Patient Safety Fellowship Opportunities & Beyond! Lessons Learned From AHA Health Forum Fellowship & Beyond! Techniques & Tools: Effectively Development and Promoting A Culture of Patient Safety By: Patti J. Magyar, RN, MSN, JD; Hospital Counsel Chelsea Community Hospital – Chelsea, MI (734) 475-3911 [email protected]
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Patient Safety Fellowship Opportunities & Beyond! Lessons Learned From AHA Health Forum Fellowship & Beyond! Techniques & Tools: Effectively Development.
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Patient Safety Fellowship Opportunities & Beyond!Lessons Learned From AHA Health Forum Fellowship & Beyond!
Techniques & Tools:Effectively Development and Promoting
A Culture of Patient SafetyBy: Patti J. Magyar, RN, MSN, JD; Hospital Counsel
to meet the primary objective of Patient safety. (Schein)
Be APatient Safety Champion!
Be Realistic: • Some Colleagues are first on the bus • Some need help getting on the bus
• Some Colleagues will board the bus late, possibly kicking and screaming
(and “’pay’ a late fee!”) • Some Colleagues will be left at the
bus stop and won’t even know it: “What ‘was’ that!”
• Some don’t care that there is a bus & may need to be “invited” to leave.
Be a Patient Safety Champion
Assess your current environment:
Informally: Open dialogue at staff meetings
Initial & On-Going Inquiry: How are we doing: NPSF: “The ABC’s of Patient Safety”
- Linkage: PSLF & NPSF! -
How can we make things safer for patients and staff?
Be a Patient Safety Champion
Assess your current environment:
Formally:
Cultural Assessment e.g., “Strategies for Leadership-”
VHA, Inc. (Supported by & available through AHA) (2000)
Cultural SurveyCCH A Survey of Hospital Clinical
& Non-Clinical Staff
Be a Patient Safety Champion Integrate Patient SafetyInto Your Hospital’s:
• Strategic goal for Excellence • Climate as a “Learning Environment”
• Formal & Informal Marketing! …
Your Hospital aspiring to be “Great!”Flower, Joe. Good to Great.
Health Forum Journal (July-August)2002, 17-20 (related editorial pp 5-6).
- PSLF Linkage –AHA Summit -
Be a Patient Safety Champion
Invite & Facilitate Resolution to:
“Wicked Questions”
- PSLF Meeting #1-
“How can we move patient safety forward given our barrier of skepticism?
… barrier of financial challenge?
… barrier of work overload?
…overlap with QI/RM?
Be Patient Safety Vigilant for:
Patient Safety Risk
Opportunity
Success
Reward
Be a Patient Safety Champion
Be a Patient Safety Champion
Recognition (verbal/card/letter/sharing of patient success stories), financial (major based on risk minimization and cost savings; minor: meal tickets, gift shop certificate, dinner out with PSO/other, pizza party for department, AmEx certificate; balloons!)
Be a Patient Safety Champion
Equipment & Systems Enhancements
Braun Outlook IV Pumps
Midas+ Integrated Systems“Chelsea Community Hospital Partnering in Patient Safety”
Be a Patient Safety Champion
Be clear & committed to critical patient safety “values”
~ Error Tolerance ~“…errors will occur in any system, no matterhow well managed, and early identification
and analysis of errors can provide an opportunity for the proactive correction
of conditions that are unsafe.” (Merry p. 127)
Be a Patient Safety Champion
Be clear & committed to critical patient safety “values”
~ Interdisciplinary Teaming ~
Patient safety problems cannot be successfully resolved
through traditional management OR traditional healthcare!
• Joint S/PS/RM “Wheelchair Availability to Guests memo
“I am so sorry you received Valium 5 mg. by mouth for your hip pain instead of the Demerol 50 mg. IV that was ordered; (it was a misreading on my part). Your physician has been made aware, and per the physician’s order I am going to give you the Demerol now for your pain relief. (Have you taken Valium before? – e.g., hx of response?). You should
have no ill effects from the Valium although you may feel … I will be back in 15 minutes to take your vital signs … >”
Be APatient Safety Champion!
Communicate:
Transfer Your Expertise!“Scripting”
”Your surgical procedure went well and you are doing very well (minimal blood loss, blood pressure is good …). As I explained
during your office visit, the plastic piece for your knee replacement was fitted into your knee after careful evaluation
during the operation. … Upon my review of your knee film after surgery, I see that a 3 mm larger plastic device would be better
for your knee stability. It will be safe to walk and bear weight on your knee over the next two weeks. Then, if you agree, I would like to do a 15” procedure replacing the smaller with the larger
device …”
Be APatient Safety Champion!
Communicate:
Transfer Your Expertise!
“Scripting”
INVITE SHARING OF CONCERNS
“…Do you have any questions or concerns at this time?”
“Please let us know at the earliest point possible if you have concerns or ideas about how we can improve the
care you are receiving..”
Be APatient Safety Champion!
Communicate: Evidence, Innovation & News!
(e.g., P & T Newsletter or Quality/Safety Newsletter or
Patient Safety/Risk Management Newsletter)
• Automatic Stop Orders and Renewals Policy • Alternative Medication Policy Revisions• New Products Added to Formulary • The “Do Not Use!” Abbreviations• Patient Fall Assessment: Who & Why!
• Department Directors• Directors of Nursing, Pharmacy, Quality, Recipient
Rights, Risk Management and Safety
• Chief of Staff and VPMA/Service Chiefs/InformalMedical Staff Leaders
• Nurse Director Group & Informal Nurse Leaders• Patients & Families!!! (e.g., Pulse; Advisory Committee)
Collaborate Internally
Executive Rounds (Great for Administrative Buy-In to
Patient Safety, after buying into rounding!) • “Have you seen or experienced any patient safety concerns during your stay?” • “Have you seen your care providers wash their hands just before providing care to you?” • “Do your nurses introduce themselves to you?” • “Do nurses look at your patient identification band just before they give you medication?”
Collaborate Internally
*Patient Safety Roundsvia
Patient Safety InterviewsBy
Diverse Staff Committed to Patient Safety
*See: Attachment
Collaborate Internally & Externally
“Align legal counsel activity
with the patient safety agenda,
ensuring accountability,
while concurrently
protecting the organization.” (Wilson, 33)
Collaborate Externally
Use the plethora of patient safety resourceswith wild abandon but share them very
strategically!
See Attached List: Patient Safety Resources
Collaborate Externally
Brainstorm with others:Your organization’s
Greatest patient safety knowledge or resource Challenge &Potential Solutions
(e.g., Human Error Factors Analysis,“Internal Neutral,” Patient/Family Inclusion in PS …)
Do a (Formal or Informal) Cost:Benefit Analysis!
A Culture of Patient Safety
• Be a Patient Safety Champion
• Attract & Cultivate Co-Champions
• Collaborate Internally
• Collaborate Externally
~ In Summary ~A Culture of Patient Safety (shared ways of thinking
and behaving) will evolve based on our underlying organizational culture, via a