Balancing Systems and Individual Accountability in a Safety Culture

More documents

Recommendations

Info

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
Page 4 and 5: Consider a Case• The ED was busy.
Page 6 and 7: But how do we prevent…?6NPSF Prof
Page 8 and 9: Accountability“Systems”“Human
Page 10 and 11: But there is hope…• Elements th
Page 12 and 13: What are the prerequisites?• Shar
Page 14 and 15: Values and leadership (modeled)allo
Page 16 and 17: Our team members feel free toreport
Page 21 and 22: Morbidity, Mortality &Improvement C
Page 23 and 24: Issues IdentifiedPEOPLEENVIRONMENTW
Page 25 and 26: What are the prerequisites?• Reso
Page 27 and 28: Accountability PyramidAdapted from
Page 29 and 30: Patient Complaints• “Dr. __ tol
Page 33 and 34: PARS ® Progress ReportTotal # of h
Page 35 and 36: Back to the case• The RCA reveale
Page 37 and 38: Back to the case• Creation of int
Page 39 and 40: You meet with Nurse 2System Needs:
Page 41 and 42: Principles for “Informal”Conver
Page 43 and 44: “Awareness” Guiding PrinciplesH
Page 45 and 46: When Surgeon X yelled…“get the#
Page 47 and 48: Definition of Disruptive Behavior
Page 49 and 50: Consequences of Disruptive Conduct:
Page 51 and 52: “RN did not call the doctor about
Page 55 and 56: Resources and ToolsEvaluating and A
Page 57 and 58: Components of a Safety Culture• S
Page 59 and 60: Path to Compliance• In June 2009
Page 61 and 62: A Project Bundle1. Learning systems
Page 63 and 64: A Project Bundle3. Organizational r
Page 65 and 66: 100%VUH Hand Hygiene Compliance Rat
Page 67 and 68: December 22, 2010To: Medical Direct
Page 69:
VUMC Hand Hygiene Compliance (FY 10
show all

Balancing Systems and Individual Accountability in a Safety Culture

Create successful ePaper yourself

Delete template?

Save as template?