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Collaborating to Prevent Harm and Improve Patient Safety - Case Study

 

As a Risk Management and Patient Safety Professional what are the resources/tools you would choose to ensure this will be an evidence-based plan?

 

63 Comments

  1. Sam Elizondo

    Feb. 9, 2021

    There is a wealth of available information from IHI, AHRQ and other organizations to being an initial literature review. Amy Edmonson has published evidence based research which outlines the science that proves that higher performing, safer organizations are associated with highly developed patient safety cultures. The Joint Commission also is a wealth of information, such as the Sentinel Event Alert that was provided as a supporting document as part of this seminar. Best practice sharing is also key. I really like the ASHRM Exchange. Is an excellent forum and sounding board for the risk professional. Finally, collecting data from your own organization. Administering HSOPS is invaluable. Using the data to leverage change and utilizing your leadership to help promote transformative change as is generally the goal.

    Reply
    1. Candace Eden

      Feb. 10, 2021

      Sam, you are on top of it. The resources are amazing and very thorough. The tough part is translating that for your executives to also understand what you know and plan what to put in place to get to that level that Amy has published. The data you describe is key as you said. HSOPS is only once every 2 years but as you said very valuable.

  2. Susie Jester

    Feb. 8, 2021

    I think a good resource and starting place would be assessing COS through survey, if not already done. I think leadership rounding and safety huddles are best practices that have leads to accountability and transparency. I also think the HRO survey by TJC is an excellent tool for leadership to discover how everyone really think they stand in this area.

    Reply
  3. trish

    Feb. 7, 2021

    Evidence based is integrating best practice with expertise. I'd seek out the clinical leaders, research the issue and once we have input, obtain a consensus on what the best practice is moving forward and make sure that it is communicated and taught.

    Reply
  4. Jacquelyn Baker

    Feb. 7, 2021

    To ensure my response will be an evidence-based plan, I would identify a team of experts in key positions within the organization who have valuable input; research the literature to be sure I have current knowledge on best practice; review and analyze the data that is available for the facility and comparable facilities.

    Reply
  5. Leilani Kicklighter

    Feb. 7, 2021

    Michelle (sorry if i misspelled your name) Thank you for your kind words. It always gives me a warm feeling when a former student shares positive feedback. enjoyed teaching and am pleased to know I was successful in providing a solid foundation for your success.

    Reply
  6. Nadia Cheevers

    Feb. 7, 2021

    To ensure the plan will be evidence based I would start with enlisting the participation of clinical leaders in this area for their insight about best practices and pinpointing evidence based solutions. As the Risk Management professional, I would also do a thorough literature and resource search to add to the options to best inform and support the decisions of the clinical leaders.

    Reply
  7. Lisa Sunday

    Feb. 7, 2021

    The two incidents have triggered interest the patient safety culture of the organization. Initially, some metrics gathering might be beneficial to evaluate the current state. Therefore, seeking to develop some initial and ongoing metrics in this regards in collaborations with the interested board members might be benificial. In addition, further staff involvement and some education in the process would be beneficial.

    Reply
  8. Mariel Kagan

    Feb. 7, 2021

    When is the "Action Learning Project" Due? To whom may we address any questions that we may have about it?

    Reply
  9. Dorothy cahill

    Feb. 7, 2021

    where on the website will we find the evaluation and ability to get a certificate? thanks

    Reply
    1. Dorothy cahill

      Feb. 12, 2021

      still no way to get a ceu cert to document I viewed the 6 hours of zoom on sat 6-sun7???please advise

    2. Dorothy cahill

      Feb. 7, 2021

      How do we check-out??? hopefully another email will come regarding credits and an evaluation..

    3. Candace Eden

      Feb. 7, 2021

      Dorothy, the agenda page has the information under optional assignment for the learning project. Once you check out you will have an evaluation. Not sure if it is right there or will come in an email afterward. Mariel-Haresh Ramjas, our past president, is going to lead a webinar with the details that Ken will send out to all who are interested. He will answer questions then.

  10. Leilani Kicklighter

    Feb. 7, 2021

    Since the Board is ultimately responsible and 2 members have shown and interest in understanding i would invite them to participate in the process and share information;-research most appropriate tools, research these events; conduct root cause analyses drilling down to the human factors, conduct FMEA analyses, identifying failures and successes identifying safety issues and contributory factors, using these facts as a foundation to strengthen or modify processes and enhance education as needed.

    Reply
    1. Michelle Miller

      Feb. 7, 2021

      Leilani, You were my instructor when I took my original risk management class through USF. Thank you so much for laying the foundation for me. I have gone back through my notes often to look for references and tips you gave us. Without your knowledge and willingness to share, I wouldn't be where I am today. I thank you!

