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Collaborating to Prevent Harm and Improve Patient Safety - Case Study

 

What specific key positions do the three of you need to collaborate with to start implementing your plan, and name two tactics you would put into place first.

 

53 Comments

  1. Sam Elizondo

    Feb. 9, 2021

    The C level executives are key, CNO, CMO, CIO. CEO must also be supportive. Board involvement and awareness is also important. Levering your safety and quality committees to make recommendations and report progress towards goals. Goals that are set should also be aligned with the organizations strategic goals. Aligning the risk, safety and quality functions.

    Reply
  2. susie jester

    Feb. 8, 2021

    You need many people but the key 3 would be the CNO,CMO,and CEO. I think starting with the results of the COS survey would provide a baseline from a staff perspective. Also reviewing safety event data to understand and prioritize system improvement moving forward.

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  3. TRISH

    Feb. 8, 2021

    I would try to involve the CNO, CMO and the committee members on patient safety and quality improvement teams. I'd also request a report on the errors within the last year and identify key areas where they are occurring and enlist the help of those department heads as well.

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    1. Candace Eden

      Feb. 10, 2021

      Trish, Susie, and Sam, All of you recognized the critical importance of the C-suite buying in and being engaged for this to be successful. The Quality and Safety teams or committees should handle the work that needs to be done and filter back to the C-suite so they can actively drive it to completion.

  4. Dorothy cahill

    Feb. 7, 2021

    did the post surveys but no link to the credits???please advise

    Reply
  5. Jacquelyn Baker

    Feb. 7, 2021

    To begin to develop the plan, I would invite key stakeholders such as Pharmacy medication Safety officer, Customer Service /Feedback Coordinator, Professional Development team member and unit managers for Nursing and Surgery. The team should conduct comprehensive review and analysis of the events; should implement plan that requires immediate and subsequent follow-up (at pre-determined intervals) with each team member who is involved in adverse events.

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    1. Candace Eden

      Feb. 8, 2021

      Jacquelyn, I like how you involved the Pharmacy officer, customer service and educational support along with the key nursing leaders. This would be a solid group to start.

  6. Danielle Manglona

    Feb. 7, 2021

    We would need to collaborate with the Patient Safety Officer, the Quality Improvement Specialist, and a Project Management Expert. Along with the CMO, CNO, and I, these individuals would create the core team. The first tactic would be to develop a play book that would first begin with an assessment of the organization’s current safety culture, the leader’s current knowledge and understanding of just culture, and the organization’s high reliability maturity level. This play book would then expand to include a road map for further action to be taken to incorporate various initiatives for culture change and the support of such change (e.g., such as resources needed). The play book would also factor in strategies to garner buy-in to allow for the team’s vision to be put into motion. As stated in today’s presentation, a culture shift can take 12 to 18 months. This playbook would create a shared mental model of where the organization is at, a vision of where the organization wants to be, a plan of how to get there, and what is needed to do so.

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    1. Candace Eden

      Feb. 8, 2021

      Danielle, very nicely structured plan. Getting that core group together, doing the assessment first , then creating the road map to follow with specific strategies is exactly what I would consider a Culture of Safety best practice. Nicely done.

  7. Nadia Cheevers

    Feb. 7, 2021

    First we need to collaborate on the information seeking phase to be sure we understand the events accurately, and then we need to come to a consensus on which areas of change would be most impactful. Just culture will be an essential tactic to put into place first. In addition, because the board members want to involve patients, we need to explore how best to do this in a manner that supports the patients and staff.

    Reply
    1. Candace Eden

      Feb. 8, 2021

      Nadia, yes, as Melissa said, make sure you have all of our information about the events first and then put the Just Culture work into place. You then need to be thoughtful about who you engage in that work as equals to drive that work.

  8. Leilani Kicklighter

    Feb. 7, 2021

    the 2 interested/involved should be invited to at least review the draft of the 2 corrective plans. While it is good to include to have "C" Suite advised of the plan(s) it is paramount that in addition to middle management representatives of those with "boots on the ground" should be active participants in each step of the process to support to colleagues the just culture and psychological support. representative surgeon power leaders, circulating nurses and scrub techs along with surgical mangers in one case and a pharmacy representative along with nurses who administer medications along with representative head nurses should be included in the second for the reasons stated above

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    1. Candace Eden

      Feb. 8, 2021

      Leilani, yes, the review of the plan is important in your 2 key stakeholders so they can provide feedback. I do think the boots on the ground people need to be active as well but I would think you would engage those power leaders first so you have a sketch of a framework to use and then engage all of those representatives you described. I love having the pharmacy representative with the nurses administering medications together. Good ideas.

