Balancing Systems and Individual Accountability in a Safety Culture

Consider a Case• The ED was busy. The trauma service was treatingother victims of the MVC.• Policy directs personnel to confirm two identifiersbefore administering blood products. After a “closecall” a year earlier, all ED and operating room (OR)personnel were retrained.Hickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.4NPSF Professional Learning Series

Consider a Case• Quality and risk teams will review records and scheduleinterviews.• Policy directs a root cause analysis (RCA) to beattended by involved personnel.• Other thoughts:• “I wonder what has been shared with the family.”• You also think about your team—nurses, physicians, or others—who are involved• You make a mental note to alert the wellness program directorHickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.5NPSF Professional Learning Series

But how do we prevent…?6NPSF Professional Learning Series

But how do we prevent…?• Hospitals and medical groups are highly complex.• Humans are complex and subject to….• Balancing systems and individual accountability iscentral to the operations of a safety culture.Hickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.7NPSF Professional Learning Series

Accountability“Systems”“Human”8NPSF Professional Learning Series

But there is hope…• Baptist Memorial Hospital–Desoto (MS) IHI’s IMPACTICU collaborative• Infection rates fell• VAP (7.5 to 3.2 per 1,000 ventilator days)• BSIs (5.9 to 3.1 per 1,000 line days)*• The Michigan Health & Hospital Association (MHA)Keystone ICU project• 60% reduction in CLABSIs• Sustained at 36 months post-implementation of interventions***Jain M et al.: Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiativefocusing on teamwork and culture change. Qual Saf Health Care 15:235–239, Aug. 2006.**Pronovost PJ et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units:Observational study. BMJ 340:c309, Feb. 2010.9NPSF Professional Learning Series

But there is hope…• Elements that promote success in pursuit of safety:1. Clear leadership commitment2. Articulated goals3. Changes in work patterns to create teams that communicate andparticipate in decision making4. Elimination of unnecessary variation5. Measures for tracking progress and providing feedback6. Stepwise, graduated interventions for personnel exhibitingnon-teamwork-promoting (disruptive) behaviorHickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.10NPSF Professional Learning Series

Pursuit of Safety• Four foundational elements:• Shared values and goals• Effective leadership• Teamwork• Safety culture• All affirm and mutually reinforce tomake health care saferHickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.11NPSF Professional Learning Series

What are the prerequisites?• Shared values and goals for team members (all)Credo• I make those I serve my highest priority.• I communicate effectively.• I conduct myself professionally.• I respect privacy and confidentiality.• I have a sense of ownership.• I am committed to my colleagues.Hickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.12NPSF Professional Learning Series

What are the prerequisites?• Clear Leadership Commitment (modeled)• Authority derives from their organization role, policy directives, andhospital and medical staff bylaws, as reflected in accreditationstandards.• Leaders understand mission and credo.• Leaders establish (and follow) processes that are transparent anddata driven.• Leaders understand their own accountability.• Leaders will not “blink.”Hickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.13NPSF Professional Learning Series

Values and leadership (modeled)allow “teams” to flourish.14NPSF Professional Learning Series

How do you know (or do you know)when an event (or near miss) occurs?Will team members report?15NPSF Professional Learning Series

Our team members feel free toreport or refer DB40%1. Strongly agree2. Agree3. Uncertain4. Disagree5. Strongly disagree5%20%26%9%1 2 3 4 516NPSF Professional Learning Series

Team members will report if:• There is psychological safety• There is a belief that the organization will reviewand act to address both unsafe systems andnon-teamwork-promoting (disruptive) behaviorHickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.17NPSF Professional Learning Series

What are the prerequisites?• Surveillance systems• Executive walk-arounds allow leaders to visit…observe, listen andask questions that elicit information about events or near misses,concerns about safety*• Team member reports – incidents, events, near misses,unprofessional behavior, observed or suspected violations ofregulatory requirements (privacy, unethical or improper conduct),harassment or discrimination complaints, unsafe equipment andmedications, equipment/product recalls*Frankel A et al. Patient safety leadership walkrounds. Jt Comm J Qual Saf 29:16–26, Jan. 2003.18NPSF Professional Learning Series

