Leading for a Safe and Reliable Culture - GSHRM...2 Prepared by Piedmont Healthcare Quality and...
Transcript of Leading for a Safe and Reliable Culture - GSHRM...2 Prepared by Piedmont Healthcare Quality and...
Leading for a Safe and Reliable Culture: Piedmont Healthcare’s Always Safe ProgramGSHRM
September 3, 2020
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Piedmont’s High Reliability Journey
Launch of Always Safe
Quality & Process Improvement Launch
“A” by May for Leapfrog
Launch RL for Variance Reporting
Move to DNV
First Hospitals ISO Certified
Quality & Patient Safety Transformation
Zero Harm by 2026
Promise Package Standard Work Launch for Infections
Standardized RCA and PPE Process
Launch Always Safe 2.0
2012 2013 2014 2015 2016 2017 2018 2019
Integration of SIX Hospitals
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Commitment to Zero Harm
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Leadership
MethodsCommitment
to Zero Harm
Error Prevention
for staff and
providers
Improved
Cause
Analysis
Transparency &
Organizational
Learning
Road to High Reliability
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How Do We Measure Harm?
Zero
Harm
Hospital Acquired Infections: Patient Safety Indicators:
Serious Safety Events: Hospital Acquired
Conditions: A hospital-acquired condition is an
undesirable situation or condition
that affects a patient and that
arose during a stay in a hospital or
medical facility.
A hospital-acquired infection is an infection
that is acquired in a hospital or other health
care facility.
Patient Safety Indicators are a set of indicators
providing information on potential in-hospital
complications and adverse events following
surgeries, procedures, and childbirth*.
A serious safety event is a
deviation from expected practice
reaching the patient resulting in
moderate to severe harm or death.
• CAUTI
• CLABSI
• CDIFF
• CLEAN 4 YOU (MRSA)
• SSI Colon/TAH/THR/TKR
Example Projects/ Promise Packages:
• PSI-12 Post-op DVT
• PSI-13 Sepsis
• PSI-11 Respiratory Failure
• PSI-19 Obstetric Trauma
* PSI 03, 06, 08-15, 17-19
Example Projects/ Promise Packages:
• Cardiac Monitoring/Telemetry
• Orders Management
• Lab Specimen
Example Projects/ Promise Packages:
• HAC 1 : Foreign Object Left in After Surgery
• HAC 5 : Falls and Trauma
*HAC 01-05, 08, 09, 11-14
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Leadership
MethodsCommitment
to Zero Harm
Error Prevention
for staff and
providers
Improved
Cause
Analysis
Transparency &
Organizational
Learning
Road to High Reliability
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Leadership Methods & Expectations
• Safety first on all agendas
– Reward and recognize safety success
• Celebrate successes
• Rapid response to safety problems; recognize & address
communication failures (de-brief)
• Provide ‘safe’ culture for reporting & speaking up
• Actively participate and lead Daily Safety Huddles
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Leadership Methods & Expectations
• Use/facilitate use of Error Prevention Tools (EPT)
– Ensure that new employees are trained individually in EPTs
– Make sure your culture also trains them!
• Round to Influence on staff
• Commit to the Leader/Safety Coach Partnership
• Incorporate Just Culture practices and principles into your
performance management processes using the Performance
Management Decision Guide
• Encourage participation in the annual Culture of Patient Safety
Survey
– Share results & ask staff for improvement ideas
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Leadership
MethodsCommitment
to Zero Harm
Error Prevention
for staff and
providers
Improved
Cause
Analysis
Transparency &
Organizational
Learning
Road to High Reliability
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Error Prevention Tools for staff and providers
I commit to… By practicing these error prevention tools…
S Support the Team• Peer Checking/Coaching
• Debrief
A Ask Questions
• ARCC: Ask a question, Request change, voice
Concern if needed Stop the Line & activate the Chain
of Command
• Validate & Verify
F Focus on Task• STAR – Stop, Think, Act, Review
• ‘NO DISTRACTION’ zones
EEffective
Communication
Every Time
• Effective Hand-offs
• Read and Repeat Backs; request & give
Acknowledgement
• Ask Clarifying Questions
• Using alpha-numeric language
• SBAR
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6,212 Members
System-wide
Total Recall Club: Commitment to Error
Prevention Tools
PHH – 327
members
PRH – 494
members
PAR – 1431
members
PNH – 268
members
PMH – 220
members
PFH – 638
members
PAH – 751
members
PWH – 221
members
PNtH – 179
members
PCRH – 374
members
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Piedmont’s Journey: EPT Recall and SSER
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Leadership
MethodsCommitment
to Zero Harm
Error Prevention
for staff and
providers
Improved
Cause
Analysis
Transparency &
Organizational
Learning
Road to High Reliability
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Transparency & Organizational Learning
• It’s not about the person involved in an error, it’s about the system
or process that allowed the error to happen.
