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Creating a Just Culture of Safety
Colleen K. Snydeman RN, MSN, PhD(c), NE-BC
Director , Patient Care Services
Office of Quality & Safety
Massachusetts General Hospital
Objectives
At the conclusion of the presentation the participant will be
able to :
1. Describe the influences in advancing the safety culture

in healthcare.
2. Describe characteristics of a just culture of safety.
3. Identify examples of a just culture of safety.
Overview
1.

Quality & Safety
a) Definitions
b) Adverse events

2.

Professional Accountability

3.

Just culture
a) Influences
b) Characteristics
c) Examples

1.

MGH
a) Just culture in action
b) Innovation initiatives
Quality (IOM, 2001)
Quality- the degree to which health services for individuals
and populations increase the likelihood of desired
outcomes and are consistent with professional
knowledge.
Quality/Cost = Value
Measures – Structure, Process & Outcomes (Donabedian, 1988)
IOM 6 Aims of Quality Care (2001)

Efficient

Equitable

Effective

Safe

Timely

Quality
Care

Patient
Centered
Safety (IOM,2000)
• Safety
– “Freedom from accidental or preventable injury”
– the first domain of quality
• Patient Safety
– prevention of harm to patients
– critical subset of quality patient care
– Includes:
1. safe care
2. practice that is consistent with current

evidence/knowledge
3. customization
• Measures - difficult to measure due to dependence on selfreporting.
Safety Culture Influences
Professional Accountability
• There is a social contract between society and a profession.
• Professions are the property of society and are responsible to

society.
• Professions acquire recognition and relevance from society.
• It is society that determines what professional skills and knowledge
are most needed and desired of a profession.
• Society grants professions authority over functions vital to itself
and allows for autonomy in the conduct of their own affairs.
Nursing Accountability
• Nursing is a profession and therefore responsible to society.
• Nursing must be perceived as serving the interests of society.
• Professions are therefore expected to act responsibly and mindful

of the public’s trust.
• Self-regulation assures high quality performance and is the
hallmark of a mature profession.
Nursing is:

The protection, promotion, and optimization of health and abilities,
prevention of illness and injury, alleviation of suffering through the
diagnosis and treatment of human response, and advocacy in the care
of individuals, families, communities, and populations.

American Nurses Association
Errors and Adverse Events
•
•

•

•

98,000/year deaths estimated from medical errors (IOM, 2000)
210,000 deaths/year associated with preventable harm in hospitals (James, 2013:
J Pt Safety).
Error - (process) an act of commission ( doing something wrong) or omission
(failing to do the right thing) leading to an undesirable outcome or significant
potential for such an outcome (AHRQ, 2013).
– Not all errors lead to adverse events.
Adverse Event – (outcome) Unintended physical injury resulting from or
contributing to by medical care (including the absence of indicated medical
treatment) that requires additional monitoring, treatment, or hospitalization, or
that results in death (IHI, 2013).
– Not due to an underlying disease
– Unpreventable
– Preventable
• Negligent – care falling below a professional standard
– Side effects – may not be preventable or a medical error
Moving toward a safer culture
James Reason
•

•

Goal: to create a safer culture consisting of:
• Reporting
• Learning
• Flexibility
• Just Culture
Swiss Cheese Model

David Marx
•
•

Just culture algorithm – systems, behavioral choices, injury severity & not
blame-free but just
Core principles:
• To err is human –human errors, systems
• To drift is human – well intentioned, cut corners, fast paced, creates risk
• Risk is everywhere
• We are all accountable
Reason’s Swiss Cheese Model
(emeraldinsight.com)
Just Culture – Human Error