What are the prerequisites?• Surveillance systems continued• Safety culture surveys• Unsolicited patient/family complaints*• Trigger tools (systematic review of patient charts to findmarkers that can identify harm)***Institute for Healthcare Improvement: IHI GlobalTrigger Tool Guide. Dec. 2006. http://www.unmc.edu/rural/patient-safety/tooltime/TT13-040207-5MillionLives/IHIGlobalTriggerToolGuideDec06.pdf (accessed July 15, 2011).** Hayden AC et al. Best practices and advanced skills in healthcare service recovery programs. Jt Comm J Qual Saf.36(7):310–318. July 2010.19NPSF Professional Learning Series

Morbidity, Mortality &Improvement ConferenceMonroe Carell Jr. Children’s Hospital at Vanderbilt[Date]Dies JN, Smith KM, Warren MD, et al. Transforming the morbidity and mortality conference into an instrument forsystem wide improvement. AHRQ: http://www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Deis_82.pdf.(accessed Sept. 9, 2011).21NPSF Professional Learning Series

MM&I = M+M & ImprovementThe discussions in this conference areFOR QUALITY IMPROVEMENT/ PEER REVIEW PURPOSES ONLYFor the purposes of M+M & Improvement, an error is defined as:“an occasion in which a planned sequence of mental or physicalactivities fails to achieve its intended outcome.”What is said here…stays here!Reason JT. Human error. NY: Cambridge University Press, 1990.22NPSF Professional Learning Series

Issues IdentifiedPEOPLEENVIRONMENTWorkloadExperience levelLack of agreement among healthcareteam re goals of treatmentMultiple services/consultantsFailure to recognize changingclinical status or vital signsOverflow policy not followedLack of awareness of back-upProcesses for “off” hoursand downtimesIncomplete or lackof “sign-out”InconsistentreassessmentFloor team not aware ofpatient’s admissionLack of reassessmentNot always clear when patient“leaves our space”;who is responsible for the patient?Busy Friday nightShift changeIncorrect patientplacement based on presentingphysical examICU bed availabilityPerceived different level of clinical ancillarysupport available “day” versus “night”Incomplete documentationIncomplete exchange ofclinical informationKey clinical information notavailable or communicatedTimes not documentedconsistentlyPatient/familycomplianceIncompletehistory givenby parentDelay in familyacceptanceof clinicalinformationAdverse Outcome/“Near Miss”POLICY/PROCEDURECommunication/DocumentationOTHERKaoru Ishikawa, 199023NPSF Professional Learning Series

Working Action PlanWHAT WHO WHENSTATUSas of Jan. 2006ED to FloorCommunicationDr. XX– Pediatric Chief ResidentDr. YY– Pediatric Chief ResidentOct. 2005CompletedSBAR - Internal TransferCommunicationZZ– VCH PM&IDr. XX– Pediatric Chief ResidentDec. 2005CompletedClinical SupportTurn-Around TimesAA– VCH Administration Nov. 2005 CompletedRapid Response TeamDr. BB– Chief of StaffCC– VCH AdministrationDD– Manager, PCCUNov. 2005ActivePhysician “sign-out”and TransferCommunicationDr. EE– Pediatric SurgeryDr. XX– Pediatric Chief ResidentDr. YY– Pediatric Chief ResidentNov. 2005Partiallyimplemented(Pediatric Medicine)24NPSF Professional Learning Series

What are the prerequisites?• Resources• Funds to support dedicated personnel• Costs of training leaders• Costs of surveillance systems for monitoring performance• Informatics and/or biostatistics support• Consultations with mechanical and human factors engineers• Methodology for assessing financial implications related to returnon investment and value-based purchasingHickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.25NPSF Professional Learning Series

Reason’s “Unsafe Acts”Algorithm (1997):• Did the team member intend to cause harm?• Did the team member come to work impaired?• Did the team member knowingly and unreasonablyincrease risk?• Would another team member in the same situationact in a similar manner?Reason JT. Managing the Risks of Organizational Accidents. Aldershot, UK: Ashgate Publishing, 1997.26NPSF Professional Learning Series

Accountability PyramidAdapted from Hickson• GB, Pichert JW, Webb LE,Gabbe SG. Acad Med.Nov, 2007.No∆PatternpersistsApparentpatternSingle“unprofessional"incidents (merit?)Level 3 "Disciplinary"InterventionVast majority of professionals - no issues -provide feedback on progressLevel 2 “Guided"Intervention by AuthorityLevel 1 "Awareness"InterventionMandatedMandated Reviews"Informal" Cupof CoffeeIntervention27NPSF Professional Learning Series

