The document proposes several initiatives to the EMT to improve patient safety culture at the hospitals. It recommends continuing executive patient safety rounds, allocating resources to support National Patient Safety Goal RIEs, and defining roles for the Patient Safety Director. It also proposes defining an ideal cultural target state, conducting cultural surveys, and chartering significant projects through the EMT. Metrics are outlined to measure tangible safety improvements and overall cultural development progress. The EMT is asked to approve these proposals and initiatives.

1. 1
Culture of Patient Safety
Todd Salnas  Jo Sandersfeld
Debra Miller  Mark Knight
Linda Hansen

2. 2
Culture of Patient Safety
EMT Proposals: Recap & Approvals (PREVIEW)
1. Does EMT agree to continue the Executive Patient Safety Rounds in the
proposed format?
2. Does EMT agree to allocate Sonoma Way resources to support NPSG RIE’s?
(or defer to TPOC?)
3. Does EMT support the Patient Safety Director Roles & Responsibilities as
defined on the slide?
4. Does EMT approve the Cultural Target State as summarized?
5. Does EMT agree to the SW Cultural Survey questions and process?
6. Does EMT agree with the proposed EMT Chartering process?
7. Does EMT agree with overall Roles & Responsibilities for EMT? AMT? Staff?
8. Does EMT agree with the revised HML & Performance Evaluations, and feel it
they are reflective of the cultural target state summary?
9. Do the 6 Metrics for Patient Safety Culture accurately reflect our desired target
state?

3. 3
Patient Safety CulturePatient Safety Culture
Overall CultureOverall Culture
Defining
Ideal Culture State
Defining
Ideal Culture State
Sonoma WaySonoma Way
RIE Standard WorkRIE Standard Work
Facilitators & RIE
Participants ensure
“Cultural” considerations
are measured
Facilitators & RIE
Participants ensure
“Cultural” considerations
are measured
Sonoma Way
Cultural Survey
Results
Sonoma Way
Cultural Survey
Results
Day-to-DayDay-to-Day
Chartering
Projects requiring
significant work
approved by EMT
Directors work
with EMT to
charter significant
projects
Everyday
Behaviors
Incorporate
Cultural
Principals into
everyday
behaviors
HML and
Performance
Evals
HML and
Performance
Evals
Tangible Improvements
In Patient Safety
Tangible Improvements
In Patient Safety
Prioritization of
Safety Goals
Prioritization of
Safety Goals
Med Reconciliation;
HAPU;
High Alert Meds;
Critical Results
Med Reconciliation;
HAPU;
High Alert Meds;
Critical Results
Patient Safety
Director leads A3’s
Patient Safety
Director leads A3’s
Failure Rates
for each area of
focus
Failure Rates
for each area of
focus
Executive Patient
Safety Rounds
Executive Patient
Safety Rounds
Patient Safety
Director, EMT;
Follow up with staff
Patient Safety
Director, EMT;
Follow up with staff
Completed follow up
items
Completed follow up
items
Employee Engagement Survey (Summer 2011)Employee Engagement Survey (Summer 2011)
Culture of Patient Safety Survey (Fall 2011)Culture of Patient Safety Survey (Fall 2011)
Focus
Areas
Roles &
Responsibilities
Measures
Of Success

4. 4
Culture of Patient Safety
Tangible Improvements in Patient Safety
 Executive Patient Safety Rounds Follow up
 National Patient Safety Goal Improvements

5. 5
Tangible Improvements in Patient
Safety
Executive Patient Safety Rounds
 One Rounding Session per month at each hospital
 Tracking process to ensure feedback loop
 Immediate follow up after debrief
 Closure with individual reporting incident
 Communication
 Team consists of Executive, Patient Safety
Director, Pharmacy Director, Risk Manager,
Physician (SRM)

6. 6
Tangible Improvements in Patient Safety
Executive Patient Safety Rounds

7. 7
Prioritization
of
National Patient Safety
Goals
Tangible Improvements in Patient Safety

8. 8 Increasing Difficulty/Complexity in Improving
01.01.01
•2 Pt.
Identifiers
•05.01.01
•Suicide
Risk
Assessment
•LASA
Meds
•03.09.01
•Labeling
Meds
•01.03.01
•Blood
Administra
tion
•07.##.01
•Infection
Control;
Hand Hygiene
•Universal
Protocol
Procedures
•03.05.07
•Anti-
Coag’s
•08.##.01
•Med
Rec
•High
Alert
Meds
•Patient
Falls
•HAPU’s
•HAC’s:
(other than
falls or
wounds)
•02.03.01
•Critical
Results
Group:
Todd
E.J.
Joanie
Larry
Ken
Brad
Jill
Kim
Gary M.
Jane
Linda H.
Capacity: 3 RIE’s rolling out over 3-4 Months
|--20 hrs prep--|
|--40 hrs RIE Event--|
Monitoring/report outs: |--20 hrs --|--10 hrs--|--10 hrs--|
Capacity: 3 RIE’s rolling out over 3-4 Months
|--20 hrs prep--|
|--40 hrs RIE Event--|
Monitoring/report outs: |--20 hrs --|--10 hrs--|--10 hrs--|
Tangible Improvements in Patient Safety
•Patient
Handoffs,
Unit to Unit

