Balancing Systems and Individual Accountability in a Safety Culture

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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
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 18 and 19: What are the prerequisites?• Surv
Page 21: Morbidity, Mortality &Improvement C
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

Balancing Systems and Individual Accountability in a Safety Culture

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