April 20th 2017 Presented By: Shanelle Van Dyke Patient Safety Culture (PSC) Survey Quality Improvement Series: Nonpunitive Response to Error April 20th 2017 Presented By: Shanelle Van Dyke

Patient Safety Culture (PSC) Survey Nonpunitive Response to Error Domain 1. Staff feel like their mistakes are held against them. (A8R) 2. When an event is reported, it feels like the person is being written up, not the problem. (A12R) 3. Staff worry that mistakes they make are kept in their personnel file. (A16R)

A Pervasive Commitment to Patient Safety Improvement in patient safety does not occur unless there is a pervasive commitment by the organization and a clearly defined and ongoing effort by leaders, physicians, and co-workers. Commit to an environment in which co-workers and physicians feel free to contribute to building and maintaining a culture of safety. Establish a non-punitive, blame-free culture that encourages co- workers to focus on safety issues; identify and report all events, “near misses” or close calls, and hazardous conditions; and help to develop and implement performance improvement processes across the organization. The success of this effort depends on each co-worker’s willingness to participate, to contribute, and to be open to sharing and receiving information about safety events and close calls. Expect and require that all co-workers fully take part in building your hospital’s culture of safety. commitment by the organization and a clearly defined and ongoing effort by leaders, physicians, and co-workers. Beginning at the highest levels of the Board of Directors and continuing through the executive leadership, management, coworkers and physicians of the hospital. Commit to an environment in which co-workers and physicians feel free to contribute to building and maintaining a culture of safety. Establish a non-punitive, blame-free culture that encourages co-workers to focus on safety issues; identify and report all events, “near misses” or close calls, and hazardous conditions; and help to develop and implement performance improvement processes across the organization. Create an environment where reporting about adverse medical events and patient safety is the norm, without fear of retribution or punishment. The success of this effort depends on each co-worker’s willingness to participate, to contribute, and to be open to sharing and receiving information about safety events and close calls. Expect and requires that all co-workers fully take part in building your hospital’s culture of safety.

A Non-punitive, Blame-free Environment Work to develop a culture of patient safety, that strongly encourages people to report adverse events and “near misses” or close calls without fearing what might happen to them. Have coworkers feel that they are full partners in the job of improving the safety of patient care processes and systems. That the organization’s primary response to adverse events is to learn from them, not to assign blame or impose discipline. A culture of safety where people are able and willing to report both adverse events and close calls without fear of punishment will lead to a safer environment for not only patients, but also co-workers, physicians and visitors. We live in a culture that manages errors by looking for people to blame, that discourages people from admitting errors, and that focuses on the end result — the error — instead of the systems or processes that led to the error. Making mistakes is part of being human. How many days have you gone through without making at least one mistake in your private or professional life? Have you ever driven into a gas station and released the trunk instead of the gas cap? How many times have you driven to the grocery story and made a wrong turn out of habit? Although most of our mistakes are easily corrected and cause no harm, mistakes in the health care field are not always that way.

Non-Punitive Policy on Patient Safety Reporting Non-punitive policy on patient safety reporting is designed to encourage co-workers to feel comfortable reporting adverse events and near misses, and to participate in improving processes and systems. At the same time, it acknowledges that individuals are responsible and accountable to patients, the public and each other for doing whatever they can to make. It helps to create a safe healing environment. Each individual is responsible for using sound judgment and being aware of potential hazards to patients before taking action.

https://youtu.be/xeMWizTodYw - AHRQ Video

What is the Communication and Optimal Resolution Process? The Communication and Optimal Resolution (CANDOR) process is a process that health care institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm. Based on expert input and lessons learned from the Agency's $23 million Patient Safety and Medical Liability grant initiative launched in 2009, the CANDOR toolkit was tested and applied in 14 hospitals across three U.S. health systems. Case studies have shown it to improve Event Reporting domains within the Patient Safety Culture Survey

What Resources Are Included in the CANDOR Toolkit? The CANDOR toolkit contains eight different modules, each containing PowerPoint slides with facilitator notes. Some modules also contain tools, resources, or videos: Implementation Guide for the CANDOR Process Module 1: An Overview of the CANDOR Process Module 2: Obtaining Organizational Buy-in and Support Module 3: Preparing for Implementation: Gap Analysis Module 4: Event Reporting, Event Investigation and Analysis Analysis Module 5: Response and Disclosure Module 6: Care for the Caregiver Module 7: Resolution Module 8: Organizational Learning and Sustainability

How Does the CANDOR Process Work? Generally, the CANDOR process begins with identification of an event that involves harm. This activates initiation of coordinated post-event processes, as depicted below and described in the CANDOR Toolkit modules.

What Will My Organization Learn? The key learnings for hospitals implementing the CANDOR process in their institutions include how to: Engage patients and families in disclosure communication following adverse events. Implement a Care for the Caregiver program for providers involved in adverse events. Investigate and analyze an adverse event to learn from it and prevent future adverse events. Review and revise the organization’s current processes to align with the CANDOR process. Establish a resolution process for the organization.

Humans Make Mistakes Encourages co-workers to report adverse events and close calls — not to assign blame, but to learn what happened so we can keep it from happening again. One of the best ways to reduce adverse events is to take advantage of lessons present in close calls, where things almost go awry but no harm is done. Most mistakes occur as a result of ineffective, improperly designed or flawed systems. When co-workers report events and close calls, we are able to track them to find patterns and trends, which helps us learn how we can improve our systems to prevent future mistakes.

Helpful Links CANDOR Toolkit – https://www.ahrq.gov/professionals/quality-patient- safety/patient-safety-resources/resources/candor/index.html#guide To Err is Human - https://psnet.ahrq.gov/resources/resource/1579 Summary - http://www.nationalacademies.org/hmd/~/media/Files/Report%20Fil es/1999/To-Err-is- Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf

The Call-in information will remain the same for each event, but the link will change. So be on the look out for each topic specific Save the Date that will be sent out before each event.

THANK YOU! Questions ? ? ? Kyle Cameron—Wyoming Flex Shanelle Van Dyke 1.406.459.8420 Shanelle.VanDyke@QualityReportingServices.com Kyle Cameron—Wyoming Flex Wyoming Office of Rural Health 1.307.777.8902 Kyle.Cameron@wyo.gov Rochelle Spinarski—Rural Health Solutions 1.651.731.5211 Rspinarski@rhsnow.com