Balancing Systems and Individual Accountability in a Safety Culture

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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
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 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: A Project Bundle3. Organizational r
Page 67 and 68: December 22, 2010To: Medical Direct
Page 69: VUMC Hand Hygiene Compliance (FY 10
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