A safety champion program engagement and empowerment of frontline staff to promote a culture of...

0

Engagement and Empowerment of

Frontline Staff to Promote a Culture

of Safety: A Safety Champion Program

Jeanette Tanafranca, MSN, RN-BC

Safety Champion

2011

1

Why do we need a

Safety Champion program?

During this 20 minute presentation:

• 5 – 7 patients across the U.S. will die due to medical error or infections

• 85 – 113 patients will be hurt

• 21 – 29 employees will experience a needle-stick injury

Improving Healthcare Using Toyota Lean Production Methods R. Chalice, 2007Levinson, D. R. (2008). Adverse events in hospitals: overview of key

issues. Department of Health and Human Services, Office of Inspector General. Retrieved at: http://oig.hhs.gov/oei/reports/oei-06-07-00470.pdf

IOM (1999). To err is human: building a safer health system. Retrieved at: http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf

Kohn, L.T., Corrigan, J.M., and Donaldson, M.S. (Eds). (2000). To err is human: building a safer health system. Committee on Quality of Healthcare in

America. Washington, DC: National Academy Press.

Health care is not safe.

2

1. Identify Top Causes of Harm

2. Enhance our Culture of Safety

3. Improve the Quality and Clarity of Clinical

Communications

4. Redesign Care To Eliminate Harm

H

A

R

M

50%

3

No Harm Campaign

Extended 3 more years

Combined Harm Rate HFHS Hospitals by Hospital

20

30

40

50

60

70

80

Jan-0

8

Mar-

08

May-0

8

Jul-08

Sep-0

8

Nov-0

8

Jan-0

9

Mar-

09

May-0

9

Jul-09

Sep-0

9

Nov-0

9

Jan-1

0

Mar-

10

May-1

0

Jul-10

Sep-1

0

Nov-1

0

Jan-1

1

Mar-

11

May-1

1

Jul-11

Rate

per 1

000 D

ays

HFH Clinton Twshp Warren West Bloomfield Wyandotte All

4

Establish a Common Language

Create Safe Environments

Build Local Structure

Formal

Team Training

HFHS Culture of Safety Building Blocks

Safety

Champions

Safety Culture Global Indicators

• Organizational commitment

• Management Involvement

• Employee Empowerment

• Reward Systems (Just Culture)

• Reporting Systems

HFHS Added:

• Partnerships with Patients and Families

Wiegmann, D.A., Zhang, H., von Thaden, T., Sharma, G. and Mitchell, A. (2002). A synthesis of safety culture and safety climate research (Technical Report ARL-02-3/FAA-02-2). Savoy, IL: Aviation Research Lab Institute of Aviation.

Enhancing our Culture of Safety

5

Impact of Safety Champion

Program2006 - 2010 Comparison of Percent Favorable:

(4 - Agree and 5 - Strongly Agree)

76

62 59

34

81 82

68

8379

70

58

7774

53

65

7473

80

0

10

20

30

40

50

60

70

80

90

100

Mgt actions

show safety is

a priority

We are

encouraged to

speak up

I would feel

safe as a

patient here

Lots of nurse

doctor

teamwork

Clinical

disagreements

resolved well

Communication

breakdown

leading to care

delays rareCulture of Safety Question

%

2006 2008 2010 AHRQ 75th Percentile 2010 AHRQ 90th Percentile 2010

N=15,767 N=15,683 N=16,566 N=10,407 N=10,994 N=10,994

6

Safety Champ vs. No Safety Champ

COS & Engagement Scores

Units with Safety Champions showed improvement for all

safety questions and engagement questions compared to units

without safety champions.