The single greatest impediment to error prevention
in the medical industry is
“that we punish people for making mistakes.”
Dr. Lucian Leape
Professor, Harvard Medical School of Public Health
Testimony before Congress on Health Care Quality Improvement
Just Culture – Systems thinking
“People make errors, which lead to accidents.
Accidents lead to deaths. The problem is seldom the fault
of the individual; it is the fault of the system.
Change the people without changing the system
and the problem will continue.”
Don Norman
Author, the Design of Everyday Things
Just Culture – Reckless behavior
“…No person may operate an aircraft
in a careless or reckless manner so as to
endanger the life or property of another.”
Federal Aviation Regulations 91.13 Careless or reckless operation
Just Culture
1. Emphasizes quality and safety over blame and punishment.
2. Promotes a process where mistakes/errors do not result in

automatic punishment but a process to uncover the root cause of
the error.
3. Human errors that are not deliberate or malicious result in
coaching, counseling, and education to decrease the likelihood of a
repeated error.
4. Promotes increase error reporting that leads to system
improvements to create safer environments for patients and staff.
Proactive Learning Culture
• Not seeing events as things to

be fixed

• Seeing events as opportunities

to improve our understanding
of risk
– System risk
– Behavior risk
Blame vs. Accountability
1. Was the individual impaired?
2. Did the individual consciously decide to engage in an unsafe act?
3. Did the caregiver make a mistake that other similar individuals

would make in similar circumstances?
4. Does the individual have a history of unsafe acts?
Fair evaluation & response (Frankel &
Leonard
Allen Frankel’s Algorithm (2010)
Examples
• Unintentional Error
– RN draws blood, gown slips over tourniquet, finds arm

swollen
• At-Risk Behavior
– RN draws blood, patient complains of noise, takes blood
out of room and labels at desk with wrong label, without
checking 2 identifiers at bedside
• Reckless Behavior
– During medication administration, bar code scanning
alerts nurse to wrong medication, nurse ignores alert and
administers wrong medication without re-checking
Evidence- Based Patient Safety Improvements
(2012, Gosbee, J.)

Weak
•
•
•
•

Double checks
Warnings
Training
New procedures

Intermediate
•
•
•
•

Redundancy
Increase staffing
Checklists
Standardize
communication
tools
• Education

Strong
• Simplify processes
• Standardize
equipment and
processes
• Force functions
• New devices with
usability testing
• Physical plant
changes
• Tangible
involvement of
leadership
Adverse Drug Events
$3.5 Billion
in costs
(CDC, 2012)
700,000 ED
visits
120,000
admissions
Yellow- no error
Purple- Error, no harm
Blue- Error, Harm
Orange- Error, Death
MGH Culture of Safety
• Edward P. Lawrence Center for Quality and
•
•

•
•
•
•
•

Safety
Just Culture embraced
Robust safety reporting – over 19,000 reports
filed in 2012
Safety Culture Perception Survey
Model to address professional conduct issues
Root Cause Analysis
Communication and Apology
Executive Leadership Safety Rounds
Patient Care Services Quality and Safety
• Office of Quality and Safety
• Safety reporting notification structure and follow up
– Root cause analysis
• Data driven
– Nurse-sensitive indicators
– Hospital-acquired conditions
– Patient satisfaction
– Nurse satisfaction
• Regulatory requirements
• Practice alerts- red flag
– SBAR
MGH Sentinel Event
Event
•

•
•
•
•
•

90 year old male surgical patient
with complete heart block sent to
CICU
Plan for pacemaker in a few days
Transferred back to surgical unit on
a cardiac monitor
Found in cardiac arrest
Code Blue activated
Patient expired

Post-event
•

•
•
•
•
•
•

•

RNs discovered monitor alarms were off
– Filed safety report
– Alerted leadership
Monitors, pumps etc… investigated
Root cause analysis initiated
Conversations with family begin
Reported to Department of Public Health
Boston Globe report
MGH launches Interdisciplinary
Physiologic Monitoring Tiger Team
– Physiologic Monitoring Criteria
– Physiologic Monitoring Assessment
– Physiologic Monitoring Practice
Standards
Clinical Technology Oversight Committee
Professional Practice Model
Magnet Recognition: External Evaluation
Staff Perceptions of the Professional Practice
Environment Survey: Internal Evaluation
• Evaluate the effectiveness of the Professional Practice Model based
on eight professional practice environment (PPE) characteristics:
- autonomy
- control over practice
- clinician-physician relationships
- communication
- teamwork
- conflict management
- internal work motivation
- cultural sensitivity
• Identify opportunities for improvement
• Trend data over time
• Provide report card for reflection and future direction
Guiding Principles
•

Care delivery should always be: patient and family-focused, evidence-based,
accountable and autonomous, coordinated and continuous.