    2. Melissa Lofton

      Feb. 7, 2021

      What a great idea to get the board more involved!

    3. Candace Eden

      Feb. 7, 2021

      Leilani, thank you for picking up on the 2 interested Board members reading those articles. They are responsible overall for the quality and care delivery the hospital/organization provides. If you get them to be engaged you will be able to do the things you mentioned quicker and more robustly because they will want to know your outcomes of using those tools.

  11. Danielle Manglona

    Feb. 7, 2021

    1. An assessment of the current safety culture would be a good way to start. AHRQ’s Survey on Patient Safety Culture and the Oro 2.0 High Reliability Assessment are two such assessment tools. Information gathered from these tools would help to provide a picture of where the organization is and is helpful in planning where the board wants the organization to be. 2. Education of the organization in Just Culture is also important. You can also take this further by building in Just Culture into event reports to visibly show how it was used to address an event. 3. Education on TeamSTEPPS and the provision of coaching to assist in the roll out and sustainment of its use. 4. Using an event reporting software that allows for reporters of events to follow up the outcome and improvements made as a result of the report would go along way in showing staff that speaking up means something and that the organization is committed to safe quality care. 5. Implementing a good catch award program. 6. Sharing lessons learned through multiple outlets (e.g., newletters, lunch and learns, unit level meetings, etc.). This helps to foster a continuous learning environment. 7. Implementation of Leadership Walkrounds to promote its commitment to the organization’s safety culture.

    Reply
    1. Faye Robbins

      Feb. 7, 2021

      Since the Board members raised their concerns about SSEs, I am responding on the premise that they are very much on board with patient safety initiatives. At this point, I would advocate to the Board, CEO, CNO, and CMO that engaging all leaders in formal Just Culture training would be a logical next step to further bolster the culture of patient safety and promote psychological safety among the staff members. Those patient safety professionals who have become certified in Just Culture have a unique toolkit that fosters psychological safety, the first and most important (in my view) is guarding against outcome bias.

    2. Candace Eden

      Feb. 7, 2021

      Danielle, what a great book of work for you for this year and into the next. All of those steps are great. With the new AHRQ survey we all need to do in Florida, we need to also look at the qualitative side, the comments, because they tell you even more than the numbers do. It is eye opening.

    3. Dorothy cahill

      Feb. 7, 2021

      very comprehensive

  12. Cheri Graham-Clark

    Feb. 7, 2021

    I would start with framing the work with the leaders. People speaking up is the last thing that happens after people see you have a system that listens and learns. I would start with what evidenced based leadership foundations...ACHE, IOM, Learning Culture literature, etc.and agree on a framework with the leaders. Ask for their sponsorship of the program. Ask what resources they may need and identify other key champions or leaders (CEO, CXO, CIO, etc). Get level 5 agreement that a plan is necessary and that they will work with you on developing.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Cheri, Doreen certainly emphasized that need you are describing to have a framework and there are several to choose from. ACHE and IOM are great ways to get that executive group interested. Especially if they are hearing if from a society they may be a part of and you are saying the same thing.

  13. Tammy Rorer

    Feb. 7, 2021

    It is important to determine current benchmarks with patient safety culture to access how to best develop program. An internal focus from a patient perspective may involve evaluating patient safety survey results and then determine if the healthcare providers and staff feel the facility supports a culture of patient safety. An independent source such as AHRQ (Agency for Healthcare Research and Quality) may be considered and compared to determine an organization’s patient safety environment and culture.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Tammy, the C-suite team always speaks in terms of the benchmark comparison because they are competitors. Bringing them that internal patient focus is good for them to balance what they choose to do based on what is needed. Again the AHRQ survey will help them compete and compare and get valuable insight into their own team. great points.

  14. Angel Barber

    Feb. 7, 2021

    I would utilize the Institute of Medicine (IOM) core competencies as communication and collaboration with supporting data and research would be the resources and tools to start with.

    Reply
    1. Michelle Cruz

      Feb. 7, 2021

      Exactly! We just learned this morning about evidenced based practice!

  15. Alex Bowers

    Feb. 7, 2021

    I think engaging with the patient experience manager to understand what types of concerns they are seeing and compare it to the grievances our risk department is getting. This information is coming directly from the patients. Event if the grievance is not validated or concerns are not "verified" it is still the patients perception and if they don't feel safe then we have to see if it is truly not a safe environment or if we need to work on communication. I would also use RCA2 process when investigating events, that allows the team to evaluate human factors. Developing a culture to speak up for safety has to come from the top and must be encouraged and supported by both nursing leadership and physician leadership. Daily rounding by leaders to check in on staff.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Angel and Michelle, You are both right about using some evidence based tools to get it started. The Science of Risk and Patient Safety is out there. We just need to add to it Alex, you are spot on about working with the patient experience team. What they are seeing/experiencing is another way of looking into what is really happening at the front line.

