Getting to Zero-Safer Care Improvement Programme
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Transcript of Getting to Zero-Safer Care Improvement Programme
©Annette Bartley Consulting Limited 2011
Getting to Zero-Safer Getting to Zero-Safer Care Care Improvement ProgrammeImprovement Programme
Annette Bartley RGN BA MSc MPHHealth Foundation/IHI Quality Improvement Fellow
09.00-09.15 Welcome & Introductions
09.15- 10.00 Background and Context Programme aims & objectives
Links to other work
10.00-11.00 Overview of Quality Improvement Tools & techniques
Measurement for improvement
The role of local coaches
11.00-11.30 Refreshment break
11.30- 13.00 Team Presentations / Storyboard rounding
13.00-13.45 Lunch
13.45-15.00 The Snorkel – Generating Ideas from frontline staff
15.00-15.15 Refreshment break
15.15-16.15 Action planning and report out
16.15-16.30 Summary next steps and close
Learning Session 1 Overview
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Understanding the Understanding the context of frontline carecontext of frontline care
What’s good about it?What’s not so good?What could be
improved?
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It’s a Fact that …“Without good and careful nursing many must
suffer greatly, and probably perish, that might have been restored to health and comfort, and become useful to themselves, their families, and the public, for many years after.”
Benjamin Franklin (1751)
The Reality in Practice
How do we make sense of all the How do we make sense of all the expectations expectations
& bring the work into a coherent & bring the work into a coherent wholewhole
Health FoundationSafer Communities National Patient
Safety Agency(NPSA)
Safety AlertsMatching Michigan
NHS III
LIPsProductive
Series
NICEQuality Standards
QUIPP & Safety Express
Safer Patients Network (SPN)
The Health Foundation(with IHI)
CQUIN targets
WHO World Alliance for Patient Safety
Department of Health
(DoH)High Quality Care for All
IP&C
CNO High Impact Changes
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Will Ideas Execution
Getting to Goal
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The politics of hope The politics of hope
“We got used to the politics of disappointment -- figuring out how soon we were going to be let down. ... There’s a different dynamic in the ... politics of hope. It’s much more challenging. It means you’ve got to get up and do something. There’s opportunity. If you don’t take advantage of that opportunity, you really have to bear responsibility for not doing so. That’s how I see the time we’re in. ”
Marshall Ganzhttp://mitworld.mit.edu/speaker/view/1047
http://www.youtube.com/watch?v=NglXpj94Z2ohttp://www.youtube.com/watch?v=LhCoz5hMhTI
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Transforming Patient Experience
Metanoia: • Reorientation of one’s way of life
(The New Economics. Deming, p. 95, 1993)
• Begins with individual• More than a change• Develop new habits of mind
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Where to beginWhere to begin
Will Ideas Execution
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Programme AimsProgramme AimsAlignment with Safety Express To reduce the incidence of Avoidable
Hospital /Community Acquired Pressure Ulcer
Reduce of Falls (falls with harm)Reduce Catheter Associated Urinary
Tract Infections (CAUTI)Prevention of Venous
Thromboembolism ( VTE)
Programme overviewProgramme overview
Select Topic
(develop mission)
Planning Group
Develop Framework & Changes
Participants (10-100 teams)
Prework
LS 1
P
S
A D
P
S
A D
LS 3LS 2
Supports
Email Visits
Phone Assessments
Monthly Team Reports
Website
Tools & Guidance,
Publications
A D
P
SExpert
Meeting
The IHI Collaborative Model
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Underpinning principlesUnderpinning principlesTransformational LeadershipSafety & ReliabilityPatient and Family Centred CareValue-added careTeamwork and Vitality
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Patients as partnersPatients as partners
“ If quality is to be at the heart of everything we do, it must be understood from the perspective of patients.”
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Alignment -Harm Free Alignment -Harm Free CareCare
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Prevention of Pressure Prevention of Pressure UlcersUlcers
Spread the Learning and celebrate the successes
!