But does an accountabilitypyramid really work?Yes, if leaders follow theprocess and don’t “blink.”28NPSF Professional Learning Series

Patient Complaints• “Dr. __ told us he was very busy and could not bespread any thinner, and that we did not appreciate thedepth of his expertise.”• “Dr. ___ is either too busy or scatterbrained to read myfiles or is dangerously neglectful.... I fear for my safetyand for her other patients....”• “Dr. __ inserted a drain and walked out of the room.After a while another MD removed the drain andexplained it wasn’t even in the cyst.”29NPSF Professional Learning Series

Academic vs. Community Medical Center% of Concerns100755025035–50% of physicians associated with NO concerns50% of concerns associated with 9–14% of physiciansAcademic Med CtrCommunity Med Ctr30 40 50 60 70 80 90 100% of PhysiciansHickson GB et al. SMJ. 2007; Hickson GB et al. JAMA. 2002 June 12;287(22):2951–2957.30NPSF Professional Learning Series

Accountability PyramidAdapted from HicksonGB, Pichert JW, Webb LE,Gabbe SG. Acad Med.Nov, 2007.No∆PatternpersistsApparentpatternSingle“unprofessional"incidents (merit?)Level 3 "Disciplinary"InterventionLevel 2 “Guided"Intervention by AuthorityLevel 1 "Awareness"InterventionMandatedVast majority of professionals - no issues -provide feedback on progressMandated Reviews"Informal" Cupof CoffeeIntervention31NPSF Professional Learning Series

Intervention on Dr. __• Letter with standings,assurances prior to and at meeting• “You are here” graph with4-yr Risk ScoresFrequency of Risk Scores for Your Institution’s PhysiciansThis graph shows the distribution of physician Risk Scores. The Risk Score isbased on an algorithm in which complaints about physicians filed in more recentyears have greater impact than those from previous years.YourRiskScore• Complaint Type Summary• “Concerns” bullet list• Redacted narrative reports32NPSF Professional Learning Series

PARS ® Progress ReportTotal # of high-complaint physicians 723Departed after initial intervention 48First follow-up later in ’11 –’12 130Total with follow-up results 545Results for those with follow-up data:Good – Intervention visits suspended 262 48%Good – Anticipate suspension in ’11-’12 95 17%Some improvement – Still need tracking 31 6%Subtotal 388 71%Unimproved/worse 115 21%Departed Unimproved 42 8%Total follow-up results 54533NPSF Professional Learning Series

Back to the case• The RCA revealed:• The incompatible units were intended for a second victim.• During the frenzy of activity, a nurse was dispatched fortrauma blood.• By chance, he pulled two units intended for another patient(E-admitting system did not “talk” to lab system).Hickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.34NPSF Professional Learning Series

Back to the case• The RCA revealed:• As the nurse approached patient’s bedside, he cameunder a barrage of expletives from Surgeon X aboutgetting the #@*&%! blood in.• Nurse asserted, “I tried once to state I was followingprocedure but felt pressured to do as ordered.”• Another team member—an RN—recognized the high-risksituation but reflected, “I just didn’t speak up.”Hickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.35NPSF Professional Learning Series

Accountability“Systems”“Human”36NPSF Professional Learning Series

Back to the case• Creation of interface between admittingand lab systems• Creation of reliable system for receivingand storing blood• ID of triggers to recruit help whendemand escalates….Hickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.37NPSF Professional Learning Series

But what about the humanaccountability?38NPSF Professional Learning Series

You meet with Nurse 2System Needs:• The observer:• Recognized a problem (colleague under verbal assault)but did not speak up or get help.• No evidence of intended harm…no history of unsafeacts.... You believe others might have behavedsimilarly.39NPSF Professional Learning Series

You meet with Nurse 2• However, by not speakingup, Nurse 2 increased theprobability of risk.• You follow up this isolatedincident with an informalcup of coffee conversation.Accountability PyramidAdapted from HicksonGB, Pichert JW, Webb LE,Gabbe SG. Acad Med.Nov, 2007.No∆PatternpersistsApparentpatternSingle“unprofessional"incidents (merit?)Level 3 "Disciplinary"InterventionMandatedVast majority of professionals - no issues -provide feedback on progressMandated ReviewsLevel 2 “Guided"Intervention by AuthorityLevel 1 "Awareness"Intervention"Informal" Cupof CoffeeIntervention40NPSF Professional Learning Series

