Safety Culture: Magic Potion

Welcome! Inova Mount Vernon

Donald J. Brideau, MD CEO, Vice President

Stacey Schaab RN, MBA, CPHQ, NHA Director of Quality Department

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Stacey Schaab RN, MBA, CPHQ, NHA Director of Quality Department Inova Mount Vernon Hospital

Safety Culture- Magic Potion

Donald J. Brideau, MD CEO, Vice President Inova Mount Vernon Hospital

Inova Mount Vernon Hospital

Inova Mount Vernon Hospital

• Founded in 1976, IMVH is a 237-bed community hospital offering patients convenience and state-of-the-art care in a unique healing environment.

• Achieved the American Heart Association/American Stroke Association award for “Gold-Plus Elite” designation for its premier stroke care.

• Received the Press Ganey Guardian of Excellence Award: 95% percentile for 2015 & 2016 related to Emergency Department Clinical Quality & Patient Satisfaction.

• Earned Straight A’s since 2014 on the Leapfrog Hospital Safety Grade.

• Recognized by CareChex National Rating for Orthopedic Surgery as 21st in the Nation and #1 in the State of Virginia.

TJC Successful Survey! December 2016 TJC Results: 3 Directs and 8 Indirects. All were abated before the end of the survey. Important to

note, there were no Nursing, Infection Control, Emergency Management or Leadership citations.

To improve safety culture, concoct the following: Mix everything together (Not just one ingredient) Add a few drops of communication Pour in some teamwork Include a bit of patient/family-centered care Apply as applicable

Applications may include: Regulatory Survey FMEA Core Measures TeamSTEPPS Engaged Staff Just Culture Shared Mental Model CUSP Safety Symposium

‘Making & Mixing the Magic’

7

Kotters 8 Steps of Change

Linens

Applying Change to the Magic

Comprehensive Unit-based Safety Program

The Comprehensive Unit-based Safety Program (CUSP) includes strategies towards making patient care safer by improving the foundation of how your physicians, nurses and other clinical team members work together. It builds the capacity to address safety issues by combining clinical best practices and the science of safety.

CUSP is a structured strategic framework for safety improvement that integrates communication, teamwork and leadership to create and support a culture of patient safety that can prevent harms.

CUSP draws from frontline providers who have the most knowledge about safety hazards and the means to lessen the severity of those hazards and provides a mechanism to help defend against hazards.

CUSP is implemented at the unit level and provides a scalable program that can be implemented throughout an organization.

Method of Communicating Change

Outcomes…

Days Infection Control-FREE - CLABSI: 0 since 12/1/17 (136 days) - CAUTI: 0 since 2/2/16 (104 days) - VAC: 0 since 10/1/16 (228 days)

2016 HSOPS Results Mount Vernon Hospital

90th Percentile 75th Percentile

Average

25th Percentile 10th Percentile or

Less

Communication Openness

Manager Expectations around

PS Non-Punitive Response to Error

Feedback About Error

Perceptions of Patient Safety

Handoffs and Transitions

Staffing Event Reporting

Management Support for Patient Safety

Organizational Learning

Teamwork Across Units

Teamwork in Unit

*Benchmarked against 2016 AHRQ Database (All Hospitals) N=953

No Change

KEY

1 Percentile Group 2 Percentile Groups

1 Percentile Group

2016 HSOPS Results Mount Vernon Hospital

(CONT’)

2016 HSOPS Results Mount Vernon Hospital

(CONT’)

Action Plan Towards Sustainability

• Promote Effective Communication and Transparency All care areas such as OR, etc. Safety Survey/ Debriefs/Goal Setting CUSP Safety Call @ 7:45am Leadership Huddle @ 9:30am

• Permit Data Review/Sharing with all Staff True North Board Staff Shift Huddles

• Provide Information re: Hospital-Wide Safety Initiatives Hand Hygiene Compliance Fall Reduction via ‘No Patient Walks Alone’ Campaign

• Propel Cultural Behavioral Change Call bell response time

Questions