9. 9
Priority NPSG Initiative SRM PVH Total
1 14. Medication Reconciliation (might be IT project- Todd to check) 7 3 10
2 5. Critical Results Communications 6 3 9
3 12. High Alert Meds (including Anti-Coagulants) 4 3 7a
4 11. HAPU's (Hospital Acquired Pressure Ulcers) 5 2 7b
5 10. Patient Falls 4 1 5
6 9. Patient Handoffs, Unit to Unit (not shift-to-shift) 2 1 3
7 7. Infection Control/Hand Hygiene 1 1 2
8 8. Universal Protocol (&Crew Training Expectations/ Budget) 2 2
9 13. Hospital Acquired Conditions, excluding HAPU's & FALLS 1 1
10 2. Suicide/Safety (Just do it? Education?) 1 1
11 4. Labeling of Medications 1 1
12 1. Two Patient Identifiers
13 3. Blood Administration
14 6. Look Alike, Sound Alike Medications -LASA (Just do it? Education?)
Tangible Improvements in Patient Safety

10. 10 *Med Rec may be handled as IT Project
Tangible Improvements in Patient Safety
Focus Area Metric
NPSG Priorities
Failure Rate
Reduction
Executive Patient
Safety Rounds
Closure of
Follow up Items

11. 11
Area Patient Safety Director
1. Managing Monitoring Process
• Manage / train others
• Personal observations
• Reviewing data & developing plans,
presenting data
2. Facilitating NPSG Sonoma Way Teams
• RIE / A3 / PDCA
3. Patient Family / Engagement Models – Year 2
(post #1-2 &post patient satisfaction hard-wiring)
4. Executive Safety Rounds
• Rounds, Debriefs
• Follow-up
5. Communication / Publication of Activities
6. Personal Follow-up
1. Policy revisions
2. Process changes
3. Patient Safety Officer role and plan
4. PPR / Survey Follow-up
* #6, beyond time

12. 12
Culture of Patient Safety
Overall Culture Development
Sonoma Way Initiatives
Day to Day Activities

13. 13
Overall Culture Development
See Exhibit # 1

14. 14
Overall Culture Development
See Exhibit # 1

15. 15
Overall Culture Development
Sonoma Way Standard Work
 Cultural Vision Survey template developed
[See exhibit # 2]
 1 -2 critical items monitored throughout VSA/RIE
Process by means of an Online Survey Tool
 Survey aimed at staff involved in change process
 Survey results reviewed at Monthly Operating Result
Review
 Survey results communicated at RIE Report Outs

16. 16
Overall Culture Development
Day to Day: EMT Chartering of Initiatives
Proposal:
 Approves high cost, high complexity, resource
intensive projects [See exhibit # 3]
 Ensures Cultural Vision is considered
– Identify key stakeholder involvement
– Clear metrics, accountability and ownership
– Resource availability
– Capacity of organization to implement and sustain project

17. 17
Overall Culture Development
Day to Day: AMT and Staff Roles &
Responsibilities [See Exhibit # 4]
 Active participation in improvement activities
 Alignment of departmental activities with strategic
initiatives
 Transparent communication and opportunities for
input and education around standard work
 Clear expectations about feedback cycle for
improvement
 Daily monitoring and refining of new processes

18. 18
Culture of Patient Safety
Day to Day: Measures of Success
[See Exhibit # 5]
Proposal:
 Revise HML to include success in demonstrating
Cultural Attributes
 Map Cultural Attributes to Performance Evaluations –
Leadership Competencies

19. 19
Culture of Patient Safety
Metric Recap
Tangible Patient Safety Improvements
 Failure Rates for Patient Safety Priorities
 Executive Rounds Follow up
Overall Culture Development
 Sonoma Way Culture Survey Results
 HML, Performance Evaluation Scores
Both:
 Employee Engagement Survey Results
 Culture of Patient Safety Survey Results

20. 20
Culture of Patient Safety
EMT Proposals: Recap & Approvals
1. Does EMT agree to continue the Executive Patient Safety
Rounds in the proposed format?
2. Does EMT agree to allocate Sonoma Way resources to support
NPSG RIE’s? (or defer to TPOC?)
3. Does EMT support the Patient Safety Director Roles &
Responsibilities as defined on the slide?
4. Does EMT approve the Cultural Target State as summarized?
Continued on next page--

21. 21
Culture of Patient Safety
EMT Proposals: Recap & Approvals (continued)
5. Does EMT agree to the SW Cultural Survey questions and
process?
6. Does EMT agree with the proposed EMT Chartering process?
7. Does EMT agree with overall Roles & Responsibilities for
EMT? AMT? Staff?
8. Does EMT agree with the revised HML & Performance evals,
and feel it is reflective of the cultural target state summary?
9. Do the 6 Metrics for Patient Safety Culture accurately reflect
our desired target state?

22. 22
Culture of Patient Safety
Questions?
Comments?