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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?