Worker / Patient Safety: Steps in a Culture Change

Mary Margaret Jackson

Director, Performance Outcome Services

Self Regional Healthcare

History of The “Journey”

Idea conceived and grant sought Combining of six organizations with common

bond of:– All JCAHO accredited and in South Carolina– All with same Worker Compensation & Liability

carriers

Process Steps

Gain organizational commitment Measure safety culture Form coordinator’s group Identify commonalities as well as individual

needs Gain consensus on next steps Begin organizational work groups

Steps Continued

Customize programs to the organization Develop individual and group measures /

indicators Share successes and failures openly within

the group Share with other S.C. organizations

Strategies / Activities

Culture change takes a multi-pronged approach

In some situations safety program reorganization needed

Maintaining an internal focus and champion

“Integrating” into current initiatives

Specific Activities

Organizational identification of:– Red Rules– Behaviors at all levels that could best prevent error

(“behavior based expectations”

Used line staff who were first educated in concept and who next chose Self specific

Additional Activities

Training in Root Cause Analysis & Common Cause Analysis

Development of a “Scorecard” to consistently track results

Enhancing communications organization-wide

Summary of the Key Activities

Red Rules Behavior Based Expectations Accountabilities Scorecard

How are Red Rules picked?

Choose those that focus employees on those rules that are most important to safety

Choose those that clarify work expectations about processes critical to safety

Choose those that make compliance with safety standards a routine activity

Getting Red Rules Implemented

We are not there yet! Removal of barriers to successful compliance

with a Red Rule Gain clear consensus on the “accountability”

portion

What makes a good Red Rule?

1. Is the proposed Red Rule critical to patient and/or employee safety if not performed consistently and exactly?

2. Can the proposed Red Rule be applied throughout the hospital?

3. Is the proposed Red Rule specific enough so interpretation is not required?

4. Is it possible to directly observe/measure compliance?

5. Are you willing, as a leader, to endorse 100% compliance as the minimum standard for the proposed Red Rule?

First Steps on Action Sheet

Gain organizational approval and support of "Red Rule

Identify processes for Medical Staff acceptance and support with Red Rules

Attach red rule accountability expectations and measures at all levels of the organization

Self’s Red Rules

1. I will always confirm patient identity using at least two hospital approved identifiers before any action.

2. I will always perform hand hygiene before and after every patient contact and as specified by my department.

3. I will always adhere to posted Personal Protective Equipment (PPE) requirements.

4. I will always wear my hospital ID badge while on duty.

Some of the Barriers

Policy conflicts Staff knowledge Ability to observe and measure compliance Need to anticipate and have solutions for

common human factors- such as “I forgot my badge”

What might the Red Rules Do?

Unify staff on safety- 100% expectation for ALL!

Gain better understanding of individual’s role in safety

Build personal accountability Create formal accountability systems Hard to argue against

What about Behaviors?

Already in use was “SELF PRIDE”

S – Show RespectS – Show Respect E – Effective CommunicationE – Effective Communication L – ListenL – Listen F – Follow ThroughF – Follow Through

P – ProfessionalismP – Professionalism R – Recognize Every IndividualR – Recognize Every Individual I – Initiate and InformI – Initiate and Inform D – Do The Job Right The 1st TimeD – Do The Job Right The 1st Time E – Expect The BestE – Expect The Best

Translates into the Following:

Use Repeat-Backs & Read-Backs and Seek FeedbackUse Repeat-Backs & Read-Backs and Seek Feedback Ask Clarification QuestionsAsk Clarification Questions Identify Self, Department, PurposeIdentify Self, Department, Purpose Hand-Off Effectively – 5 “P’s” – Patient, Plan, Purpose, Hand-Off Effectively – 5 “P’s” – Patient, Plan, Purpose,

Precautions, ProblemsPrecautions, Problems Follow Red Rules, Policies, ProceduresFollow Red Rules, Policies, Procedures Practice Peer Checking & Coaching Using ARC (Ask, Request, Practice Peer Checking & Coaching Using ARC (Ask, Request,

Concern)Concern) STAR – Stop, Think, Act, ReviewSTAR – Stop, Think, Act, Review STOP when Unsure and AskSTOP when Unsure and Ask

How are Behaviors Introduced?

Trainers developed Sessions grouped so communication

improvements are emphasized Trainers carry “the message” Integrated into orientation and all safety

training

What Other Things did the Six Facilities focus on?

Training in Root Cause Analysis Introduction to increased use of Common Cause

Analysis Identification of leading, lagging, and real time

indicators of both patient and worker safety (Scorecard)

Defining incident types and sharing results openly

Results

50.02573982

38.77553476

0

10

20

30

40

50

60

2003 Total 2004 Total

Year

Leve

l 1 E

vent

s pe

r 10

,000

Pat

ient

Day

s

Better

Consortium Patient Level 1 Events per 10,000 Patient Days(5 of 6 hospitals)

SCWPSI Consortium Patient Level 1 Events per 10,000 Patient Days decreased by 22.5% from 2003 to 2004

ResultsConsortium Worker Level 1 Events per Full Time Employees

18.59133259

9.395285275

0

5

10

15

20

2003

Tot

al

2005

Tot

al

Year

Le

ve

l 1 E

ve

nts

pe

r F

ull

Tim

e E

mp

loy

ee

s

Level 1 Linear (Level 1)

Better

2005 data is January 1 - June 30, 2005

SCWPSI Consortium Worker Level 1 Events per Full Time Employee decreased by 50% from 2003 to 2004

Results?

It is a three year journey- at least! Re survey of culture next year Does it make a difference- you bet! Gives a framework for change