•

It’s important to know the patient.

•

Inpatient and family care is provided by a designated nurse and physician
who are accountable and responsible for continuity of care.

•

Continuity of the team is a basic precept.

•

Every novice team member deserves mentoring from an experienced
clinician.

•

Every patient deserves the opportunity to participate in the planning of
his/her care.

•

Advancements in technology create opportunity for improved provider
communication and efficiency.
“Patient Journey” Framework

Before

Preadmission
Care

During
Admission
Process: ED,
Direct Admits,
Transfers

Patient Stay;
Direct Patient
Care, Tests, Treatments, Procedu
res,
Clinical Support,
Operational Support

Post

Discharge
Process

Support Functions: Finance, Information Systems, HR

Goal: High-performing interdisciplinary teams that deliver safe, effective, timely,
efficient and equitable care that is patient and family centered.

Where Are There Opportunities to Reduce Costs Across These Processes of Care?

Post
Discharge
Care
Innovations in Care Delivery
Patient Journey Framework

Discharge
process

Intervention

Patient stay; direct patient care;
tests; treatments; procedures;
clinical support;
operational support

After
Intervention

Admission
process: ED,
direct admits,
transfers

Intervention

Preadmission
care

During
Intervention

Before

Postdischarge
care

Goal: High-performing, inter-disciplinary teams that deliver safe, effective, timely,
efficient, and equitable care that is patient- and family-centered

The Interventions
•Enhance clinical datacollection before admission
•Create Innovation Unit
Welcome Packet
•Engage Patients and
families in redesign

•Revise Domains of Practice
•Implement inter-disciplinary team rounds
•Install unit census and in room whiteboards
•Utilize communication devices
•Utilize wireless laptop computers
•Business cards
•Hourly rounding
•Quiet hours

•Implement Discharge
Follow-up Call Program

Relationship-based care
Increased accountability through the attending nurse role
Utilization of Evidence Based staffing and care delivery;
Utilization of the Hand-Over Rounding Checklist
Relationship Based Care
• Mary Koloroutis: a model for transforming practice
• 3 Crucial relationships
– Care provider’s relationship with patients and families
– Care provider’s relationship with self
– Care provider’s relationship with colleagues
• Incorporates a formula for leading change with:
– Inspiration
– Infrastructure
– Education
– Evidence
– Bolstered by 5 Cs – clarity, competence, confidence,

collaboration, commitment
Relationship-Based Care
Patient safety is most effectively safe guarded when an advocate (most often
the nurse) in the health care system knows the patient, family, and what matters
most to them.
Attending Nurse Role
Responsible Nurse/Attending Nurse 
Expand staff nurse role.
•

Accountable for patient/family continuity and progression along the
developed overall plan of care from admission to discharge

•

Ensures, along with the Attending MD, that patient care meets the unit’s clinical
standards and vision of patient- and family-centered care

•

Develops and revises the patient care goals with the clinical care team daily

•

Coordinates meetings with clinicians for timely decision making and connects
nurses to optimize handoffs across the continuum

•

Is the primary bedside communicator with the patient and family, discussing
plan of the day, care progress, potential discharge, and answers
questions/teaches/coaches
Evaluation
•
•
•
•

•
•
•
•

Dashboards - outcomes
Nurse Director walk rounds
Patient & Family Advisory Councils (PFAC)
Patient interviews – follow up phone calls, on-site
interviews
Focus groups
Audits
Retreats
Weekly meetings with Attending RNs
Innovation Unit Dashboard
Throughput and Efficiency
 LOS
 TSI bud/flex
 Wait time for bed to be ready
 Admits
 Medication turnaround time
Patient & Staff Satisfaction
 MD & RN Communication
 Responsiveness
 Cleanliness
 Noise reduction
 Staff perception of support
 Equitable care

Massachusetts General Hospital - PCS Innovation Units Dashboard
Measures

Pediatrics
Ortho Oncology Medicine NICU
Surgery
White 6 Lunder 9 Ellison 16 Blake 10 Ellison 17 Ellison 18 White 7

