sharp containers and the inappropriate use of biohazard bags. – An EOC audit showed a spike in finding
the biohazard bags used inappropriately – SC Team conducted additional education
and weekly
HF West BloomfieldImpact of Safety Champion Program
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HFH Inpatient PharmacyImpact of Safety Champion Program
• Process 7,000 medications orders per day• Dispense 17,000 medication doses per day• Recognize human limitations and have made 49
system improvements since joining the program
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Safety Champion Program
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Core CoursesPatient Safety 101
Introduction to the Safety Champion Role
-Human Factors
CommunicationMonthly Toolkits
Bi-Monthly Newsletters/Great Catch
Process Improvement
Reporting
Strategies
Projects
Sharing
LearningQuarterly Forums
2 Minute Tutorials
Professional DevelopmentIHI Open School
Conferences
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Safety Champion Successes
• 378 Safety Champions (multidiscplinary, multiple business units)
• 100% would recommend program
• >95% favorable with class and forum surveys
• 95% share toolkits and newsletters
• 88% believe they have made an impact on the culture of safety for their units
• 80% participate in safety improvement work
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I am a Safety Champion because I do my best to live the Henry Ford Experience of caring about people by helping to make sure they are safe,…on a daily basis..Ruth
Patient Safety means......" putting forth a conscience effort to protect our patients and
employees by minimizing risk and adhering to all set standards while providing the highest quality care in the safest work environment possible!!!! Dawn Dombek-Bailey, CHSP
I make a difference in the lives of all persons who enter HFHS properties. MaryAnn L. Northcote, CPP, CHSP I am a safety champion because
I want to be proactive in spreading wellness to individuals
that are in my reach. Injury prevention is a key component in
helping our loved ones and others in our community stay safe and
healthy..Katie Horn
I am a safety champion
because I CAN and DO make a difference one person at a time". Stephanie B. Anderson, RN, MSN
Patient Safety means….delivering the highest quality care that is reliable and coordinated for the patients we serve each day..Judy Caretti-Rourke
I make a difference to
everyone that comes in contact with me in the
Henry Ford Health system..Latonya Phillips
I am a Safety Champion because......the environment I work in and the people I serve are
important to me“ LesaBorden Sanford RN, BSN
Patient Safety means being pro-active in creating and maintaining
safe environments for our patients who depend on us when they are most vulnerable. Judy Czerepowicz, CHSP
Safety Champions Can and Do Make a Difference in Patient Safety by Being
Proactive, Minimizing Risk, Creating Safe Environments Because its Important to the
Lives of ALL.
-HFHS Safety Champions
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Thank You to all of the HFHS Safety Champions for making a difference.
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Contact Information
Jeanette Tanafranca, MSN, RN-BC
Office of Clinical Quality and Safety
One Ford Place, Detroit, MI 48202
313.874.7181
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