PSO Toolbox Sample

The goal is for staff to say:

“I felt like I was heard”

“I made a difference today”

2

Chaos, Culture, and Predictability

Improve predictability = less chaos = better safety- Standardized interactions, checklists, familiarity

Reduce predictability = more chaos = worse safety- New Manager, New Location, New Technology

Data Driven Triage of Improvement Tools

staffing levels inadequate?/info lost at shift change?: consider

Morning/Shift Briefings

Interdisciplinary patient management issues?: consider Daily Goals

Trouble resolving conflicts/lack of role clarity?: consider Shadowing

Exercise

Difficulty speaking up?: consider standardizing through SBAR or

using Critical Language

If staff lack consensus about quality and safety issues? Share “Safety as a System” module with staff:

www.dukepatientsafetycenter.org

Feel unsafe or unengaged in safety and quality?

Learning from Defects

Executive Partnership 4

PSO Toolbox

Morning Briefing

Easy to use, little training, quick

• Charge nurse, attending/fellow at 7:30am

• What happened overnight? – Adverse events, near misses, admissions and discharges

• Where should I begin rounds?

– high-acuity patients, patient flow

• “What are your concerns regarding potential problems for

today?”

– patient scheduling, equipment availability, outside patient

testing, staffing, and provider skill mix.

Jt Comm J Qual Patient Saf. 2005 Aug;31(8):476-9.

Sample

Daily Goals

J Crit Care 18(2):71-75, 2003

Critical Language

• Key phrases understood by all to mean “stop and listen to me – we have a potential problem”

– When you hear this phrase, grab an elbow and join in the request for clarity

• Allina – “ I need some clarity”

• United Airlines CUS program –– I’m concerned

– I’m uncomfortable

– this is unsafe… I’m scared