Transforming Care at the Bedside framework
Prevent the Incidence of
Pressure Ulcers, Falls,
CAUTI, by April 2012 using the
Intentional rounding process
Patient and Family
Centred Care
Engage the wider MDT team Set sims and plan tests together Share learning
Ensure there is leadership support for this work at every level in the organization
Transformation Leadership at ward/unit level
Team work
Leadership engagement
Reliable Implementation of the
The Intentional Rounding process
Address the 8 key behaviours and incorporate the : SKIN Bundle Surface Keep Moving Incontinence Nutrition
Create Patient centred healing environment – Use the ESTHER story Support and Involve patients and families Provide spiritual and emotional support Ensure patients rights , privacty and dignity are maintaines
Content Area Drivers Interventions
Educate staff regarding the assessment process, identification and classification of, and treatment of pressure ulcers Educate Patients & family Develop patient information pack
Training & Education
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Pressure Ulcers Pressure Ulcers The “Case for Change”The “Case for Change”
◦National Focus on Patient Safety◦I in 10 patients harmed by what we do
◦Poor Public Perception of Care◦Impact of financial cutbacks ◦Pressure Ulcer Incidence 1 in 5◦As high as 1 in 3
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Prevention of Falls (Harm Prevention of Falls (Harm from falls)from falls)•Falls prevention is a complex issue crossing the boundaries of healthcare, social care, public heath and accident prevention.
•Across England and Wales, approximately 152,000 falls are reported in acute hospitals every year, with over 26,000 reported from mental health units and 28,000 from community hospitals.
•A significant number of falls result in death or severe or moderate injury, at an estimated cost of £15 million per annum for immediate healthcare treatment alone (NPSA, 2007).
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FactsFacts
Pressure sores are an increasing problem that affect thousands of people unnecessarily every year..
They are painful, debilitating and can be life threatening
The cost of treating a pressure ulcer varies from £1,064 -£10,551 with the estimated total cost in the UK of between £1.4–£2.1 billion annually- 4% of total NHS expenditure (Bennett et al 2004)
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What matters most to What matters most to inpatients.inpatients.Consistency and coordination of care
Treatment with respect and dignity
Involvement
Doctors
Nurses
Cleanliness
Pain control
Methods and ToolsMethods and Tools
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◦We must become masters of improvement◦We must learn how to improve rapidly◦We must learn to discern the difference
between improvement and illusions of progress
Change vs. Change vs. ImprovementImprovement
Of all changes I’ve observed, about 5% were improvements, the rest, at best, were illusions of progress.
W. Edwards Deming
The Lens of Profound The Lens of Profound knowledgeknowledge
Deming
Appreciation of a system
PsychologyTheory of Knowledge
Understanding Variation
CQI
Aims or values
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Quality Improvement Quality Improvement Methods /ToolsMethods /Tools
The Model for Improvement The Science of ReliabilityDriver DiagramChange Package Lean/5SSafety Cross/ Safety
ThermometerSSKIN Bundle/ Intentional
Rounding
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The Model for Improvement will underpin the programme, enabling teams to connecting an aim to action and measurement which will enable you to demonstrate their progress.
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Improvement requires a clear aim Improvement requires a clear aim
Measurement & Action
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AIMAIM Aims infuse meaning and hope in our lives,
they create a target to achieve and inspire and motivate us to achieve it.
How good do you want to be and by when?Make your aims SMART
• Specific• Measurable• Achievable• Realistic• Timely
Developing a systems-based approach to the prevention of hospital acquired pressure ulcers
Risk Identification
Communication of Risk status
Risk Assessment
Appropriate preventative strategy implemented
Evaluation of outcome
What will success look like?
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The “Case for Change”The “Case for Change”
◦National Focus on Patient Safety◦I in 10 patients harmed by what we do
◦Public Perception of Care◦Impact of financial cutbacks ◦Strong link between Patient Satisfaction & Employee Satisfaction
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Purpose of Using DataPurpose of Using Data & Measuring & Measuring
The purpose of measuring is to answer critical questions and to guide intelligent action.
Cliff Norman- Associates in Process Improvement
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“In God we trust.
All others bring data.”
