Transcript Safety Champion Program - Henry Ford Health System

Engagement and Empowerment of
Frontline Staff to Promote a Culture
of Safety:
A Safety Champion Program
Jeanette Tanafranca, MSN, RN-BC
Safety Champion
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Why do we need a
Safety Champion program?
Health care is not safe.
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.
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H
1. Identify Top Causes of Harm
A
2. Enhance our Culture ofRSafety
M
3. Improve the Quality and Clarity of Clinical
Communications
50%
4. Redesign Care To Eliminate Harm
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HFH
Clinton Twshp
Warren
West Bloomfield
Wyandotte
Jul-11
May-11
Mar-11
Jan-11
Nov-10
Sep-10
Jul-10
May-10
Mar-10
Jan-10
Nov-09
Sep-09
Jul-09
May-09
Mar-09
Jan-09
Nov-08
Sep-08
Jul-08
May-08
Mar-08
Jan-08
Rate per 1000 Days
No Harm Campaign
Extended 3 more years
Combined Harm Rate HFHS Hospitals by Hospital
80
70
60
50
40
30
20
All
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Enhancing our Culture of Safety
Safety Culture Global Indicators
•
•
•
•
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Organizational commitment
Management Involvement
Employee Empowerment
Reward Systems (Just Culture)
Reporting Systems
Formal
Team Training
Build Local
Safety
Structure
Champions
Create Safe Environments
HFHS Added:
• Partnerships with Patients and
Families
Establish a Common Language
HFHS Culture of Safety Building Blocks
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 4
of Aviation.
Impact of Safety Champion
Program
2006 - 2010 Comparison of Percent Favorable:
(4 - Agree and 5 - Strongly Agree)
100
90
76
80
70
81 80
77 82 83
79
74 74
62
68 73
70
59
60
% 50
40
65
58
53
34
30
20
N=15,767
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0
N=15,683
Mgt actions
We are
show safety is encouraged to
a priority
speak up
N=16,566
I would feel
safe as a
patient here
N=10,407
Lots of nurse
doctor
teamwork
Culture of Safety Question
2006
2008
2010
AHRQ 75th Percentile 2010
N=10,994
N=10,994
Clinical
Communication
disagreements
breakdown
resolved well leading to care
delays rare
AHRQ 90th Percentile 2010
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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.
Engagement Scores Improvement 2010 vs. 2008
Safety Champ vs. No Safety Champ (Clinical Units)
0.14
0.22
0.19
0.14
0.09
NO Safety Champ
COS
C07 Question
C08
Communication
breakdowns
uncommon
C06
Disagreements
resolved well
C05
Lots of teamwork
between nurses and
doctors
Feel Saf e as a Patient
at HFHS f acility
Safety Champ
Difference Between 2010 and
2008 GMEAN Scores
0.3
Encouraged to Speak
Up
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
-0.05
-0.1
Management Actions
Difference Between 2010 and 2008 Mean
Scores
Safety Champion vs. No Safety Champion (Clinical Units)
Improvement 2010 vs. 2008
0.15
0.16
0.14
0.12
0.1
0.08
No Safety Champion
0.08
Safety Champion
0.06
0.04
0.02
0
Q12 GMEAN
12 Engagement Questions GMEAN
C09
C10
0.1 improvement = meaningful
0.2 improvement = statistically significant
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Safety Champion Program
“Coming together is a beginning;
Keeping together is progress;
Working together is success.”
Henry Ford
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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
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Who are Safety Champions?
•
Front line, multidisciplinary employees that act as a “Voice” and
“Face” of Safety.
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–
–
–
–
–
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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
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Conceptual Framework
Adapted from Dr. Patricia Benner’s Stages of Clinical Competence
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Safety
Champion
Program
Professional
Development
IHI Open School
Conferences
Communication
Monthly Toolkits
Bi-Monthly
Newsletters/Great
Catch
Facebook
Core
Courses
Patient Safety 101
Introduction to the
Safety Champion Role
-Human Factors
Process
Improvement
Reporting
Strategies
Projects
Sharing
Learning
Quarterly
Forums
2 Minute
Tutorials
Program Start: June, 2008
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Core Courses
I. Patient Safety 101
II. Introduction to the
Safety Champion Role
(Human Factors)
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
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Which
is generally
the One
Cent
U.S. Coin?