CICU
ICU Obstetrics Psych Vascular
Ellison 9 Blake 12 Blake 13 Blake 11 Bigelow 14

QUALITY AND SAFETY
Patient-Centered Outcome Measures
Falls per 1,000 Patient Days
Total Fall Rate
Observed (N)
Falls with Injury per 1,000 Patient Days
Falls with Injury Rate
Observed (N)

4.50
11

1.46
3

4.95
13

0.77
1

1.92
2

1.32
2

2.16
5

1.79
2

TBD

0.65
2

4.85
10

0.45
1

0.41
1

0.49
1

1.52
4

0.00
0

0.96
1

0.00
0

0.00
0

0.89
1

TBD

0.00
0

1.45
3

0.45
1

0.0%
0

6.9%
2

0.0%
0

0.0%
0

0.0%
0

0.0%
0

7.7%
1

TBD

NA

4.8%
1

4.2%
1

0.0%
0

0.0%
0

0.0%
0

0.0%
0

0.0%
0

0.0%
0

7.7%
1

TBD

NA

4.8%
1

4.2%
1

0.0%
0

0.0%
0

0.0%
0

0.0%
0

0.0%
0

0.0%
0

7.7%
1

TBD

NA

0.0%
0

0.0%
0

NA

NA

0.0%
0

0.0%
0

0.0%
0

NA

NA

NA

NA

NA

NA

2.90
1

4.76
1

0.00
0

1.10
1

1.70
2

TBD

NA

0.00
0

0.00
0

Hospital Acquired (HA) Pressure Ulcers
Total HA Pressure Ulcer Prevalence Rate
0.0%
Observed (N)
0
Hospital Acquired (HA) Pressure Ulcers Type II or Greater
Total HA Pressure Ulcer Type II or Greater Prevalence Rate
0.0%
Observed (N)
0
Restraints
Total Restraint Prevalence Rate
Observed (N)

0.0%
0

Peripheral Intravenous (PIV) Infiltrations - Pediatric/Neonatal
Total PIV Infiltration Prevalence
NA
Observed (N)

Central Line-associated Bloodstream Infections per 1,000 Line Days (CLABSI)
Total CLABSI Rate
6.54
NA
1.36
Observed (N)
1
1

Quality and Safety
Note: metrics to be reported beginning FY 2012
Color Shading relative to Benchmark:
 Unplanned Return to OR
Rate is worse (higher) than benchmark.
Catheter-associated Urinary Tract Infections per 1,000 Device Days
 Readmission Rate
Rate is better (lower) than benchmark.
Ventilator-associated Pneumonia per 1,000 Vent Days
 Restraint Free Rate
 Falls/Pressure Ulcer Reduction
Innovation Unit Dashboard
 Foley Catheter Days
July – September 2011
 Hard-stop Time Out Performance
A Strong Safety Culture
1. Creates a learning culture
• Foundation of patient safety
2. Creates an open, fair and just culture
• Encourage reporting
• Reinforce accountability for safety at all levels
3. Designs safe systems
• Systems have the greatest influence on patient safety
4. Manages behavioral choices
• Critical thinking and decision making emphasizes the

continuous evaluation of risk
• Choices lead to desired safety outcomes
References
•
•
•
•
•

•
•
•
•
•

Agency for Healthcare Research and Quality. Available at: http://webmm.ahrq.gov/glossary.aspx
Committee on Health Care in America, Institute of Medicine (2001). Crossing the Quality Chasm: A
New Health System for the 21st Century. Washington D.C.: National Academies Press.
Committee on Quality of Health Care in America, Institute of Medicine (2000). To Err is Human:
Building a Safer Health System. Washington D.C.: National Academies Press.
Donabedian, A. (1988). The quality of care. How can it be assessed? JAMA 1988;260:1743-1748.
Gosbee, J. (2012). Assessing the strength of healthcare facility improvement actions. Massachusetts
Board of Registration in Medicine Quality and Patient Safety. Retrieved from:
www.patientsafety.gov
Institute for Healthcare Improvement, Available at: http://www.IHI.org
James, J. (2013). A new, evidence-based estimate of patient harms associated with hospital care.
Journal of Patient Safety 9(3) 122-128.
Koloroutis, M. (Ed.) (2004). Relationship-based Care: A model for transformational practice. Minneapolis,
MN: Creative Healthcare Management Inc.
Leonard, M.W. & Frankel, A. (2010). The path to safe and reliable healthcare. Patient Education and
Counseling 80: 288-292.
Wachter, R.M. (2012). Understanding Patient Safety 2nd ed. New York, NY: McGraw Hill|LANGE.

