FY12 Annual Report - St. John Health System

10
Leading the way to a High-Reliability Organization
Collaborative shift changes lead to safety improvements
Literature shows that every hand-off, whether from shift to shift or unit to unit, is a potential root cause for errors. Units at St. John Macomb-Oakland, Providence Park and
St. John Hospital and Medical Center began piloting a new process for conducting patient hand-offs at the bedside during shift changes. Supported by education and scripting,
the units began using new Standard Operating Procedures designed to address barriers that had been thwarting effective hand-offs and most importantly, actively include the
patient in the process. Key components of the new SOP included:
• Nurses would try to resolve their patients’ pain before the end of their shifts.
• A private brief, nurse-to-nurse report would precede
bedside reports. Bedside reports include goal setting with
each patient and last two to three minutes. Reports would
begin within 10 minutes of shift start.
• Nurses would turn their in-house phones off during bedside
reports. Calls would go to unit coordinators and patient
care technicians.
• It became mandatory to complete the white boards in all
patient rooms.
• Patients and family members would receive
information about the hand-off process.
• Certain blocks of time were designated as
protected time for nursing, with ‘no admissions’
and ‘no procedures.’
• Breaks would not occur in the hour prior to shift change.
Nurses meet at St. John Hospital and Medical Center.
“My colleagues have special qualities that make them great nurses. I am proud to call them my co-workers and friends.”
—Donna Moran, St. John Macomb-Oakland, Macomb Center