Achieving Results in Safety

©Copyright Lee Memorial Health System • All rights reserved

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Caring People, Caring for People

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Mission: To meet the health needs and improve the health status of the people of SW Florida. Vision: To be the best patient-centered health system in Florida. Values: Safety, Quality, Service, Compassion and Teamwork.

MAKE HARM VISIBLE

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Changing Behaviors

Set Expectations

Educate & Build Skill

Reinforce & Build

Accountability

© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Serious Safety Event •Reaches the patient •Results in moderate to severe harm or death Cause Analysis: RCA Required

Precursor Safety Event •Reaches the patient •Results in minimal harm or no detectable harm Cause Analysis: ACA, possible RCA

Good Catch Safety Event •Does not reach the patient – error is caught by a last strong detection barrier designed to prevent event Cause Analysis: report, no formal review

Precursor Safety Events

Serious Safety Events

Good Catch Near Miss

Safety Event

Monthly Patient Safety Progress Report – New Feature - Safety Coach Corner

Reinforce & Build Accountability

Safety coaches are individuals who have received extra training to provide “just-in-time” peer checking and peer coaching for safety in their department.

Coaches use both formal (documented behavioral observations) and informal (“on the spot”) techniques.

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Slide 7

Influencing Behaviors at the Sharp End

Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994)

Design of Culture

Outcomes

Behaviors of Individuals & Groups

Design of Structure

Design of Technology & Environment

Design of Work

Processes

Design of Policy & Protocol

© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

“You have to manage a system. The system doesn't manage itself.”

W. Edwards Deming

"A bad system will DEFEAT a good person every time.“

W. Edwards Deming

The Secret Sauce: Safety Coaches • “Sharp end” is where we have our greatest

opportunity to harm or to heal. • Safety coaches complement and partner with

leaders to help to establish peer accountability. • Safety coaches model a cooperative culture. • Safety Coach program goals:

– Reduce behaviors and practices that could result in harm

– Improve/promote active communication between disciplines

– Identify problems, seek resolution – Share lessons learned

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Reinforce & Build Accountability: Report All Safety Events & Problems

• Encourage reporting of all “near-miss” events. • Remove the “shame” around reporting mistakes. • Re-educate staff on use of Incident Reporting System. • Explore causes to prevent future errors. • Celebrate staff who “raise the safety question”

including physically going to that work unit to personally recognize individual staff members.

• Promote monthly Patient Safety Progress Report.

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How Do We Monitor Safety Journey Effectiveness? Annual Safety Survey Results

• Continued real improvement over past 2 years. • 20/43 questions showed statistically significant

improvement. • Positive increase in 11 out of 12 safety composites. • 5 composites showed statistically significant

improvement: 1. Handoffs and Transitions 2. Teamwork ACROSS units 3. Feedback and Communication about Errors 4. Non-punitive Response to Errors 5. Overall Perceptions of Patient Safety

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What We’ve Learned: • Broad diversity of “spread” team improved the quality of our

output. • Strongly supported Unit-Based Safety Coaches are the “secret

sauce”. • Physician involvement is the “super secret sauce” • Developing new HABITS requires daily surveillance. • Best-Practices are out there– look for them—celebrate them. • Staff responds to “patient safety” exponentially better than

“quality of care”. • It’s critically important to “hang tight and keep paddling” through

the “transparency” white-water debate. • Using creativity, committed people can accomplish amazing

things. 11

“Caring People, Caring For People.”

10/31/2014 12

It’s not our slogan. It’s our promise.

Lee Memorial Safety Culture Roadmap

Safety Culture Effectiveness = Plan Effectiveness x Implementation Effectiveness

Task Implementation Engraining & Sustaining

Diagnostic Assessment

Safety Culture Survey

Common Cause Analysis

of Past Events

Diagnostic Interviews

Safety Behaviors for Error Prevention

Education & Training of Leaders, Staff, & Physicians

Red Rules for Safety

Leadership Method for Performance

Excellence

Cause Analysis Program Improvement

Operational Leaders Establish

Safety as Core Value

Leadership Method Application

Behavior Observation &

Coaching

Safety Success Stories

Align Existing Work Processes

Integration with Process

Improvement Methods

Integration with Cause Analysis & Lessons Learned

Board & Senior Leaders Establish

Safety as Core Value

Executive Sponsor

Medical Staff Sponsor

Integration with Vision, Mission, &

Values

Integration with Strategic & Annual

Goals

Integration with Hiring Processes

Integration with Orientation &

Training Processes

Intervention Implementation

Accountability Systems

Process Alignment

Culture Change Preparation

Hardwiring the Change

Safety Culture Lead & Team

Vertical Communication Infrastructure

Alignment with Key Stakeholders &

Programs Safety Coaches Other Diagnostic-

Based Interventions

Results & Interventions Recommendations

Report

Document & Data Review

Integration with Performance Review

Process

Safety Metrics & Control Loops

Complete

In Progress

© 2007 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

Next Focus

As of 24 January 2011

Three Drivers of Accountability

Individual • Integrate into hiring criteria

Peers • Safety Success Stories • Safety Coaches • Peer checking & coaching • Integrate into preceptor and

mentoring programs

Leaders • Integrate into vision and mission

• Align goals, metrics, and incentives

• Rounding to observe and coach • Find and fix system problems

Optimal Accountability

Why a Safety Coach Program?