Memory- we
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.
A Simple Example of the Limits of Memory
Image Source:http://www.dcity.org/braingames/pennies/
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Safety
Champion
Program
Professional
Development
IHI Open School
Conferences
Communication
Monthly Toolkits
Bi-Monthly
Newsletters/Great
Catch
Facebook
Core
Courses
Patient Safety 101
Introduction to the
Safety Champion Role
-Human Factors
Process
Improvement
Reporting
Strategies
Projects
Sharing
Learning
Quarterly
Forums
2 Minute
Tutorials
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Safety
Champion
Program
Professional
Development
IHI Open School
Conferences
Communication
Monthly Toolkits
Bi-Monthly
Newsletters/Great
Catch
Facebook
Core
Courses
Patient Safety 101
Introduction to the
Safety Champion Role
-Human Factors
Process
Improvement
Reporting
Strategies
Projects
Sharing
Learning
Quarterly
Forums
2 Minute
Tutorials
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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
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Safety
Champion
Program
Professional
Development
IHI Open School
Conferences
Communication
Monthly Toolkits
Bi-Monthly
Newsletters/Great
Catch
Facebook
Core
Courses
Patient Safety 101
Introduction to the
Safety Champion Role
-Human Factors
Process
Improvement
Reporting
Strategies
Projects
Sharing
Learning
Quarterly
Forums
2 Minute
Tutorials
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Process Improvement
•
•
•2 patient identifier projects
Accurate
Voluntary
reporting
•Revised SBARand
form for
patient hand-offs
•Selecting
equipmentsystem.
for hospital
our
reporting
•Post-fall management program
Project
survey.
•Handicapped
parking assistance
•Bladder health and collaborative project
•Handwashing projects
•Medication review process
•Mammogram process review
•Medication dispensing projects
•A3s-Needlestick prevention
•More…..
through
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HF West Bloomfield
Impact of Safety Champion Program
• 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
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HFH Inpatient Pharmacy
Impact 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
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Safety
Champion
Program
Professional
Development
IHI Open School
Conferences
Communication
Monthly Toolkits
Bi-Monthly
Newsletters/Great
Catch
Facebook
Core
Courses
Patient Safety 101
Introduction to the
Safety Champion Role
-Human Factors
Process
Improvement
Reporting
Strategies
Projects
Sharing
Learning
Quarterly
Forums
2 Minute
Tutorials
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Safety Champion Successes
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•
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•
•
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
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Safety Champion
I am a
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, CHSP
all
Safety Champions
Can and Do
I make a difference in the lives of
persons who enter HFHS properties.
MaryAnn L. Northcote, CPP, CHSP
I am a safety champion because
Make
a
Difference
in
Patient
Safety
by
I
want
to
be
proactive
in
Patient Safety means….delivering the highest
spreading wellness to individuals
quality careBeing
that is reliable
and coordinated for
the
Proactive,
Minimizing
Risk,
that are in my reach. Injury
patients we serve each day..Judy Caretti-Rourke
prevention is a key component in
I am a Safety
Champion
because......the
Creating
Safe
Environments
helping ourBecause
loved ones and others
environment I work in and the people I serve are
in our community stay safe and
important
me“ LesaBorden Sanford
healthy..Katie Horn
itstoImportant
to RN,
the Lives of ALL.
BSN
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 being proactive in creating and maintaining
I make a
difference to
everyone that comes in
contact with me in the
for our patients who depend on us
Henry Ford Health
when they are most vulnerable.
system..Latonya
Judy Czerepowicz, CHSP
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Phillips
safe environments
-HFHS Safety Champions
Thank You to all of the HFHS Safety Champions for making a difference.
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Contact Information
Jeanette Tanafranca, MSN, RN-BC
Office of Clinical Quality and Safety
One Ford Place, Detroit, MI 48202
313.874.7181
[email protected]
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