  9. Faye Robbins

    Feb. 7, 2021

    I agree with those who have posted that a key Board member is crucial to success; I also believe you must have the full executive leadership team on board, including your Chief HR Officer to ensure success in building a culture of psychological safety and Just Culture.

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    1. Candace Eden

      Feb. 8, 2021

      Faye, agreed. Both the Board member and the full leadership team need to be onboard to drive the change in culture.

  10. Lisa Sunday

    Feb. 7, 2021

    Options to include could be the interested board members, medical staff, administration, department managers, supervisors, employees and patients. The key three would be one from top leadership, mid management, and employees or/and patients. Patient involvement and feedback is very powerful. In addition, metrics to identify the ongoing status as well as accuracy / willingness to report could be an essential driving component.

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    1. Candace Eden

      Feb. 8, 2021

      Lisa, I love that one of your key 3 is a patient. We need to involve them more going forward so that we know what they need and look for in an organization they will seek for care after this last year.

  11. Tammy Rorer

    Feb. 7, 2021

    It would be important to engage the member of the board who has oversight of Quality & Safety and ask key leadership and department managers to select a core team of physicians, allied health, and front line staff to participate in this directive. Utilize their feedback and benchmarking results to collaborate with existing committees to drive performance improvement with patient safety culture. Results of improvement must be communicated and shared with the entire organization. Goals, on-going monitoring, engagement, and corrective action must be a continuum to develop, improve and demonstrate a culture that is psychologically safe.

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    1. Candace Eden

      Feb. 8, 2021

      Tammy, absolutely, the Board member that is already interested will help in driving the PI you come up with. Having the baseline and improvement results for them to see as you describe is critical.

  12. Cheri Graham-Clark

    Feb. 7, 2021

    Would want CNO, CMO, CEO to be sponsors...would want other C suite (CXO, CFO, CIO) to be engaged. Other stakeholders include midlevel and front line leaders from the interdisciplinary team as well as medical staff leaders (MEC, Committee or dept. chairs). Since there is no program, #1 Assess culture and need-would use a standardize culture survey such as AHRQ that could be benchmarked #2 Would convene a core group with CNO and CMO sponsoring to review the culture survey results and prioritize focus areas, develop a plan with SMART goals for each focus area so can measure progress. #3 Would likely start an education campaign about what the focus will be and why for everyone in the organization front line staff to Board of Directors. #4 Work the plan engaging staff, patient advisors, and physicians. #5 As the survey priorities are worked on, do a structural assessment of program needs with sponsors and stakeholders to identify structural elements for maturity into a program and for sustainment (IE ongoing education; reward and recognition; annual culture assessment; measurement system of events, learnings, near misses; communication and reporting in the organization.)

    Reply
    1. Candace Eden

      Feb. 8, 2021

      Much like what Danielle has said, establishing that core group that can drive change, doing the assessment, reviewing specific data such as the culture results and setting up an education campaign is a great start. Having the structural elements as the program matures is something people may forget so putting it into place in the beginning is a great idea.

  13. Jenna

    Feb. 7, 2021

    To begin implementing the plan, Leadership, Patient Safety, Quality, Risk Management and Medical Staff all must be involved and actively participating. The focus on Just Culture, particularly psychological safety is paramount.

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  14. Lauren Hyer

    Feb. 7, 2021

    It would be important to engage the following roles: CNO, CMO, Nursing Directors/Managers, key providers, the Pt. Safety/Risk Officer and additional members from the Quality Team. It would be important to create SMART goals to ensure they are clear about their desired outcomes and timeframe. Provide the team EBP (or overview of EBP) so they can collectively decide on the model and subsequent strategies.

