Leading for a Safe and Reliable Culture - GSHRM...2 Prepared by Piedmont Healthcare Quality and Safety Department Piedmont’s High Reliability Journey Launch of Always Safe Quality

Leading for a Safe and Reliable Culture: Piedmont Healthcare’s Always Safe ProgramGSHRM

September 3, 2020

2Prepared by Piedmont Healthcare Quality and Safety Department

Piedmont’s High Reliability Journey

Launch of Always Safe

Quality & Process Improvement Launch

“A” by May for Leapfrog

Launch RL for Variance Reporting

Move to DNV

First Hospitals ISO Certified

Quality & Patient Safety Transformation

Zero Harm by 2026

Promise Package Standard Work Launch for Infections

Standardized RCA and PPE Process

Launch Always Safe 2.0

2012 2013 2014 2015 2016 2017 2018 2019

Integration of SIX Hospitals


Commitment to Zero Harm


Leadership

MethodsCommitment

to Zero Harm

Error Prevention

for staff and

providers

Improved

Cause

Analysis

Transparency &

Organizational

Learning

Road to High Reliability


How Do We Measure Harm?

Zero

Harm

Hospital Acquired Infections: Patient Safety Indicators:

Serious Safety Events: Hospital Acquired

Conditions: A hospital-acquired condition is an

undesirable situation or condition

that affects a patient and that

arose during a stay in a hospital or

medical facility.

A hospital-acquired infection is an infection

that is acquired in a hospital or other health

care facility.

Patient Safety Indicators are a set of indicators

providing information on potential in-hospital

complications and adverse events following

surgeries, procedures, and childbirth*.

A serious safety event is a

deviation from expected practice

reaching the patient resulting in

moderate to severe harm or death.

• CAUTI

• CLABSI

• CDIFF

• CLEAN 4 YOU (MRSA)

• SSI Colon/TAH/THR/TKR

Example Projects/ Promise Packages:

• PSI-12 Post-op DVT

• PSI-13 Sepsis

• PSI-11 Respiratory Failure

• PSI-19 Obstetric Trauma

* PSI 03, 06, 08-15, 17-19


• Cardiac Monitoring/Telemetry

• Orders Management

• Lab Specimen


• HAC 1 : Foreign Object Left in After Surgery

• HAC 5 : Falls and Trauma

*HAC 01-05, 08, 09, 11-14


Leadership

MethodsCommitment

to Zero Harm

Error Prevention

for staff and

providers

Improved

Cause

Analysis

Transparency &

Organizational

Learning



Leadership Methods & Expectations

• Safety first on all agendas

– Reward and recognize safety success

• Celebrate successes

• Rapid response to safety problems; recognize & address

communication failures (de-brief)

• Provide ‘safe’ culture for reporting & speaking up

• Actively participate and lead Daily Safety Huddles


Leadership Methods & Expectations

• Use/facilitate use of Error Prevention Tools (EPT)

– Ensure that new employees are trained individually in EPTs

– Make sure your culture also trains them!

• Round to Influence on staff

• Commit to the Leader/Safety Coach Partnership

• Incorporate Just Culture practices and principles into your

performance management processes using the Performance

Management Decision Guide

• Encourage participation in the annual Culture of Patient Safety

Survey

– Share results & ask staff for improvement ideas


Leadership

MethodsCommitment

to Zero Harm

Error Prevention

for staff and

providers

Improved

Cause

Analysis

Transparency &

Organizational

Learning



Error Prevention Tools for staff and providers

I commit to… By practicing these error prevention tools…

S Support the Team• Peer Checking/Coaching

• Debrief

A Ask Questions

• ARCC: Ask a question, Request change, voice

Concern if needed Stop the Line & activate the Chain

of Command

• Validate & Verify

F Focus on Task• STAR – Stop, Think, Act, Review

• ‘NO DISTRACTION’ zones

EEffective

Communication

Every Time

• Effective Hand-offs

• Read and Repeat Backs; request & give

Acknowledgement

• Ask Clarifying Questions

• Using alpha-numeric language

• SBAR


6,212 Members

System-wide

Total Recall Club: Commitment to Error

Prevention Tools

PHH – 327

members

PRH – 494

members

PAR – 1431

members

PNH – 268

members

PMH – 220

members

PFH – 638

members

PAH – 751

members

PWH – 221

members

PNtH – 179

members

PCRH – 374

members


Piedmont’s Journey: EPT Recall and SSER


Leadership

MethodsCommitment

to Zero Harm

Error Prevention

for staff and

providers

Improved

Cause

Analysis

Transparency &

Organizational

Learning



Transparency & Organizational Learning

• It’s not about the person involved in an error, it’s about the system

or process that allowed the error to happen.



