Balancing Systems and Individual Accountability in a Safety Culture

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100%1 st Letter: Dec 2010Intervention Letter Resultsas of March 31, 20111 st Letter: Jan 20111 st Letter: Feb 201090%80%70%60%50%40%30%20%10%0%A B C D E F G H I J K L M NVUMC Compliance March 2011VUMC Compliance YTDCompliance Pre-Letter (YTD) Compliance Post-Letter (YTD) Compliance Post-Letter (March 11)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 persons68NPSF Professional Learning Series
VUMC Hand Hygiene Compliance (FY 10 – FY11)QuarterlyMonthly69NPSF 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 and 64: A Project Bundle3. Organizational r
Page 65 and 66: 100%VUH Hand Hygiene Compliance Rat
Page 67: December 22, 2010To: Medical Direct
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Balancing Systems and Individual Accountability in a Safety Culture

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