Principles for “Informal”Conversations• Your role:• To report an event• To let the colleague know that the behavior/actionwas noticed (surveillance)• To avoid embarrassment/humiliation• Know message and “stay on message.”• Allow the individual to be a professional.41NPSF Professional Learning Series

You meet with Nurse 1• Came under verbal assault by Surgeon X.• Reason’s Unsafe Acts Algorithm: Did not intend...no priorhistory.... The nurse acknowledges violating a policy.• You believe a Level 1 “Awareness” feedback would beappropriate to allow the nurse, as a professional, toreflect on what happened.• Goal is to provide feedback in a way designed to protectother patients and to protect the well-being of your team.42NPSF Professional Learning Series

“Awareness” Guiding PrinciplesHow to have the conversation:• Review whatever “data” or story you have.• Seek subordinate colleague's view (anticipatepotential responses).• Invite (subordinate) colleague to take time to identifypotential ways to address issue(s).• Express appreciation if possible; acknowledgecontributions to organization; however…• Explain that you will follow up….• Document the conversation.43NPSF Professional Learning Series

You meet with Nurse 1• You affirm that Nurse 1 is avalued team member.• You review the results ofthe RCA.• Ask Nurse 1 to reflect on theissues….• Nurse 1 asks for assertivenesscoaching as is concerned thathe allowed another teammember to intimidate him.Accountability PyramidAdapted from HicksonGB, Pichert JW, Webb LE,Gabbe SG. Acad Med.Nov, 2007.No∆PatternpersistsApparentpatternSingle“unprofessional"incidents (merit?)Level 3 "Disciplinary"InterventionMandatedVast majority of professionals - no issues -provide feedback on progressMandated ReviewsLevel 2 “Guided"Intervention by AuthorityLevel 1 "Awareness"Intervention"Informal" Cupof CoffeeIntervention2744NPSF Professional Learning Series

When Surgeon X yelled…“get the#@*&%! blood in…”(non-teamwork promoting)?45NPSF Professional Learning Series

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Definition of Disruptive Behavior• Disruptive behavior includes, but is not limited to,words or actions that:• Prevent or interfere w/an individual’s or group’s work, academicperformance, or ability to achieve intended outcomes(e.g., intentionally ignoring questions or not returning phone calls orpages related to matters involving patient care, or publicly criticizingother members of the team or the institution).• Create, or have the potential to create, an intimidating, hostile,offensive, or potentially unsafe work or academic environment(e.g., verbal abuse, sexual or other harassment, threatening orintimidating words, or words reasonably interpreted as threateningor intimidating).• Threaten personal or group safety, aggressive or violent physicalactions.• Violate VUMC policies, including conflicts of interest andcompliance.Vanderbilt University and Medical Center Policy #HR-027, 2010.47NPSF Professional Learning Series

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Consequences of Disruptive Conduct:Patient Perspective(tip of the iceberg)Drop out, leaving AMALawsuitsErrorsVoicedComplaintsNon adherence/noncomplianceBad-mouthing the practiceto others49NPSF Professional Learning Series

Failure to Address Disruptive BehaviorLeads to:• Team members may adopt disruptive person’s negativemood/anger (Dimberg & Ohman, 1996)• Lessened trust among team members can lead to lessenedtask performance (always monitoring disruptive person)...affects quality and patient safety (Lewicki & Bunker, 1995;Wageman, 2000)• Withdrawal (Schroeder et al, 2003; Pearson & Porath, 2005)Felps W et al. How, when, and why bad apples spoil the barrel: Negative group members anddysfunctional groups. Research and Organizational Behavior. 2006;27:175–222.50NPSF Professional Learning Series

“RN did not call the doctor about change inpatient condition because he had a history ofbeing abusive when called. Patient sufferedbecause of this.”Rosenstein A, O’Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J AmColl Surg. 2006;203:96–105.51NPSF Professional Learning Series

Prior to the meeting with Surgeon X• Review results of RCA• Review other performance/behavior data• 3 med mal claims• An apparent pattern on non-teamwork promoting (disruptive)behavior directed toward patient and staff• You previously spoke with Surgeon X about complaintsfrom coworkers and patients.• You find it concerning that Surgeon X failed to self-correctafter previous (awareness) feedback.52NPSF Professional Learning Series

