Balancing Systems and Individual Accountability in a Safety Culture

More documents

Recommendations

Info

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
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 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: “Awareness” Guiding PrinciplesH
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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?