  16. Lavonneda Hyland

    Feb. 7, 2021

    There are a variety of excellent resources available. I would start with resources available on IHI, IOM, and AHRQ. But most importantly I would suggest starting with Just Culture. Just Culture can be the foundation of moving forward to improve patient safety for the organization. The tools and resources used should support Just Culture as the central tenet for change in the organization.

    Reply
  17. Melody Saikali

    Feb. 7, 2021

    With regards to help in reducing harm and enhancing psychological safety, I think one would first start by: - assessing the current safety culture, by using evidence based tools such as the AHRQ safety culture survey. Once the data is available, relay to the C-suites to help devise improvement actions. -Training leadership about just culture is key -Teamwork training (TEAMSTEPPS) -Feedback loops, leader walkrounds, safety huddles and briefings, learning boards in units and having a senior exec adopt a work unit can also help the workforce feel that their opinions matter, and that safety is the leadership's priority. With regards to involving patients more, organizations could include patients as advisors in committees, enforce bedside handovers, implement disclosure policies, and using the IDEAL discharge planning tool (include, discuss, educate and listen). (Sorry for the long comment!)

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Lavonneda and Melody, you are right about the choice of resources. TEAMSTEPPS is one of my favorites Melody, I used it for my Doctorate work. I really like the point of making sure the workforce needs to feel that their opinions matter, because they do. And of course the foundations of both psychological safety and a Just Culture are important for this all to work.

  18. Debi Seagroves

    Feb. 7, 2021

    I would use the IHI National Action Plan and also work with our managing partners who have already set up a successful patient safety plan.

    Reply
  19. Lauren Hyer

    Feb. 7, 2021

    It would be important to review or obtain baseline data through a Patient Safety Survey. I would also advocate to implement a Just Culture Model to address their concerns about the psychological safety of the staff and systems thinking.

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    1. Candace Eden

      Feb. 7, 2021

      Lauren, you are so right about baseline data. Remember DATA drives executives. that will help you advocate for the Just Culture model to be used.

  20. Jen

    Feb. 7, 2021

    There are many great resources to ensure best practices are implemented. IHI is great for doing assessments and gives guidance on implementing plans. Additionally the NQF and AHRQ are good resources for EBP. Using the Culture of Safety Survey conducted regularly by the Quality department can be a good method of identifying where change needs to occur.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Debi and Jen, that IHI plan is great because not only does it provide direction from many sources it gives you assessments and implementation plans. You have it all in one package. You just need to "sell" it to your executives and get the Board excited about it too.

  21. Heather Joyce-Byers

    Feb. 7, 2021

    I would use the Just Culture, a form of error prevention training, and current best practices from the appropriate professional societies. This way all aspects of the event can be evaluated with appropriate staff support being provided.

    Reply
  22. Jana Lyner

    Feb. 7, 2021

    I think first we need to evaluate the staffs perception of the current culture of safety. I believe often leaders are under the impression it is adequate until an event occurs or two in this case and we realize maybe it’s not as prevela the as believed.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Heather and Jana, the Just Culture is a good way to begin and doing that assessment ahead as Jana suggests can inform the error training prevention needed. I love Heather that you use the best practices from the professional societies. Not only is FSHRMPS or ASHRM good resources, so is AORN and other Nursing or physician societies.

  23. Becky Singleton

    Feb. 7, 2021

    Evaluate what happened, identify training needs, focus on patient-centered goals.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Becky, good plan to start. Look at that National safety plan-it may provide some specific tactics that can help.

  24. Mariel Kagan

    Feb. 7, 2021

    As a RM and PS Professional, I would engage the CNO and CMO in a discussion aimed at establishing a culture of safety at our organization, by way of an evidence-based plan. Moving our organization forward in the principles of a “High Reliability Organization” (HRO) would be a way of addressing the patient safety concerns we see. A HRO philosophy/model as a resource is a way to acknowledge the error-prone nature of healthcare, develop resilience and quick action to address/detect threats to safety, and to increase the comfortability of staff to discuss failures and/or near misses, when they happen. The tools available to ensure it would be an evidence-based plan, could include the AHRQ Patient Safety Culture Survey as well as the Safety Attitudes Questionnaire (SAQ).