Accountability PyramidAdapted from HicksonGB, Pichert JW, Webb LE,Gabbe SG. Acad Med.Nov, 2007.No∆PatternpersistsApparentpatternSingle“unprofessional"incidents (merit?)Level 3 "Disciplinary"InterventionLevel 2 “Guided"Intervention by AuthorityLevel 1 "Awareness"InterventionMandatedVast majority of professionals - no issues -provide feedback on progressMandated Reviews"Informal" Cupof CoffeeIntervention53NPSF Professional Learning Series

Guided Intervention• Pattern, no improvement; or• Singular significant event• Plan developed:• Authority figure and individual co-develop a plan; or• Authority figure develops and specifies plan• Clearly defined consequences if plan not followedor doesn’t work within defined time54NPSF Professional Learning Series

Resources and ToolsEvaluating and Addressing DB• Coaches, Counselors• Eval/Assmt Centers• Risk Managers• Physician Wellness• State Med Assoc• Office of GeneralCounsel• Professional Societies• Quality/Safety Officers• Patient Relations Staff• Employee AssistanceProgram• Joint Commission• Courses, Groups• 360 Evaluations• Others55NPSF Professional Learning Series

Accountability“Systems”“Human”56NPSF Professional Learning Series

Components of a Safety Culture• Safety is one of our organization’s primary goals.• Leaders recognize that adverse (or “bad”) outcomesoccur because of systems’ and/or individuals’contributions.• Leaders commit to a balanced approach toaddressing both system and individual accountability.Hickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.57NPSF Professional Learning Series

A Call for Clean Hands:Vanderbilt Hand HygieneTom Talbot, MD, MPHTitus Daniels, MD, MPHClaudette Fergus, BA, RNGerald Hickson, MD, and theHand Hygiene Committee,a Pillar Goal Committee58NPSF Professional Learning Series

Path to Compliance• In June 2009 VUMC Hand Hygiene Compliance was 58%• July 2009 marked the beginning of Hand HygieneCompliance as a metric in the VUMC Allocation RebateProgram with the following goals for March–May of 2010:• Reach 80% compliance rate• Target 75% compliance rate• Threshold 70% compliance rate59NPSF Professional Learning Series

A Project Bundle1. Learning systems2. People3. Organizational readinessHickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.60NPSF Professional Learning Series

A Project Bundle1. Learning systems• Surveillance systems• Event reporting (staff observations of DB)• Executive walk-arounds• Patient/family complaints• Benchmarking data• National alerts• Needs assessment and impact analysis• Process to review data, seek trends, and report out• Measurement systems and tools• Multilevel professional education and training61NPSF Professional Learning Series

A Project Bundle2. People• Leadership commitment• Endorsement and support (will not “blink”)• Accountable to Board, mission, and vision• Will act to support and sustain a culture of safety• Dedicated project team• Reasonable (neither “wimps” nor “on a mission”)• Willing and able• No “token” members• Robust load-leveling• Project champions• Willing and able• No “token” leaders• X-factor: objective and with ability to inspire, sustain62NPSF Professional Learning Series

A Project Bundle3. Organizational readiness• Alignment with goal• Pillar priority• Leader, chair, section chief, unit leaders• Congruent or adaptable policies – “Who anointed you…?”• Plan and model for improvement• Implementation of best practices (adopt or adapt)• Plan to develop and test new interventions• Resources for team• $$• Intradepartmental coordination of resource allocation• Value analysis and impact63NPSF Professional Learning Series

100%VUMC Hand Hygiene Compliance90%80%70%Our data was lessthan ideal…60%50%40%Jun-09 Sep-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11Quarterly DataThreshold Target Reach HH Monthly HH YTD64NPSF Professional Learning Series