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  15. Mariel Kagan

    Feb. 7, 2021

    The four key positions that we will need to collaborate with to start implementing our plan, in addition to our present team of CNO and CMO and RMPS Leader, will be: (1) a representative of the C-Suite (for an HRO, I would recommend the COO or Chief of Patient Advocacy [if such a C-Suite position exists in the organization]); (2) a Risk/Safety Champion member of the Medical Staff; (3) The Chief Quality Officer; and (4) the Board Member who oversees the Quality and Risk/Patient Safety Committee of the Board of Directors. The two tactics I would put into place initially would be: (1) Education of the newly developed collaborative team with respect to the issues of concern (data driven, to promote understanding and buy-in to the need for addressing the concerns and moving forward with the principles of HROs); and (2) Setting mutually agreed-upon Goals to assure team ownership of the Goals, and importance of moving forward.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Jenna, Lauren and Mariel, you have all mentioned the Nursing and/ or Medical staff. You need them both to back you to implement anything and drive it. Giving them the focus on Just Culture, creating some SMART goals, and Mariel, extending all that to the Board of Directors as you mentioned will move from the safety culture philosophy to that HRO philosophy. It just has to be done in those steps to keep it going. That's a 1-2 year process.

  16. Melody Saikali

    Feb. 7, 2021

    As mentioned today and yesterday, it is important that RM/PS professionals have a seat at the table, to collaborate with the CNO, CMO and decision makers in order to review the data, the facts and identify what happened and the how improvements can be made. To help our plan, engaging physician and senior leaders in things such as teamwork training and just culture training. With these 2 elements, if implemented correctly, would help foster psychological safety within the organization.

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    1. Candace Eden

      Feb. 7, 2021

      Yes, Melody, Angel and Debi, having that seat at the table with the C-suite to analyze and review incidents, engage them in the plan going forward and getting their buy-in will help you be successful and thus your hospital or organization.

  17. Angel Barber

    Feb. 7, 2021

    Communication and collaboration between the departments but also imperative with the C-suite. Senior leadership is essential their buy in and participation is a key factor into the success and implementation of the plan.

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  18. Debi Seagroves

    Feb. 7, 2021

    Getting physicians involved, along with some of your front line workers, CNO and Risk Management joining your CEO to work together for this common goal. Analysis and review of current incidents to see where our important issues are. Creating and educating others on 'just culture' and the need to report without fear.

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  19. Lavonneda Hyland

    Feb. 7, 2021

    I think you have to have collaboration with physicians, front line staff, and what I think is an often overlooked group - middle management. I find that team members give input and will even feel like senior leadership will hear their concerns. The front line team members also believe in the messages that senior leaders are sending. But the manager/director level the message gets lost or not implemented. And the team members don't always feel the manager/director level are really hearing their concerns. I think this is a key group that is often overlooked when we talk about making changes sustainable in an organization. You need to have ownership at all levels in the organization not just senior level and not just front line. Without those in the middle reinforcing and taking ownership sustainable change will not happen. Key tactics to begin with would be a culture of safety survey to get the pulse of the organization on safety. And of course Just Culture with a focus on psychological safety will be key.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Lavonneda, thank you for bringing up the middle-management group. They do need to be owners as well. they are the ones delivering that message daily in what they model. Very good point.

  20. Alex Bowers

    Feb. 7, 2021

    I believe we would need buy in from all leadership in the organization. I believe providing safety culture training to leadership is paramount in a successful launch. Providing positive feedback to the staff when they speak up and understanding it will no be punitive in nature. I would also encourage leaders to go through the RCA2 training. This training will help them ask questions to elicit human factors that contributed to the event happening.

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  21. Jana Lyner

    Feb. 7, 2021

    A group should be formed that includes stakeholders from the medical staff and also the front line staff in addition to administration. Goal is to determine where the facility safety culture currently stands and a goal of where the facility needs to be. From there the RM and possibly a member of admin should attend at least one unit based safety huddle weekly as well as other events in the hospital where safety modalities for error prevention are in place to grasp an idea of how those processes are working.

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  22. Heather Joyce-Byers

    Feb. 7, 2021

    First - that staff need to feel safe with in the organization’s culture. When staff are supported, they will feel better suited to report adverse event or even stop the line. To me it’s all about supporting our staff. If the culture is hostile or punitive the. The patient safety program will not gain momentum.

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    1. Candace Eden

      Feb. 7, 2021

      Staff support and that feeling they are safe in the organization is key.