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Transparency & Organizational Learning
• A High Reliability Organization is one that is constantly learning,
and this involves transparency through a reporting culture
• Reporting both actual incidents and ‘near misses’ allows the
organization to examine the systems/processes for improvement
• Actual harm incidents are examined for their multiple root causes,
to also guide improvement
• Submit a safety event report whenever anything happens that you
were not expecting
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Transparency & Organizational Learning
• The science of patient safety influenced by the Heinrich Triangle
Theory dictates that for ONE serious safety event, there are:
– 29 precursor events: Events that reach the patient and cause minor harm or
no harm
– 300 near miss events: Events that have a deviation that do not reach the
patient
Near Misses
300
Precursor
29
SSE
1
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Transparency & Organizational Learning
So what exactly is the role of a safety coach?
Safety coaches are team members who provide real-time feedback
about practice and compliance with our safety behaviors and error
prevention tools, and who help to prevent events of harm.
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Transparency & Organizational Learning
What are Safety Coaches expected to do?
Monthly Safety Coach Meeting:
• Safety Coach attends one meeting a month
• Documented by meeting host
Document Safety Observations:
• Credit for documenting at least 4 entries
Monthly Safety Coach Debrief with Manager:
• Credit when documented by Leader
Monthly Goal:
1. Attend a Safety Coach
Meeting
2. Document at least 4
observations
3. Debrief with your
Manager
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Transparency & Organizational Learning
What is the Leader / Coach Partnership?
• The Safety Coach’s leader introduces safety coach and prepares staff
to receive coaching
• Leader provides dedicated time for coach to attend training and routine
safety coach meetings
• Leader provides time on department meeting agenda for safety coach
to discuss safety
• Leader meets with safety coach at least monthly to:
– Review coaching observations
– Review staff’s responses to coaching and use of EPTs
– Discuss safety mitigation strategies for your team
– Hear what was discussed during the safety coach meetings
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Huddle
S.A.F.EPrinciples w/
Error Prevention Tools
Coach
Speak Up!
Standard Work(Process Measures)
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Creating a Culture of Patient Safety
Performance Tracking Resources: Standard Work of Always Safe
EPT RecallCoach Activity
Safety
HuddlesSpeaking Up
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Leadership
MethodsCommitment
to Zero Harm
Error Prevention
for staff and
providers
Improved
Cause
Analysis
Transparency &
Organizational
Learning
Road to High Reliability
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Improved Cause Analysis
• Root Cause Analysis
– A structured problem-solving technique that analyzes processes and
standards resulting in one or more corrective actions to prevent the
occurrence of an event.
• The goal of an RCA is to derive a statement of root cause of an event
by addressing:
– What happened?
– Why did it happen?
– What can we do to prevent it from happening again?
• Piedmont has a system-wide approach to RCAs
• Learnings are shared across the system
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Progress Toward Zero Harm
Harm Definition:
Hospital Acquired Infections: CAUTI, CLABSI, C-Diff, MRSA, SSI: Colon, TAH, THR/TKR
Hospital Acquired Conditions: HAC 01-05, 08, 09, 11-14
Patient Safety Indicators: PSI 03, 06, 08-15, 17-19
Hospitals: FY 15-17 (Legacy), FY 18 (+PAR), FY 19 (+PWH, PRH)
763
adverse
events
FY 19
(9 Hospitals)
593harm events prevented
(FY 15 compared to FY 19)
797
adverse
events
FY 18
(7 Hospitals)
808
adverse
events
FY 17
(6 Hospitals)
1001
adverse
events
FY 16
(6 Hospitals)
1356
adverse
events
FY 15
(5 Hospitals)
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Saved by Skill, Knowledge, and
the Culture of Safety
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Questions from the Participants