W. E. Deming
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S+P=0S+P=0S=StructureThe environment in which health care is
providedP=ProcessThe method by which health care is
providedO=OutcomeThe consequence of the health care
provided
Avedis Donabedian Physician
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Research Research vs vs Measurement for Measurement for ImprovementImprovement
Three Types of MeasuresThree Types of Measures
Outcome Measures: Voice of the customer or patient. How is the system performing? What is the result?
Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned?
Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures? (e.g. unanticipated consequences, other factors influencing outcome)
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Measurement GuidelinesMeasurement Guidelines
A few key measures that clarify a team’s aim and make it tangible should be reported, and studied by the team, each month
Be careful about over-doing process measures for monthly reports
Make use of available data bases to develop the measures
Integrate data collection for measures into the daily routine
Plot data on the key measures each month during the life of the project
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Measurement GuidelinesMeasurement Guidelines
The question - How will we know that a change is an improvement? - usually requires more than one measure• A balanced set of five to eight measures
will ensure that the system is improved• Balancing measures are needed to assess
whether the system as a whole is being improved
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Measurement- It is YOUR Measurement- It is YOUR data!! (data MUST be locally data!! (data MUST be locally owned) owned)
Outcome measures ◦ Incidence ( count on safety cross)◦ Days between events
Process measures◦ Percent Compliance with risk assessment◦ Percent Compliance with process ( bundle)◦ Percent compliance with Intentional Rounding tool
Balancing measures Patient Experience Staff satisfaction Length of Stay Complaints Staff turnover /Sickness rates Budget implication
Visual MeasurementVisual Measurement
1 2
3 4
5 6 (3)
7 8 (1) 9 10 11 12
13 14 15 16 17 18
19 20 (1) 21 22 23 24 (1)
25 (1) 26
Days since last... 27 28 (1)
___ days 29 30 31
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Real Time Data for improvement – Real Time Data for improvement – ProcessProcess
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It’s time…It’s time…
A little less conversation a little more action
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Getting it rightGetting it rightCo-ordinating CareCo-ordinating Care
Health Care Processes Health Care Processes
Desired - variationbased on clinical criteria, no individual autonomy to change the process,process owned from start to finish,can learn from defects before harm occurs, constantly improved by collective wisdom - variation
Current - Variable, lots of autonomynot owned,poor if any feedback for improvement, constantly altered by individual changes, performance stable at low levels
Terry Borman, MD Mayo Health System
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Intentional Rounding Intentional Rounding The EvidenceThe Evidence
The Studer GroupAlliance for Health Care Research
◦38% Reduction in Call Lights◦12 point mean increase in Pt
Satisfaction◦50% reduction in patient falls◦14% reduction in pressure ulcersFlaws in the study but…
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On Finding What Works…On Finding What Works…
“We need to standardize, simplify, and steal shamelessly from everyone who can contribute, because we’ve reached a point where no excuses are allowable.”
Roger Resar, MDSenior Fellow, IHI
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Intentional Rounding – Intentional Rounding – What is it?What is it?
Structured process where frontline staff regularly round on patients and reliably perform scheduled/required tasks
Rounding with purpose- linked to an aim8 key behaviors
1. Opening key words – managing up2. Perform scheduled tasks3. Address the 3 p’s of pain, potty? position
(SKIN Bundle)(toileting), and4. Assess comfort needs5. Environmental assessment6. Closing key words7. Explain when you or others will return8. Document the round on the log
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OMHS Intentional Rounding - OMHS Intentional Rounding - winswins
59% reduction in Pressure ulcers54% reduction in call lights (2878 fewer calls after rounding)Patient feedback – ‘I know someone will be
back to check on me, when they come…’ Improved employee satisfaction – 5.67 on a
7 point scale compared to national norm of 4.66 (Baird and Borling)
Reduction in cost ◦ $3.02/pt 6 month avg. prior◦ $2.39/pt 8 months avg. following
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Tools – Rounding LogTools – Rounding Log
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Tools – Badge CardTools – Badge Card
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Tools – Accountability ToolTools – Accountability Tool
Rounding commenced
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Intentional Rounding -Intentional Rounding -Benefits Benefits
• Provide staff with better control of their time
• Improved outcomes / promote safety
• Results • Increase Patient Satisfaction • Decreases anxiety• Increase trust and give sense of comfort
• Increase Employee Satisfaction
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Additional BenefitsAdditional Benefits
Centred on patients/Catches allProvides a quality assurance
framework for nursing careHelps to evidences what nurses
doHelps demonstrates the impact
on patient outcomesPotential to impact on the bottom
line
57
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What they are not…What they are not…A radical change to a system
/process Full blown trust-wide
implementation Mini projects (monumental
proportion) Top down directives
‘PDSA’s' ‘test’ a proposed change
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Paper Plane ExercisePaper Plane ExerciseAim – To design a paper plan that will
fly the longest distance ◦ Assign a design team◦ Assign someone to assemble the plane◦ Assign a measurement person to measure
the distance flown (in feet)Run your tests a few times?What are you learning?How are you factoring your leanring
into the next test?