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Creating a Just Culture of Safety

  • 1. Creating a Just Culture of Safety Colleen K. Snydeman RN, MSN, PhD(c), NE-BC Director , Patient Care Services Office of Quality & Safety Massachusetts General Hospital
  • 2. Objectives At the conclusion of the presentation the participant will be able to : 1. Describe the influences in advancing the safety culture in healthcare. 2. Describe characteristics of a just culture of safety. 3. Identify examples of a just culture of safety.
  • 3. Overview 1. Quality & Safety a) Definitions b) Adverse events 2. Professional Accountability 3. Just culture a) Influences b) Characteristics c) Examples 1. MGH a) Just culture in action b) Innovation initiatives
  • 4. Quality (IOM, 2001) Quality- the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with professional knowledge. Quality/Cost = Value Measures – Structure, Process & Outcomes (Donabedian, 1988)
  • 5. IOM 6 Aims of Quality Care (2001) Efficient Equitable Effective Safe Timely Quality Care Patient Centered
  • 6. Safety (IOM,2000) • Safety – “Freedom from accidental or preventable injury” – the first domain of quality • Patient Safety – prevention of harm to patients – critical subset of quality patient care – Includes: 1. safe care 2. practice that is consistent with current evidence/knowledge 3. customization • Measures - difficult to measure due to dependence on selfreporting.
  • 8. Professional Accountability • There is a social contract between society and a profession. • Professions are the property of society and are responsible to society. • Professions acquire recognition and relevance from society. • It is society that determines what professional skills and knowledge are most needed and desired of a profession. • Society grants professions authority over functions vital to itself and allows for autonomy in the conduct of their own affairs.
  • 9. Nursing Accountability • Nursing is a profession and therefore responsible to society. • Nursing must be perceived as serving the interests of society. • Professions are therefore expected to act responsibly and mindful of the public’s trust. • Self-regulation assures high quality performance and is the hallmark of a mature profession.
  • 10. Nursing is: The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. American Nurses Association
  • 11. Errors and Adverse Events • • • • 98,000/year deaths estimated from medical errors (IOM, 2000) 210,000 deaths/year associated with preventable harm in hospitals (James, 2013: J Pt Safety). Error - (process) an act of commission ( doing something wrong) or omission (failing to do the right thing) leading to an undesirable outcome or significant potential for such an outcome (AHRQ, 2013). – Not all errors lead to adverse events. Adverse Event – (outcome) Unintended physical injury resulting from or contributing to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment, or hospitalization, or that results in death (IHI, 2013). – Not due to an underlying disease – Unpreventable – Preventable • Negligent – care falling below a professional standard – Side effects – may not be preventable or a medical error
  • 12. Moving toward a safer culture James Reason • • Goal: to create a safer culture consisting of: • Reporting • Learning • Flexibility • Just Culture Swiss Cheese Model David Marx • • Just culture algorithm – systems, behavioral choices, injury severity & not blame-free but just Core principles: • To err is human –human errors, systems • To drift is human – well intentioned, cut corners, fast paced, creates risk • Risk is everywhere • We are all accountable
  • 13. Reason’s Swiss Cheese Model (emeraldinsight.com)
  • 14. Just Culture – Human Error The single greatest impediment to error prevention in the medical industry is “that we punish people for making mistakes.” Dr. Lucian Leape Professor, Harvard Medical School of Public Health Testimony before Congress on Health Care Quality Improvement
  • 15. Just Culture – Systems thinking “People make errors, which lead to accidents. Accidents lead to deaths. The problem is seldom the fault of the individual; it is the fault of the system. Change the people without changing the system and the problem will continue.” Don Norman Author, the Design of Everyday Things