• People at the sharp end have our greatest opportunity to harm or heal

• Safety coaches complement and partner with leaders to help to establish peer accountability

• Safety coaches model a cooperative culture • Goals of a safety coach program:

– Reduce behaviors and practices that could result in harm – Improve/promote active communication between disciplines – Identify problems, seek resolution – Share lessons learned

Safety Coach Roles: • a communicator, ensuring that your co-workers understand

our behavior expectations for preventing infections. • an educator, ensuring that your co-workers have a practical

knowledge of how to practice these behaviors. • a role model, demonstrating and leading the way in our

culture change. • an observer, positively reinforcing, by real time interaction

with co-workers, the expectations for preventing infections • a storyteller, by seeking out every opportunity to share our

patient safety stories with your team members. • a partner with your manager in helping us reach our goal of

no hospital acquired infections for our patients

Roles & Responsibilities

• Primary role is habit formation: • Teach safety behaviors at “bedside” • Provide feedback & reinforcement • May document some observations using a tool

• Secondary roles: • Environment of care monitoring • National Patient Safety Goal monitoring • Communication channel to leaders2staff • Communication channel staff2leaders • Apparent Cause Analysis

Lessons Learned from Other Programs • Leadership commitment is critical to oversee/ support program

and to enable coaches to take time from their normal duties to perform coaching activities.

• Safety coaches need a firm grasp on the tools/techniques used with the safety behaviors (and how/when they are used in their departments)

• Provide continuing education at the monthly meetings • Establish routine check-in for coaches • Ensure meetings are efficient:

– Educational presentations – Share lessons learned and best practices – Role play coaching and feedback – Encourage, reward, recognize, and motivate

Blue Print for Safety Coaches • Each facility should plan their program based on their needs

– Base coach assignments on one (1) per Unit – Share coaches across patient care areas – Focus resources on areas with greatest identified need

• Training & education: – Initial training for safety coaches – Monthly meetings 1hr per month (evidence indicates 15%)

• Plan monthly targets, program focus, & coaching methods • Receive ongoing education and coaching materials

• Duties include: approx. 4 hrs per month per unit per shift

– Rounding (behavior observation) – Environment of care monitoring – Facilitate habit formation – Feedback & reinforcement – Collect concerns from staff

Selecting for Fit

Basic Qualities: • Acts like an Influencer • Belief in Founding Principles and Core Values • Passion for the patient, patient safety, and quality • Has credibility with leaders and staff • Life-long learner

Practical considerations • 60/40 split between clinicians and support • Flexibility in work days (difficult for nurses) • Diversity

Influencer

Make the Undesirable Desirable

Harness Peer Pressure

Design Rewards and

Demand Accountability

Surpass Your Limits

Find Strength In Numbers

Change the Environment

PERSONAL

SOCIAL

STRUCTURAL

MOTIVATION ABILITY Vital Behaviors Use positive deviance to search for vital behaviors. Apply influence so the behaviors become habits

It is not enough to do your best; you must know what to do, and THEN do your best.

- W. Edwards Deming

Safety Coach Curriculum • Fundamentals (safety, systems thinking, human error)

• Behavior super-users (error prevention techniques)

• Feedback & reinforcement skills (5:1 feedback)

• Observation skills (observable standards, observation tool)

Continuing education • Current events in patient safety & quality • Lessons-learned from cases (external + Lee) • Patient safety results and areas of emphasis Plan a four (4) hour orientation for new coaches

Provides uniform schedule Forces leaders to take on tough

passages – not just the easy messages Aids in sharing resources and insights

while preparing to influence

Cycle Safety Coach Topic 1 Speak Up for Safety Using CUS 2 Reporting of Safety Events, Errors, & Unsafe Conditions 3 Safety Practice: Time outs 4 Cross Monitoring 5 Red Rule: Patient Identification

6 Communicating Clearly by Asking & Encouraging Clarify Questions

7 Hand Hygiene for HAI Prevention 8 Staffing Shortages: Crisis or Chronic?

Safety Behavior Habit Scale

1 2 3 4 5 6 7 8 9 10

Our Safety Behaviors are just how we do things around here! We do it when we

know someone’s watching

Safety Behaviors? What are they?

No one else is doing it, so I feel

out of place

I do it most of the time, but when I get

busy, I forget

What Makes a Great Story Great??? Everyday excellence – not just the great saves Language we can all understand Name names to recognize Link to a behavior expectation

More Clever: Use the number of published safety success stories as

a real-time metric.

Environmental Services Associate Speaks Up For Safety While going about her daily duties of cleaning a patient room, Janice, an Environmental Services Associate observed a physician and nurse enter the room and prepare to perform a minor procedure. She knew the hospital’s rule about site verification before a procedure, yet noticed that the team was about to proceed without the verification. Janice politely questioned the physician and nurse, “Shouldn’t we verify the site before the procedure?” The physician and nurse thanked the Associate and verified the site. By being aware of what was going on around her and being willing to speak up, Janice helped ensure that the procedure was performed on the correct site.