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People are treated with respect and dignity. Health care providers communicate and share
complete and unbiased information with patients and families in ways that are affirming and useful.
Individuals and families build on their strengths through participation in experiences that enhance control and independence.
Collaboration among patients, families, and providers occurs in policy and program
development and professional education, as well as in the delivery of care.
Source: Institute for Family Centred Care, Bethesda USA
Patient &family centred Patient &family centred care care
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Local Coaches/FacilitatorsLocal Coaches/FacilitatorsGroup of volunteersWilling to play a key role locally
as coaches /facilitatorsSupport participants and help to
accelerate momentum and the progress
They will be the links between you and the programme team
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Storyboard roundingStoryboard roundingSplit up into your teamsIdentify a space to display your
storyboardSelect at least one member to present the
findingsEveryone else will rotate around the
teams Approximately 7-8 mins to describe your
team/aspirations/learning from pre-workBell will sound and teams will rotate to
the next space
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HarvestHarvestIdentify three things you learnt
during the rounding
◦Could be meeting new people◦Harvesting Ideas from another team◦Results/learning from their pre-work
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The SnorkelThe Snorkel
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Fostering Creativity and Fostering Creativity and Brainstorming?Brainstorming?
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Methods for Methods for Generating New IdeasGenerating New Ideas
Change ConceptsUsing TechnologyCritical ThinkingIDEO BrainstormingMetaphorical
ThinkingObservationProvocationPrototypingIdealized Design
Innovation and Work Redesign
http://theartofinnovation.com/purchase.htm
GETncm/justsaycust-recrate-itemcommunittg/stores/dtg/stores/d-
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Resources for “Snorkel”Resources for “Snorkel”
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Outline of “Snorkel”Outline of “Snorkel”Review of Project Vision and CharterWhat do we know about …. Propose a Design ChallengeStorytellingHow might we….?BrainstormingSelect top ideas (multi-vote)Prioritize ideas for development Plan prototypes EnactmentsDesign first series of tests
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StorytellingStorytelling In lieu of doing actual observations, use
storytelling to “observe” actual experiences
Recall an actual story or experience which relates to the specific design challenge (personal, friend or family member or work-related experience)
Who was involved? What happened? How did individuals feel and react?
Give an example
Tell stories in small groups (nor more than 2 minutes each)
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How might we….? How might we….? (used to create ideas for the (used to create ideas for the brainstorming)brainstorming)
…. Prevent harm
…Engage Patients and families in preventing harm
…Optimise nutrition
Ideas should be actionable Write each idea on post-it notes or flip c
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Rules for Brainstorming (20 Rules for Brainstorming (20 mins)mins)
Chose one or two “how might we scenarios….
encourage wild ideas go for quantity – want more than 500
ideas defer judgment be visual – draw pictures one conversation at a time build on ideas of others stayed focused on topic (“how might
we…” scenarios)
Write each idea on post-it notes
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Multi-voting to Select Top Ideas Multi-voting to Select Top Ideas
Cluster together similar ideas from brainstorming exercise
Use dots to vote:
What are your personal favorites? What idea would you most like to try on your
unit? What idea do you think will have the biggest
impact toward achieving the “how might we…”
Participants can distribute their dots however they want –- all on one idea, each dot on a separate idea, or anything in between
Report out on favorite ideas (where there are most dots)
Matrix of Change IdeasMatrix of Change Ideas
Difficult to Implement
Easy to Implement
Low Cost High Cost
Place concepts in matrix. Strive for easy, low-cost solutions. Translate high-cost solutions into low-cost alternatives.