  • 16. Just Culture – Reckless behavior “…No person may operate an aircraft in a careless or reckless manner so as to endanger the life or property of another.” Federal Aviation Regulations 91.13 Careless or reckless operation
  • 17. Just Culture 1. Emphasizes quality and safety over blame and punishment. 2. Promotes a process where mistakes/errors do not result in automatic punishment but a process to uncover the root cause of the error. 3. Human errors that are not deliberate or malicious result in coaching, counseling, and education to decrease the likelihood of a repeated error. 4. Promotes increase error reporting that leads to system improvements to create safer environments for patients and staff.
  • 18. Proactive Learning Culture • Not seeing events as things to be fixed • Seeing events as opportunities to improve our understanding of risk – System risk – Behavior risk
  • 19. Blame vs. Accountability 1. Was the individual impaired? 2. Did the individual consciously decide to engage in an unsafe act? 3. Did the caregiver make a mistake that other similar individuals would make in similar circumstances? 4. Does the individual have a history of unsafe acts?
  • 20. Fair evaluation & response (Frankel & Leonard
  • 22. Examples • Unintentional Error – RN draws blood, gown slips over tourniquet, finds arm swollen • At-Risk Behavior – RN draws blood, patient complains of noise, takes blood out of room and labels at desk with wrong label, without checking 2 identifiers at bedside • Reckless Behavior – During medication administration, bar code scanning alerts nurse to wrong medication, nurse ignores alert and administers wrong medication without re-checking
  • 23. Evidence- Based Patient Safety Improvements (2012, Gosbee, J.) Weak • • • • Double checks Warnings Training New procedures Intermediate • • • • Redundancy Increase staffing Checklists Standardize communication tools • Education Strong • Simplify processes • Standardize equipment and processes • Force functions • New devices with usability testing • Physical plant changes • Tangible involvement of leadership
  • 24. Adverse Drug Events $3.5 Billion in costs (CDC, 2012) 700,000 ED visits 120,000 admissions Yellow- no error Purple- Error, no harm Blue- Error, Harm Orange- Error, Death
  • 25. MGH Culture of Safety • Edward P. Lawrence Center for Quality and • • • • • • • Safety Just Culture embraced Robust safety reporting – over 19,000 reports filed in 2012 Safety Culture Perception Survey Model to address professional conduct issues Root Cause Analysis Communication and Apology Executive Leadership Safety Rounds
  • 26.
  • 27. Patient Care Services Quality and Safety • Office of Quality and Safety • Safety reporting notification structure and follow up – Root cause analysis • Data driven – Nurse-sensitive indicators – Hospital-acquired conditions – Patient satisfaction – Nurse satisfaction • Regulatory requirements • Practice alerts- red flag – SBAR
  • 28.
  • 29. MGH Sentinel Event Event • • • • • • 90 year old male surgical patient with complete heart block sent to CICU Plan for pacemaker in a few days Transferred back to surgical unit on a cardiac monitor Found in cardiac arrest Code Blue activated Patient expired Post-event • • • • • • • • RNs discovered monitor alarms were off – Filed safety report – Alerted leadership Monitors, pumps etc… investigated Root cause analysis initiated Conversations with family begin Reported to Department of Public Health Boston Globe report MGH launches Interdisciplinary Physiologic Monitoring Tiger Team – Physiologic Monitoring Criteria – Physiologic Monitoring Assessment – Physiologic Monitoring Practice Standards Clinical Technology Oversight Committee
  • 32. Staff Perceptions of the Professional Practice Environment Survey: Internal Evaluation • Evaluate the effectiveness of the Professional Practice Model based on eight professional practice environment (PPE) characteristics: - autonomy - control over practice - clinician-physician relationships - communication - teamwork - conflict management - internal work motivation - cultural sensitivity • Identify opportunities for improvement • Trend data over time • Provide report card for reflection and future direction
