Patient Safety Fellowship Opportunities

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Patient Safety Fellowship Opportunities
Beyond!Lessons Learned From AHA Health Forum
Fellowship Beyond!Techniques
ToolsEffectively Development and PromotingA
Culture of Patient Safety

• By Patti J. Magyar, RN, MSN, JD Hospital
  Counsel
• Chelsea Community Hospital Chelsea, MI
•  
• [phone]
• pjm_at_cch.org

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A Culture of Patient
Safety Shared ways of thinking and behaving that
work to meet the primary objective of Patient
safety. (Schein)
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Be APatient Safety Champion!

• Be Realistic Some Colleagues are first on
  the bus Some need help getting on the bus
• Some Colleagues will board the bus
  late, possibly kicking and screaming
• (and pay a late fee!)
• Some Colleagues will be left at the
• bus stop and wont even know
  it
• What was that!
• Some dont care that there is a bus
  may need to be invited to leave.

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Be a Patient Safety Champion

• Assess your current environment
• Informally
• Open dialogue at staff meetings
• Initial On-Going Inquiry How are we doing
  NPSF The ABCs of Patient Safety
• - Linkage PSLF NPSF! -
• How can we make things safer for patients and
  staff?

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Be a Patient Safety Champion

• Assess your current environment
• Formally
• Cultural Assessment
• e.g., Strategies for Leadership-
• VHA, Inc. (Supported by available through AHA)
  (2000)
• Cultural Survey
• CCH A Survey of Hospital Clinical
• Non-Clinical Staff

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Be a Patient Safety Champion

• Integrate Patient Safety
• Into Your Hospitals
• Strategic goal for Excellence
• Climate as a Learning Environment
• Formal Informal Marketing!
• Your Hospital aspiring to be Great!
• Flower, Joe. Good to Great.
• Health Forum Journal (July-August)
• 2002, 17-20 (related editorial pp 5-6).
• - PSLF Linkage AHA Summit -

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Be a Patient Safety Champion

• Invite Facilitate Resolution to
• Wicked Questions
• - PSLF Meeting 1-
• How can we move patient safety forward given
  our barrier of skepticism?
• barrier of financial challenge?
• barrier of work overload?
• overlap with QI/RM?

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Be a Patient Safety Champion

• Be Patient Safety Vigilant for
• Patient Safety Risk
• Opportunity
• Success
• Reward

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Be a Patient Safety Champion

• Recognition (verbal/card/letter/sharing of
  patient success stories), financial (major based
  on risk minimization and cost savings minor
  meal tickets, gift shop certificate, dinner out
  with PSO/other, pizza party for department, AmEx
  certificate balloons!)

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Be a Patient Safety Champion

• Equipment Systems Enhancements
• Braun Outlook IV Pumps
• Midas Integrated Systems
• Chelsea Community Hospital Partnering in Patient
  Safety

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Be a Patient Safety Champion

• Be clear committed to critical patient safety
  values
• Error Tolerance
• errors will occur in any system, no matter
• how well managed, and early identification
• and analysis of errors can provide
• an opportunity for the proactive correction
• of conditions that are unsafe. (Merry p. 127)

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Be a Patient Safety Champion

• Be clear committed to critical patient safety
  values
• Interdisciplinary Teaming
• Patient safety problems cannot be successfully
  resolved
• through traditional management OR traditional
  healthcare!
• Joint S/PS/RM Wheelchair Availability to
  Guests memo
• FMEA Medication Administration Patient
  Identification
• Interdisciplinary education (e.g., UMMC
  Conference _at_ CCH)
• HiQ Teams Legibility in the Medical Record
  (PosterBoard)

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Be a Patient Safety Champion

• Be clear committed to critical patient
  safety values
• A Just Culture
• PSLF
• Accountability v. Blame!
• Patient/Visitor Occurrence Reporting
  Process
• Peer Review (Real PE! with input,
  ensuring
• competence /or conduct issues are
  addressed early to salvage, develop
  and retain talented physicians!)
• Performance Evaluation

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Be APatient Safety Champion!

• Communicate
• Evidence, Innovation News!
• Create effective feedback loops regarding latent
  workplace conditions and latent organizational
  conditions (Merry, 127)

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Be APatient Safety Champion!

• Communicate
• Evidence, Innovation News!
• Latent Workplace Conditions
• Undue time pressure
• Inadequate maintenance
• Inadequate tools
• Inadequate training
• Understaffing
• Unworkable procedures (Merry, 126)

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Be APatient Safety Champion!

• Communicate
• Evidence, Innovation News!
• Latent Organizational Conditions
• Budgeting
• Communication
• Norms and Informal Expectations
• Planning
• Resource Allocation
• Senior Level Decisions
• Strategic Decisions (Merry, 126)

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Be APatient Safety Champion!

• Communicate
• Transfer Your Expertise!
• Scripting
• I am so sorry you received Valium 5 mg. by mouth
  for your hip pain instead of the Demerol 50 mg.
  IV that was ordered (it was a misreading on my
  part). Your physician has been made aware, and
  per the physicians order I am going to give you
  the Demerol now for your pain relief. (Have you
  taken Valium before? e.g., hx of response?).
  You should have no ill effects from the Valium
  although you may feel I will be back in 15
  minutes to take your vital signs gt

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Be APatient Safety Champion!

• Communicate
• Transfer Your Expertise!
• Scripting
• Your surgical procedure went well and you are
  doing very well (minimal blood loss, blood
  pressure is good ). As I explained during your
  office visit, the plastic piece for your knee
  replacement was fitted into your knee after
  careful evaluation during the operation. Upon
  my review of your knee film after surgery, I see
  that a 3 mm larger plastic device would be better
  for your knee stability. It will be safe to walk
  and bear weight on your knee over the next two
  weeks. Then, if you agree, I would like to do a
  15 procedure replacing the smaller with the
  larger device

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Be APatient Safety Champion!