  23. Michelle McKiernan

    Feb. 7, 2021

    We need to work on the culture of safety for staff and increasing their psychological safety to be able to tell us when things are not going well, increased reporting from the front lines and empowering staff to participate in improving quality and patient safety. Buy in by leadership is important since we need the leadership to understand that getting increased reports from staff about near misses etc. is a good thing. We also need to involve patients. If the hospital does not already have a patient advisory committee, they should plan to start one. We want to find patient volunteers to help with our improvement work as much as possible and listen to them.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Michelle, you are so right about that Patient Advisory Committee. Last year, my intent was to involve them more at my organization but...COVID. So this year I'm working on Residents and Advisory members to be on some of our committees so we are getting their input. Like we are supposed to-remember co-design and co-produce care delivery. that may help to get them to feel safe to come in for those financial needs of an organization like having admissions and elective surgeries. It is a business after all.

    2. Michelle Cruz

      Feb. 7, 2021

      When we added a Patient Advisory Committee, it was a game changer. Real time feedback from real patients in the room with the clinicians. It truly showed a focus on the patient and improving care.

  24. Becky Singleton

    Feb. 7, 2021

    1. create psychological safety 2. understand or create team structure and clarity

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  25. Lory Harte

    Feb. 7, 2021

    In follow-up to my post on the first question, I believe that the CNO, CMO, and I would need to agree on Ombudsman interviewing of patients related to adverse events and trends in near misses, all members of the executive team completing leadership rounds with a list of key questions that should always be asked, and partnering with a human factors engineer on the investigation and design improvements for high risk and/or high volume events or near misses. The first 2 tactics would be to create a process, including questions to ask, for Ombudsman interviewing of patients and a accountability process, including questions to ask, for executive leader rounding.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Purposeful leadership rounding-with specific questions is the way to make it successful. One of those questions could be :what is the next safety issue you think could occur? How can I help prevent that?

  26. Kim

    Feb. 7, 2021

    Key would be collaborating with Quality/Safety, Nursing, Physicians in key roles and coordinating approach for psychological safety, human factors and systemness.

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  27. Nancy Somerset

    Feb. 7, 2021

    Collaboration among Risk Mgmt, Patient Safety, Nursing, Medical Staff and Performance Improvement program would be initiated.

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  28. Dorothy cahill

    Feb. 7, 2021

    Psych safety-Feedback..team performance

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  29. Michelle Miller

    Feb. 7, 2021

    Involving key team members from essential departments. Setting goals, ensuring a psychologically safe environment and agreeing that patient safety as a core value is a priority to patients, families, team members and stakeholders.

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  30. Kristen Sapienza

    Feb. 7, 2021

    We collaborate closely with the quality team and they are comprised of the patient safety officer, the safety/quality physicians as well as the VP of Quality and regulatory. We also need to insure the clinical teams are on board, such as nursing and physician leadership.

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  31. Kristen

    Feb. 7, 2021

    Immediate action - gather involved and non involved team members to discuss event. Gain an understanding of why the event may have occurred. Scrub nurse, circulating nurse, surgeon, etc. Add a post surgical time out with a double or triple check of instruments. etc.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Identifying and collaborating with those essential departments, like Quality, with immediate action on goals you have developed is key. we do need to understand from every player in the event what their perspective is to make the change that will last.

  32. Beth

    Feb. 7, 2021

    Collaboration with Patient safety, Quality, Nursing and Physician leadership

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  33. Lisa

    Feb. 7, 2021

    In order to institute a program, the buy in from medical staff, C-suite leadership, quality/safety departments will be vital.

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  34. Suzanne

    Feb. 7, 2021

    I would ensure we have key stakeholders from nursing as well as physicians collaborating with us to begin implementing a plan. I'd recommend we start with ensuring a common purpose as well as ensuring a psychologically safe environment.

    Reply
    1. Candace Eden

      Feb. 7, 2021

      Beth, Lisa and Suzanne, thank you for bringing up physician leadership. We know from the literature that for change to happen, especially in areas like surgery where most of our serious adverse events dwell, we have to have physicians engaged and leading that drive.

    2. Candace Eden

      Feb. 7, 2021

      Yes, I think you are right. Psychological safety is critical and a common purpose.

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