  • 33.
  • 34. Guiding Principles • Care delivery should always be: patient and family-focused, evidence-based, accountable and autonomous, coordinated and continuous. • It’s important to know the patient. • Inpatient and family care is provided by a designated nurse and physician who are accountable and responsible for continuity of care. • Continuity of the team is a basic precept. • Every novice team member deserves mentoring from an experienced clinician. • Every patient deserves the opportunity to participate in the planning of his/her care. • Advancements in technology create opportunity for improved provider communication and efficiency.
  • 35. “Patient Journey” Framework Before Preadmission Care During Admission Process: ED, Direct Admits, Transfers Patient Stay; Direct Patient Care, Tests, Treatments, Procedu res, Clinical Support, Operational Support Post Discharge Process Support Functions: Finance, Information Systems, HR Goal: High-performing interdisciplinary teams that deliver safe, effective, timely, efficient and equitable care that is patient and family centered. Where Are There Opportunities to Reduce Costs Across These Processes of Care? Post Discharge Care
  • 36. Innovations in Care Delivery Patient Journey Framework Discharge process Intervention Patient stay; direct patient care; tests; treatments; procedures; clinical support; operational support After Intervention Admission process: ED, direct admits, transfers Intervention Preadmission care During Intervention Before Postdischarge care Goal: High-performing, inter-disciplinary teams that deliver safe, effective, timely, efficient, and equitable care that is patient- and family-centered The Interventions •Enhance clinical datacollection before admission •Create Innovation Unit Welcome Packet •Engage Patients and families in redesign •Revise Domains of Practice •Implement inter-disciplinary team rounds •Install unit census and in room whiteboards •Utilize communication devices •Utilize wireless laptop computers •Business cards •Hourly rounding •Quiet hours •Implement Discharge Follow-up Call Program Relationship-based care Increased accountability through the attending nurse role Utilization of Evidence Based staffing and care delivery; Utilization of the Hand-Over Rounding Checklist
  • 37. Relationship Based Care • Mary Koloroutis: a model for transforming practice • 3 Crucial relationships – Care provider’s relationship with patients and families – Care provider’s relationship with self – Care provider’s relationship with colleagues • Incorporates a formula for leading change with: – Inspiration – Infrastructure – Education – Evidence – Bolstered by 5 Cs – clarity, competence, confidence, collaboration, commitment
  • 38. Relationship-Based Care Patient safety is most effectively safe guarded when an advocate (most often the nurse) in the health care system knows the patient, family, and what matters most to them.
  • 39. Attending Nurse Role Responsible Nurse/Attending Nurse  Expand staff nurse role. • Accountable for patient/family continuity and progression along the developed overall plan of care from admission to discharge • Ensures, along with the Attending MD, that patient care meets the unit’s clinical standards and vision of patient- and family-centered care • Develops and revises the patient care goals with the clinical care team daily • Coordinates meetings with clinicians for timely decision making and connects nurses to optimize handoffs across the continuum • Is the primary bedside communicator with the patient and family, discussing plan of the day, care progress, potential discharge, and answers questions/teaches/coaches
  • 40. Evaluation • • • • • • • • Dashboards - outcomes Nurse Director walk rounds Patient & Family Advisory Councils (PFAC) Patient interviews – follow up phone calls, on-site interviews Focus groups Audits Retreats Weekly meetings with Attending RNs