Share Safety Success Stories

Consensus Scale (encourages all to express their thought)

3 4 5 2 1

Thinking and feeling reasons in favor of the

proposal

Thinking and feeling reasons against the

proposal

Consensus is achieved when the group is greater than 4 and no one is a 1.

Objectives of Observation & Coaching

Reinforce the use of our Safety Behaviors – convert them to our work habits 1

Reveal symptoms of problems before they become events that result in harm 2

Provide data from observations so we can track how we’re doing 3

How We Want to Provide Feedback Be Proactive... Stop an unsafe act or behavior that could lead to harm.

Be Discrete... Provide feedback in a private manner – giving feedback in front of patients and

peers only leads to embarrassment and is not effective. Be Helpful... The goal of behavior observation is to improve individual and team performance

by recognizing good behaviors and correcting unsafe, unproductive behaviors – not to catch someone doing something wrong.

Good Habits for Coaching 5:1 feedback • Based on observation and fact • No sandwich approach • Immediate feedback, yet pick

appropriate time and location • “Lightest touch” possible to get the

desired results • Ask for commitment to change

behavior

Delivering the Message Invitation: “May I point something out…”

Observation: “I could tell that you were struggling in your phone conversation with Dr. Smith about your patient.”

Expectation: “Using SBAR is a Safety Behavior expectation at Memorial Hermann. It helps us frame the conversation when communicating about a situation that requires a decision or action.”

Facilitation: “Let’s do one together. Why don’t we talk through your patient case using SBAR.”

Commitment: “Next time you communicate with someone about a decision that has to be made, will you use SBAR?”

The Question Behind the Question

How are you going to participate in improving the situation?

How can you be a good Peer Coach

for your team member?

How Would You Respond?

“It takes too much time.”

“I’ve never had a problem before.”

“I use the Safety Behaviors when it’s important.”

“No one else is doing it.”

“Who are you to tell me what to do?”

Self-Checking Using STAR

Expectation

• We focus our attention to think before we act when performing familiar, routine acts.

• We use STAR ALWAYS before performing an irrevocable act that could impact safety.

Observable Standards

(What You See)

• They pause, to put head before hands. • They don’t engage in unrelated conversation with others. • When interrupted, they resist (“please wait – I’m doing something

important”). • They use their finger to point to important information that needs

to be checked or should match.

Coaching Tips (What You Say)

• Make it a habit • Visualize the act • Self talk

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Let’s Practice!

• Read the safety situation aloud. • Then C.U.S. with a partner to make the situation safe.

CUS When It’s Critical!

Questioning Attitude

Expectation • We apply a strong Questioning Attitude when considering

direction we are given, information that we receive, and making choices as to how to proceed.

Observable Standards

(What You See)

• They pause to reflect before acting. • They ask Clarifying Questions. • They consider both the source (Qualification) and the information

(Validation).

Coaching Tips (What You Say)

• Good care providers ask when unsure. • Good care providers also ask just to be sure. • Questioning Attitude is not just asking questions, it is questioning

the answers. • Curse of Knowledge – common sense is not always that

common, and the obvious is not always so obvious

Implement Red Rules • An act that has the highest level of

risk or consequence to patient or employee safety if not performed exactly each and every time.

• “Red" designates the rule as a safety absolute with the highest priority for exact compliance.

• if conditions cannot be met.

PATIENT SAFETY WORK PRODUCT—Created as part of LPSES - the LMHS Patient Safety Evaluation System 36

(Insert “It takes Two” Video)

Red Rules

Expectation • We apply a strong, intelligent compliance when performing patient

care governed by Red Rules. If we cannot comply, we stop patient care.

Observable Standards

(What You See)

• Patient Identification: have answer in hand, touch ID bands, and inquire patient name.

• Time Out: all participate; led by physician; verify patient name, procedure, and location; verbal concurrence by all.

• Checks: at bedside, independent, full scope.

Coaching Tips (What You Say)

• Inquire name, “could you tell me your name again, please, for the purpose of identification.”

• Verbal concurrence, “I concur (or yes)” • Location is laterality or level of spine or multiple structures • Say “correct” not “right” (right goes with left) • Independent means that the checker has the same scope as the

doer.

Clear Communication Bundle

Expectation • The Sender and Receiver use 3-Way Repeat Backs, 3-Way

Read Backs, Clarifying Questions, and Phonetic & Numeric Clarifications when communicating.

Observable Standards

(What You See)

• They do a 3-Way Repeat Backs when exchanging information that could affect safety and quality.

• They do a 3-Way Read Backs when communicating telephone orders and critical values.

• They ask Clarifying Questions when critical information is exchanged and when information is high risk, incomplete, incorrect, or ambiguous.

• They use Phonetic and Numeric Clarifications for sound alike letters, words, and numbers.

Coaching Tips (What You Say)

• Use our safety phrases: –“Let me repeat that back.” –“I’d like to ask a clarifying question.”

“The world is not a dangerous place because of those who do harm, but because of those who look on and do nothing.”

Albert Einstein

LMHS Safety Coaches