Walking the Talk of Patient Safety by eo0e167a

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									Walking the Talk of Patient Safety


                Bruce Roe, MD
                Executive Director
                 Clinical Programs
                Chief Medical Officer
Challenge

   High level discussion of safety/quality issues
   Response to safety issues mostly reactive

   How to impact on safety culture and engage
    front-line staff and physicians in discussions
    and innovation?
Strategies


  Patient Safety Leadership Walk Rounds




             Safety Huddles
Patient Safety Leadership Walk Rounds
Goals

   Demonstrate commitment of executive team
    to safety

   Identify issues which could result in harm to
    our patients

   Implement changes based on systems
    issues identified
Patient Safety Leadership Walk Rounds
Goals

   Further drive culture change amongst our
    teams
   Demonstrate non-punitive approach to
    eliminating medical errors
   Supporting establishment of safety huddles
    on units/teams
Who?

   3 members of Executive team
   Quality expert
   Recorder
Mechanism

   Weekly rounds to clinical and nonclinical areas.
   20-30 minutes in each area
   Pre-announced, with pre-circulated question or topic
   Help ward staff identify 2-3 problems that can be
    solved by rapid improvement, and help shape
    priorities about changes that will take longer and
    require more extensive resources.
   Connect team with other expertise within institution
The “script”
Communication Themes

   SBGH is working as an organization to make
    patient safety a priority.
   open discussion focusing on system issues,
    and not on individuals
   confidentiality
Sample Questions

1.   When was the last time a patient was harmed on
     your unit; how and when they think the next person
     would be hurt and how that could be prevented
2.   Can you identify any issue or concern that may
     pose a risk to the safety of our patients?
3.   Can you identify any physical issue that may pose
     a risk to patient safety?
4.   How are we actively promoting a just and learning
     culture?
Response

   Identify opportunities for safety-based
    improvements
   Develop plan for solutions whether local or
    requiring broader resources/strategy
   Follow-up and feedback key components
Measures of Success

   safety culture surveys
   Occurrence reporting
   Number of interventions made
   Follow-up surveillance data
Experience so far

   Development team
   Plan / rehearse / evolve
   Weekly rounds since May 2005
   22 clinical and nonclinical areas visited
   Issues eventually tracked in database
Lessons we have learned

   Start now, perfect later
   Consistency re messaging
   Help staff prioritize issues
   before walkrounds finished, restate issues,
    responsibility for actions, and follow-up
   Communication with managers and directors
Resources

   IHI (www.ihi.org)
   Frankel et al, Jt Comm J Qual Saf. 2003
    Jan;29(1):16-26

								
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