  • 41. Innovation Unit Dashboard Throughput and Efficiency  LOS  TSI bud/flex  Wait time for bed to be ready  Admits  Medication turnaround time Patient & Staff Satisfaction  MD & RN Communication  Responsiveness  Cleanliness  Noise reduction  Staff perception of support  Equitable care Massachusetts General Hospital - PCS Innovation Units Dashboard Measures Pediatrics Ortho Oncology Medicine NICU Surgery White 6 Lunder 9 Ellison 16 Blake 10 Ellison 17 Ellison 18 White 7 CICU ICU Obstetrics Psych Vascular Ellison 9 Blake 12 Blake 13 Blake 11 Bigelow 14 QUALITY AND SAFETY Patient-Centered Outcome Measures Falls per 1,000 Patient Days Total Fall Rate Observed (N) Falls with Injury per 1,000 Patient Days Falls with Injury Rate Observed (N) 4.50 11 1.46 3 4.95 13 0.77 1 1.92 2 1.32 2 2.16 5 1.79 2 TBD 0.65 2 4.85 10 0.45 1 0.41 1 0.49 1 1.52 4 0.00 0 0.96 1 0.00 0 0.00 0 0.89 1 TBD 0.00 0 1.45 3 0.45 1 0.0% 0 6.9% 2 0.0% 0 0.0% 0 0.0% 0 0.0% 0 7.7% 1 TBD NA 4.8% 1 4.2% 1 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 7.7% 1 TBD NA 4.8% 1 4.2% 1 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 7.7% 1 TBD NA 0.0% 0 0.0% 0 NA NA 0.0% 0 0.0% 0 0.0% 0 NA NA NA NA NA NA 2.90 1 4.76 1 0.00 0 1.10 1 1.70 2 TBD NA 0.00 0 0.00 0 Hospital Acquired (HA) Pressure Ulcers Total HA Pressure Ulcer Prevalence Rate 0.0% Observed (N) 0 Hospital Acquired (HA) Pressure Ulcers Type II or Greater Total HA Pressure Ulcer Type II or Greater Prevalence Rate 0.0% Observed (N) 0 Restraints Total Restraint Prevalence Rate Observed (N) 0.0% 0 Peripheral Intravenous (PIV) Infiltrations - Pediatric/Neonatal Total PIV Infiltration Prevalence NA Observed (N) Central Line-associated Bloodstream Infections per 1,000 Line Days (CLABSI) Total CLABSI Rate 6.54 NA 1.36 Observed (N) 1 1 Quality and Safety Note: metrics to be reported beginning FY 2012 Color Shading relative to Benchmark:  Unplanned Return to OR Rate is worse (higher) than benchmark. Catheter-associated Urinary Tract Infections per 1,000 Device Days  Readmission Rate Rate is better (lower) than benchmark. Ventilator-associated Pneumonia per 1,000 Vent Days  Restraint Free Rate  Falls/Pressure Ulcer Reduction Innovation Unit Dashboard  Foley Catheter Days July – September 2011  Hard-stop Time Out Performance
  • 42. A Strong Safety Culture 1. Creates a learning culture • Foundation of patient safety 2. Creates an open, fair and just culture • Encourage reporting • Reinforce accountability for safety at all levels 3. Designs safe systems • Systems have the greatest influence on patient safety 4. Manages behavioral choices • Critical thinking and decision making emphasizes the continuous evaluation of risk • Choices lead to desired safety outcomes
  • 43. References • • • • • • • • • • Agency for Healthcare Research and Quality. Available at: http://webmm.ahrq.gov/glossary.aspx Committee on Health Care in America, Institute of Medicine (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington D.C.: National Academies Press. Committee on Quality of Health Care in America, Institute of Medicine (2000). To Err is Human: Building a Safer Health System. Washington D.C.: National Academies Press. Donabedian, A. (1988). The quality of care. How can it be assessed? JAMA 1988;260:1743-1748. Gosbee, J. (2012). Assessing the strength of healthcare facility improvement actions. Massachusetts Board of Registration in Medicine Quality and Patient Safety. Retrieved from: www.patientsafety.gov Institute for Healthcare Improvement, Available at: http://www.IHI.org James, J. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety 9(3) 122-128. Koloroutis, M. (Ed.) (2004). Relationship-based Care: A model for transformational practice. Minneapolis, MN: Creative Healthcare Management Inc. Leonard, M.W. & Frankel, A. (2010). The path to safe and reliable healthcare. Patient Education and Counseling 80: 288-292. Wachter, R.M. (2012). Understanding Patient Safety 2nd ed. New York, NY: McGraw Hill|LANGE.

Editor's Notes

  1. IHINPSFECRI – Emergency Care Research InsitituteMITSS – Medically induced trauma support services
  2. Safety improvements – medication reconciliation Bar coding safe dispensing – profiling scanning for correct patient identification drug libraries Smart infusion pumps