0.09

0.140.22

0.19

0.14

0.3

-0.1

-0.05

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Manag

em

ent

Actio

ns

Enco

ura

ged

to

Sp

eak

Up

Feel S

afe

as a

Patient

at H

FH

S f

acili

ty

Lo

ts o

f te

am

wo

rk

betw

een n

urs

es a

nd

d

octo

rs

Dis

ag

reem

ents

re

so

lved

well

Co

mm

unic

atio

n

bre

akd

ow

ns

unco

mm

on

C05 C06 C07 C08 C09 C10

Dif

fere

nce B

etw

een

2010 a

nd

2008 M

ean

S

co

res

COS Question

Safety Champion vs. No Safety Champion (Clinical Units)Improvement 2010 vs. 2008

NO Safety Champ

Safety Champ

Engagement Scores Improvement 2010 vs. 2008

Safety Champ vs. No Safety Champ (Clinical Units)

0.08

0.15

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

Q12 GMEAN

12 Engagement Questions GMEAN

Dif

fere

nc

e B

etw

ee

n 2

01

0 a

nd

20

08

GM

EA

N S

co

res

No Safety Champion

Safety Champion

0.1 improvement = meaningful0.2 improvement = statistically significant

7

Safety Champion Program

“Coming together is a beginning;

Keeping together is progress;

Working together is success.”

Henry Ford

8

Program Objectives

• To develop a network of

multidisciplinary front-line

safety experts

• Create ‘error wisdom’ at the

front line

• Support HFHS core values

for patient safety and the No

Harm Campaign – build a

culture of safety

First Safety Champions 6/2008

9

Who are Safety Champions?

• Front line, multidisciplinary employees that act as a “Voice” and

“Face” of Safety.

– Have a genuine interest in safety

– Model safe practices

– Model HFHS Core Values for Patient Safety

– Respected by peers

– Are willing and able to communicate information (i.e. patient safety goals,

personal safe practices, reporting) at department

meetings/briefings/huddles

– Are willing to embrace a leadership opportunity

– Create a ripple effect

10

Conceptual Framework

Adapted from Dr. Patricia Benner’s Stages of Clinical Competence

11

Safety

Champion

Program

11

Core CoursesPatient Safety 101

Introduction to the Safety Champion Role

-Human Factors

Communication

Monthly Toolkits

Bi-Monthly Newsletters/Great

Catch

Facebook

Process Improvement

Reporting

Strategies

Projects

Sharing

Learning

Quarterly Forums

2 Minute Tutorials

Professional Development

IHI Open School

Conferences

Program Start: June, 2008

1212

Human factors research has shown that even highly skilled,

motivated professionals are vulnerable to error due to

inherent human limitations – really ‘good’ people will make

mistakes

Core Courses

I. Patient Safety 101

II. Introduction to the Safety Champion Role

(Human Factors)

1313

Which is the One Cent U.S. Coin?

A Simple Example of the Limits of Memory

Memory- we generally store only partial

descriptions of things to be remembered,

descriptions that are sufficiently precise to work

at the time something is learned but may not work

later on when new experiences are encountered.

Image Source:http://www.dcity.org/braingames/pennies/

14

Safety

Champion

Program

14



-Human Factors

Communication

Monthly Toolkits


Catch

Facebook

Process Improvement

Reporting

Strategies

Projects

Sharing

Learning

Quarterly Forums

2 Minute Tutorials


IHI Open School

Conferences

16

Safety

Champion

Program

16



-Human Factors

Communication

Monthly Toolkits


Catch

Facebook

Process Improvement

Reporting

Strategies

Projects

Sharing

Learning

Quarterly Forums

2 Minute Tutorials


IHI Open School

Conferences

17

Sharing & Learning

• Quarterly Forums: Identify top causes of harm, Culture of Safety, Just

Culture,Error Reporting & Error Prevention, Speak Up, Speak Out: Creating

Safe Environments, Getting LEAN with Hand Hygiene, Healthcare Equity and

Culturally Competent care, Emergency Preparedness and Patient Safety….