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Yes, Mariel, I like the concept of us flowing towards that HRO model using those 5 principles to guide what we do. Everyone is saying how critical it is to make staff feel safe, be comfortable, and empowered to speak up. the AHRQ Survey we will are all mandated to do this next year in the State of Florida will give us good information.

  25. Michelle McKiernan

    Feb. 7, 2021

    There are some good resources for guidance on using evidence based strategies to improve the culture of patient safety. I am most familiar with IHI and National Patient Safety. The hospital can join a PSO and participate in a QIO. I agree with the other post about getting more data via the safety culture survey to understand where the issues really are.

    Reply
  26. Lory Harte

    Feb. 7, 2021

    In order to involve patients in our improvement efforts, it is important to have a strong Ombudsman and Patient Experience department. These colleagues are trained in communicating with patients and families and most importantly in listening. Collaboration between patient safety, risk and patient experience is imperative in breaking down the process of investigation so that roles are clear and more can be achieved in a short period of time allowing for a multi-perspective view of the event and contributing factors. In my opinion, leaders are instrumental in ensuring that staff feel psychologically safe to speak up. Leadership rounding demonstrates that leaders are interested in the day and life of the frontline worker. Leaders should ask questions about what keeps the employee up at night, where does the front line worker see opportunity for improvement or risk for harm to a patient. Then the leader needs to follow-up on those concerns and report back to that front line worker what is planned to address the concern. Human factors is a innovative way to break down problems and design better solutions. Now, you can find HF Engineers in healthcare to support improvement in problem prone areas. Partnering with or hiring HF engineers offers a unique skill set that may not be available within the current employee pool.

    Reply
  27. Nancy Somerset

    Feb. 7, 2021

    Patient Safety and Risk Management along with CMO and appropriate personnel would conduct RCA, utilize safety culture survey and monitor for improvement opportunities as needed. Reporting to appropriate committee and agency would be performed.

    Reply
  28. Jenna

    Feb. 7, 2021

    To ensure this will be an evidence-based plan, there needs to be an integration of leading research with clinical expertise and patient values for high quality of care. Participation in learning and research activities are essential. Adopting best practices allow for ultimately improving processes. The focus also must be on Just Culture.

    Reply
  29. Kim

    Feb. 7, 2021

    Great place to start would be using just culture and great catches.

    Reply
  30. Lisa

    Feb. 7, 2021

    Our hospital participates in the culture of safety survey and Leapfrog.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Yes, those basics are key to be a part of.

  31. Kristen Sapienza

    Feb. 7, 2021

    One of our Hospital Systems joined the patient safety collaborative through the state patient safety organization and in doing so trained representatives throughout our facilities to do risk assessments and reward reporting. We bring great catches forward and celebrate great saves.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Yes, Kristen, the Patient Safety Collaborative is a great method and provides networking opportunities and comparisons.

  32. Kristen

    Feb. 7, 2021

    We at AdventHealth utilize HFACs to guide us through these events - RCA2 process. I myself have two RCA2 projects that my teams are currently working on. Both are truly leading our campus and hopefully our system to process improvements to allow for better patient outcomes. These process's are very fulfilling as they allow many different departments to offer incite and thought to the improvements themselves.

    Reply
    1. Dorothy cahill

      Feb. 7, 2021

      can u give more info on the RCA-2

    2. Michelle Miller

      Feb. 7, 2021

      what is a HFAC? Not coming from a hospital, I haven't heard of this.

    3. Candace Eden

      Feb. 7, 2021

      Kristen, we are now using HFACS too. We got the idea from AdventHealth. Great RCA Methodology.

  33. Dorothy cahill

    Feb. 7, 2021

    evaluate/review policy/procedures/resources..utilize all information around the case..staff intreviews...team performance

    Reply
  34. Beth Keller

    Feb. 7, 2021

    Great catch and just culture

    Reply
  35. Michelle Miller

    Feb. 7, 2021

    First, outline the need for promoting a culture of patient safety, but demonstrating what is already in place and what is the current culture. Use data analysis to target what improvements you would like to focus one and then start with a unit-based approach to engage staff and highlight reporting transparency, staff engagement for actionable improvements and also how adverse events can be used as opportunities for improvement and not punitive.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Good methods in great catch, the just culture or culture of patient safety, following the policies in place and using data for actions are all good ideas. We truly need to shift that culture from being punitive to being opportunity for being better and a Leading Organization.

  36. Suzanne

    Feb. 7, 2021

    Having nothing in place I would start with the IHI Quadruple Aim and the Institute of Medicine's core competencies. We would also want to get involved with a safety culture survey as a starting point.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Good way to start. Very strong methodology.

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