Balancing Systems and Individual Accountability in a Safety Culture

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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
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Consider a Case• The ED was busy.
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But how do we prevent…?6NPSF Prof
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Accountability“Systems”“Human
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But there is hope…• Elements th
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What are the prerequisites?• Shar
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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 and 64: A Project Bundle3. Organizational r
Page 65: 100%VUH Hand Hygiene Compliance Rat
Page 69: VUMC Hand Hygiene Compliance (FY 10
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Balancing Systems and Individual Accountability in a Safety Culture

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