Matrix of Change IdeasMatrix of Change Ideas
Low Impact
High Impact
Low Cost High Cost
Translate high-cost solutions into low-cost alternatives.
Strive for high-impact , low-cost solutions.
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Outline of “Snorkel”Outline of “Snorkel”Review of Project Vision and CharterWhat do we know about…… Propose a Design Challenge StorytellingHow might we….?BrainstormingSelect top ideas (multi-vote)Prioritize ideas for development Plan prototypes EnactmentsDesign first series of tests
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IDEO’s Design PrinciplesIDEO’s Design Principles
1. Keep people informed throughout process
2. Value people, time, and energy3. Enable learning and teaching4. Give people appropriate levels
of control5. Facilitate connections among
people
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EnactmentsEnactments
Create an enactment to illustrate an extreme future vision for your prototype
Create storyline and buildRehearse and refinePresent to whole groupSelect elements and build on
ideas
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EnactmentsEnactments
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What could you do by next What could you do by next TuesdayTuesday??Think of some changes that you
believe might enable you to get results
Think of 1 changePlan your first PDSA’s
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Small Scale Tests of Small Scale Tests of Change on:Change on:
One bay/wardOne day / shiftOne patient
One nurse
Action Planning SessionAction Planning Session
Hunches Theories Ideas
Changes That Result in Improvement
A P
S D
APS
D
A P
S D
D SP A
DATA
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
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Next StepsNext StepsACTION PERIOD
◦Seek out a coach/facilitator◦Get measures in place◦Test the rounding process small scale◦Connect with Tina Chambers/calls
Learning session 2 ◦Is all about YOU◦We want to hear your progress and
see some results
PDSA Cycle No 1 : General Wards 9 & Ward 4Worksheet for Testing Change Aim: To reduce Pressure Ulcer Incidence to zero by December 2012 (Overall goal you would like to reach) Every goal will require multiple smaller tests of change
Describe your first (or next) test of change Person Responsible
When to be done
Where to be done
Test SSKIN Bundle on one patient on one ward next Tuesday JD& RW
Week commencing 18th April
Ward 4 & Ward 9
Plan
List the tasks needed to set up this test of changePerson Responsible
When to be done
Where to be done
1)Identify similar information from other Trusts 2)Discuss with team3)Identify a nurse and patient who are prepared to participate.4)Identify a suitable patient and seek their permission
JD W/C18TH April
Predict what will happen when the test is carried out Measures to determine if prediction succeeds
The patient & nurse will understand the reason’s for the test and be happy to participate The test will go well The patients’ risk of HAPU is reduced
Views of patients and professionals will be sought
Act:What will you differently as a result of your test?What will your next test be?
Do:
Study: What happened? What did you learn?
What surprised you?
You are this HospitalYou are this Hospital You are what people see when they arrive here.
Yours are the eyes they look into when they’re frightened and lonely. Yours are the voices people hear when they are in the lifts and when they try to sleep and when they try to forget their problems. You are what they hear on their way to appointments that could affect their destinies and what they hear after they leave those appointments.
Yours are the comments people hear when you think they can’t. Yours is the intelligence and caring that people hope they’ll find here. If you’re noisy, so is the hospital. If you’re rude, so is the hospital. And if you’re wonderful – so is the hospital.
No visitors, no patients can ever know the real you, the you that you know is there — unless you let them see it. All they can know is what they see and hear and experience.
And so I have a stake in your attitude and in the collective attitudes of everyone who works at Cooley Dickinson Hospital. We are judged by your performance. It is judged by the care you give, the attention you pay and the courtesies you extend.
Thank you for all you are doing. CEO Cooley Dickinson Healthcare Org