• A High Reliability Organization is one that is constantly learning,

and this involves transparency through a reporting culture

• Reporting both actual incidents and ‘near misses’ allows the

organization to examine the systems/processes for improvement

• Actual harm incidents are examined for their multiple root causes,

to also guide improvement

• Submit a safety event report whenever anything happens that you

were not expecting



• The science of patient safety influenced by the Heinrich Triangle

Theory dictates that for ONE serious safety event, there are:

– 29 precursor events: Events that reach the patient and cause minor harm or

no harm

– 300 near miss events: Events that have a deviation that do not reach the

patient

Near Misses

300

Precursor

29

SSE

1



So what exactly is the role of a safety coach?

Safety coaches are team members who provide real-time feedback

about practice and compliance with our safety behaviors and error

prevention tools, and who help to prevent events of harm.



What are Safety Coaches expected to do?

Monthly Safety Coach Meeting:

• Safety Coach attends one meeting a month

• Documented by meeting host

Document Safety Observations:

• Credit for documenting at least 4 entries

Monthly Safety Coach Debrief with Manager:

• Credit when documented by Leader

Monthly Goal:

1. Attend a Safety Coach

Meeting

2. Document at least 4

observations

3. Debrief with your

Manager



What is the Leader / Coach Partnership?

• The Safety Coach’s leader introduces safety coach and prepares staff

to receive coaching

• Leader provides dedicated time for coach to attend training and routine

safety coach meetings

• Leader provides time on department meeting agenda for safety coach

to discuss safety

• Leader meets with safety coach at least monthly to:

– Review coaching observations

– Review staff’s responses to coaching and use of EPTs

– Discuss safety mitigation strategies for your team

– Hear what was discussed during the safety coach meetings


Huddle

S.A.F.EPrinciples w/

Error Prevention Tools

Coach

Speak Up!

Standard Work(Process Measures)


Creating a Culture of Patient Safety

Performance Tracking Resources: Standard Work of Always Safe

EPT RecallCoach Activity

Safety

HuddlesSpeaking Up


Leadership

MethodsCommitment

to Zero Harm

Error Prevention

for staff and

providers

Improved

Cause

Analysis

Transparency &

Organizational

Learning



Improved Cause Analysis

• Root Cause Analysis

– A structured problem-solving technique that analyzes processes and

standards resulting in one or more corrective actions to prevent the

occurrence of an event.

• The goal of an RCA is to derive a statement of root cause of an event

by addressing:

– What happened?

– Why did it happen?

– What can we do to prevent it from happening again?

• Piedmont has a system-wide approach to RCAs

• Learnings are shared across the system


Progress Toward Zero Harm

Harm Definition:

Hospital Acquired Infections: CAUTI, CLABSI, C-Diff, MRSA, SSI: Colon, TAH, THR/TKR

Hospital Acquired Conditions: HAC 01-05, 08, 09, 11-14

Patient Safety Indicators: PSI 03, 06, 08-15, 17-19

Hospitals: FY 15-17 (Legacy), FY 18 (+PAR), FY 19 (+PWH, PRH)

763

adverse

events

FY 19

(9 Hospitals)

593harm events prevented

(FY 15 compared to FY 19)

797

adverse

events

FY 18

(7 Hospitals)

808

adverse

events

FY 17

(6 Hospitals)

1001

adverse

events

FY 16

(6 Hospitals)

1356

adverse

events

FY 15

(5 Hospitals)


Saved by Skill, Knowledge, and

the Culture of Safety


Questions from the Participants

Documents

Leading for a Safe and Reliable Culture - GSHRM...2 Prepared by Piedmont Healthcare Quality and Safety Department Piedmont’s High Reliability Journey Launch of Always Safe Quality