100%VUH Hand Hygiene Compliance Rate YTD (7.1.10 - 2.28.11)95%90%85%80%75%70%65%60%55%50%45%40%TVC HR/PACU6 S Cardiac Short Stay/Inter11 N Myelo (BMT/Onc)TVC RadiologyVOR PACU9 S Gen Surgical3/4 RW Colorectal/Genl SurgeryMCE Holding/ PACU11 S Burn Unit5 N Cardio ICUVOS OR/HR/PACUCardiac Catherization Lab6 N Neurology/Epilepsy8 N General Medical4 N Labor and Delivery7 RW Medicine/Geriatrics9 N General Surgical Stepdown8 S General Medical5 S Cardio Progressive Care5/6 RW Ortho/Urology6T3 Neuro Care Unit4 S Gynecology Surgery4 E10 N Trauma Care7 N Cardiac Stepdown Unit10 S Renal Transplant8T3 Medical ICU10 S DialysisVOR POD #2 - NeuroVOR POD #3 - OrthoCT Radiology9T3 SICUVUH EDVOR POD #4 - HGTVMRI RadiologyVOR POD #1 - OOPSVOR Holding RoomVOR POD #5 - CardiacThis information is peer review material designed to improve the quality of patient care and is privileged and confidentialpursuant to TCA section 63-6-219.65NPSF Professional Learning Series

Accountability PyramidAdapted from HicksonGB, Pichert JW, Webb LE,Gabbe SG. Acad Med.Nov, 2007.No∆PatternpersistsApparentpatternSingle“unprofessional"incidents (merit?)Level 3 "Disciplinary"InterventionLevel 2 “Guided"Intervention by AuthorityLevel 1 "Awareness"InterventionMandatedVast majority of professionals - no issues -provide feedback on progressMandated Reviews"Informal" Cupof CoffeeIntervention66NPSF Professional Learning Series

December 22, 2010To: Medical Director, MDAdministrative ManagerFrom: Thomas R. Talbot, MD, MPHChair, Hand Hygiene Pillar Goal CommitteeGerald B. Hickson, MDDirector, VUMC Clinical Risk and Loss PreventionNancye Feistritzer, RN, MSNCo-Chair, Hand Hygiene Pillar Goal CommitteeAssociate Hospital Director, Perioperative ServicesCC: Department Chair, MDQuality and Patient Safety Director, MDAssociate Hospital Director (units), RN, MSNAdministrative Area Manager, RN, MSNWe are allcommitted tominimizing therisk ofhealthcareassociatedinfections.Performinghand hygiene isthe mostimportantaction we cantake …Awareness Letter…your areacompliancerate was 35%,and for FY11-to-date, 47%.A member of ourPillar GoalCommittee team willcontact you toschedule a time tomeet so we maypartner in achievingincreased handhygiene in your area.Re: Hand Hygiene Compliance - Level 1 “Awareness”We are all committed to minimizing the risk of healthcare-associated infections. Performing hand hygiene is the most important action we can taketo reduce the spread of these infections to our patients and ourselves. For FY11, VUMC’s reach goal for hand hygiene is 95% compliance.A recent audit of hand hygiene observations places your area among those services with a low rate of compliance with hand hygiene. We arewriting to share the data with you.The average compliance rate for all VUMC units was 80% in November 2010 and 79% for FY11-to-date. Many units have achieved compliancerates above the threshold goal of 85%. For November 2010, your area compliance rate was 35%, and for FY11-to-date, 47%.A member of our Pillar Goal Committee team will contact you to schedule a time to meet so we may partner in achieving increased hand hygiene inyour area. In the interim, a copy of the hand hygiene expectations for all Vanderbilt employees is attached so that you may review with your staff.Information on how to improve hand hygiene compliance may also be found at www.mc.vanderbilt.edu/handhygiene.Thank you in advance for your team’s active participation and efforts to improve your area’s hand hygiene compliance rate to help us reduce therisk of infection for VUMC patients. As this is an ongoing quality improvement program, we will continue to provide you with regular reportsregarding the compliance rate within your area. If you have questions or need more information, please do not hesitate to contact either of us.This material is confidential and privileged information under the provisions set forth in T.C.A. 63-6-219 and shall not be disclosedto unauthorized persons.67NPSF Professional Learning Series

100%1 st Letter: Dec 2010Intervention Letter Resultsas of March 31, 20111 st Letter: Jan 20111 st Letter: Feb 201090%80%70%60%50%40%30%20%10%0%A B C D E F G H I J K L M NVUMC Compliance March 2011VUMC Compliance YTDCompliance Pre-Letter (YTD) Compliance Post-Letter (YTD) Compliance Post-Letter (March 11)This material is confidential and privileged information under the provisions set forth in T.C.A. 63-6-219 and shall not be disclosedto unauthorized persons68NPSF Professional Learning Series

VUMC Hand Hygiene Compliance (FY 10 – FY11)QuarterlyMonthly69NPSF Professional Learning Series