• 2 Minute Tutorials: “How To’s”

• Great Catch Stories

17

18

Safety

Champion

Program

18



-Human Factors

Communication

Monthly Toolkits


Catch

Facebook

Process Improvement

Reporting

Strategies

Projects

Sharing

Learning

Quarterly Forums

2 Minute Tutorials


IHI Open School

Conferences

19

Process Improvement

• Accurate and Voluntary reporting through

our reporting system.

• Project survey.

19

•2 patient identifier projects

•Revised SBAR form for patient hand-offs

•Selecting equipment for hospital

•Post-fall management program

•Handicapped parking assistance

•Bladder health and collaborative project

•Handwashing projects

•Medication review process

•Mammogram process review

•Medication dispensing projects

•A3s-Needlestick prevention

•More…..

20

• Safety Champions reviewed employee injury data and identified that lift injuries are in the top 3 (2010-2011).– Conducted a survey that employees

stated that lifts were a number one concern of what injury they felt would happen in their area.

• Conducted A3s on sharp containers and the inappropriate use of biohazard bags.– An EOC audit showed a spike in finding

the biohazard bags used inappropriately

– SC Team conducted additional education and weekly

HF West BloomfieldImpact of Safety Champion Program

21

HFH Inpatient PharmacyImpact of Safety Champion Program

• Process 7,000 medications orders per day

• Dispense 17,000 medication doses per day

• Recognize human limitations and have made 49 system improvements since joining the program

22

Safety

Champion

Program

22



-Human Factors

Communication

Monthly Toolkits


Catch

Facebook

Process Improvement

Reporting

Strategies

Projects

Sharing

Learning

Quarterly Forums

2 Minute Tutorials


IHI Open School

Conferences

23

Safety Champion Successes

• 378 Safety Champions (multidiscplinary, multiple business units)

• 100% would recommend program

• >95% favorable with class and forum surveys

• 95% share toolkits and newsletters

• 88% believe they have made an impact on the culture of safety for

their units

• 80% participate in safety improvement work

23

25

I am a Safety Champion because I do my best to live the Henry Ford

Experience of caring about people by helping

to make sure they are safe,…on a daily

basis..Ruth

Patient Safety means......" putting forth a

conscience effort to protect our patients and

employees by minimizing risk and

adhering to all set standards while providing

the highest quality care in the safest work

environment possible!!!!

Dawn Dombek-Bailey, CHSPI make a difference in the lives of all persons who enter HFHS properties.

MaryAnn L. Northcote, CPP, CHSP I am a safety champion because

I want to be proactive in

spreading wellness to individuals

that are in my reach. Injury

prevention is a key component in

helping our loved ones and others

in our community stay safe and

healthy..Katie Horn

I am a safety champion

because I CAN and

DO make a difference

one person at a

time". Stephanie B.

Anderson, RN, MSN

Patient Safety means….delivering the highest

quality care that is reliable and coordinated for the

patients we serve each day..Judy Caretti-Rourke

I make a

difference to everyone that comes in

contact with me in the

Henry Ford Health

system..Latonya

Phillips

I am a Safety Champion because......the

environment I work in and the people I serve are

important to me“ LesaBorden Sanford RN,

BSN

Patient Safety means being pro-

active in creating and maintaining

safe environments for our patients who depend on us

when they are most vulnerable.

Judy Czerepowicz, CHSP

Safety Champions Can and Do

Make a Difference in Patient Safety by

Being Proactive, Minimizing Risk,

Creating Safe Environments Because

its Important to the Lives of ALL.

-HFHS Safety Champions

26

Thank You to all of the HFHS Safety Champions for making a difference.

27

Contact Information

Jeanette Tanafranca, MSN, RN-BC

Office of Clinical Quality and Safety

One Ford Place, Detroit, MI 48202

313.874.7181

[email protected]

27

A safety champion program engagement and empowerment of frontline staff to promote a culture of...

Healthcare

Transcript of A safety champion program engagement and empowerment of frontline staff to promote a culture of...