• Communicate
• Transfer Your Expertise!
• Scripting
• INVITE SHARING OF CONCERNS
• Do you have any questions or concerns at this
  time?
• Please let us know at the earliest point
  possible if you have concerns or ideas about how
  we can improve the care you are receiving..

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Be APatient Safety Champion!

• Communicate
• Evidence, Innovation News!
• (e.g., P T Newsletter or Quality/Safety
  Newsletter or
• Patient Safety/Risk Management Newsletter)
• Automatic Stop Orders and Renewals Policy
• Alternative Medication Policy Revisions
• New Products Added to Formulary
• The Do Not Use! Abbreviations
• Patient Fall Assessment Who Why!

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Be APatient Safety Champion!

• Communicate Evidence, Innovation News!
• Dynamic In-person Updates
• Self or Other PS Champions
• Administrative Staff
• BOT
• Hospital Staff (Dept. Mtgs., Directors
• Hospital Forums)
• Medical Staff (MEC v Services v
  Entire) Volunteers (Annual Mtg)(Leadership)

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Be APatient Safety Champion!

• Written Communication with clinicians
• e.g., Memo Morphine Sulphate Unit Dosage
  Nation-wide Backorder Shortage (January 23, 2003)
• e.g., Reminders of f/u process when illegible
  entries are found remind of commitment!
• Judicious use of e-mails

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Be APatient Safety Champion!

• Transfer your expertise
• Scripting
• I am sorry you received Valium 5 mgs. by mouth
  for your hip pain
• instead of the Demerol 50 mg. IV that was
  ordered. You are not
• allergic to Valium correct? Your physician has
  been made aware
• and per the physicians order I am going to give
  you the Demerol
• 50 mg for your pain relief. (Have you ever taken
  Valium
• before?) You should have no ill effects from the
  Valium although you
• may feel I will be back in 15 minutes to check
  on you (/or take
• your vital signs)

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Be APatient Safety Champion!

• Transfer your expertise
• Scripting Hospital Orientation Beyond
• Patient/Visitor Occurrence Initial Apology
• Guidelines for Explaining the Facts when Error
  occurs in a complex procedure
• Any/all staff in effective listening to a
  patient/family member sharing a complaint

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Attract CultivatePatient Safety
Co-Champions!Personally Exude Service
Excellence!How Can I Be of Help?Acknowledge
others capabilitiesCo-Present and Share
Ideas ResourcesInternally
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Attract CultivatePatient Safety Co-Champions!

• Nurture relationships with prospective
  co-champions (e.g., orthopedic surgeon, internal
  medicine specialist, Directors, staff)
• Put others in the spotlight as often as possible!
  (e.g.,
• I want to thank and recognize Kim for in PS)
• Involve physician as (co)/speakers, nurses
  other clinicians as FMEA leaders /or team
  members)
• Celebrate patient safety achievements!
  (Literally Celebrate party shared summary!)

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Collaborate Internally
Externally!

• Collaborate
• Join Forces !
• Team Up !!
• Work in Partnership !!!
• Pool Resources !!!!

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Collaborate!

• Collaborate Internally
• Department Directors
• Directors of Nursing, Pharmacy, Quality,
  Recipient Rights, Risk Management and Safety
• Chief of Staff and VPMA/Service Chiefs/Informal
• Medical Staff Leaders
• Nurse Director Group Informal Nurse Leaders
• Patients Families!!! (e.g., Pulse Advisory
  Committee)

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Collaborate Internally

• Executive Rounds (Great for Administrative Buy-In
  to Patient Safety, after buying into
  rounding!)
• Have you seen or experienced any patient
• safety concerns during your stay?
• Have you seen your care providers wash
  their
• hands just before providing care to you?
• Do your nurses introduce themselves to you?
• Do nurses look at your patient
  identification
• band just before they give you medication?

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Collaborate Internally

• Patient Safety Rounds
• via
• Patient Safety Interviews
• By
• Diverse Staff Committed to Patient Safety
• See Attachment

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Collaborate Internally Externally

• 
  Align legal counsel activity
• with the patient safety agenda,
  
• ensuring accountability,
• while concurrently
• protecting the organization.
  (Wilson, 33)

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Collaborate Externally

• Use the plethora of patient safety resources
• with wild abandon
• but share them very
• strategically!
• See Attached List Patient Safety Resources

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Collaborate Externally Brainstorm with
others Your organizations Greatest patient
safety knowledge or resource Challenge
Potential Solutions (e.g., Human Error Factors
Analysis, Internal Neutral, Patient/Family
Inclusion in PS )   Do a (Formal or Informal)
CostBenefit Analysis!
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A Culture of Patient Safety

• Be a Patient Safety Champion
• Attract Cultivate Co-Champions
• Collaborate Internally
• Collaborate Externally

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In Summary

• A Culture of Patient Safety (shared ways of
  thinking and behaving) will evolve based on our
  underlying organizational culture, via a
• Process of Evolution over
• time

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• A Culture of Patient Safety
• Moving Hospitals and Healthcare to Greatness!
• Thank You AHA Health Forum PSLF!!!

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Questions DiscussionLeadership, Disclosure,
Tools Techniques /or PSLF!

• AHA Health Forum
• Patient Safety Leadership Fellowship 1
• 2002-2003
• http//www.hospitalconnect.com/healthforum/hfeduca
  tion/
• Co-sponsored by
• AHA-HRET, AONE, ASHRM, NPSF