June 15th 2017 Presented By: Shanelle Van Dyke Patient Safety Culture (PSC) Survey Quality Improvement Series: Feedback & Communication About Error June 15th 2017 Presented By: Shanelle Van Dyke

Patient Safety Culture (PSC) Survey Communication & Feedback About Error Domain 1. We are given feedback about changes put into place based on event reports. (C1) 2. We are informed about errors that happen in this unit. (C3) 3. In this unit, we discuss ways to prevent errors from happening again. (C5)

Patient Safety Workshop – Learning From Error Developed by the World Health Organization, this patient safety workshop is designed to be suitable for health-care workers (e.g., nurses, doctors, midwives, pharmacists), health care workers in training (e.g., nursing students, medical students, residents), health care managers or administrators, patient safety officers, and any other groups involved in delivering health care. The workshop explores how multiple weaknesses present within the hospital system can lead to error. It aims to provide all health care workers and managers with insight into the underlying causes of such events. Workshop participants should be introduced to an understanding of why errors occur; begin to understand which actions can be taken to improve patient safety; be able to describe why there should be greater emphasis on patient safety in hospitals; and identify local policies and procedures to improve the safety of care to patients. http://www.who.int/patientsafety/activities/technical/vincristine_learning-from-error.pdf

Patient Safety Workshop – Learning From Error The WHO Workshop materials provide the following information and resources: Guidance for Course Organizers Suggested Schedule Factors Contributing to Error Root Cause Analysis Sheet One: Fishbone Template Sheet Two: Questions to Consider Sheet Three: Evaluation Form http://www.who.int/patientsafety/activities/technical/vincristine_learning-from-error.pdf http://www.who.int/patientsafety/activities/technical/vincristine_learning-from-error.pdf

Patient Safety Workshop – Learning From Error Learning objectives - By the end of this workshop, participants should: Be introduced to an understanding of why errors occur Begin to understand which actions can be taken to improve patient safety Be able to describe why there should be greater emphasis on patient safety in hospitals Identify local policies and procedures to improve the safety of care to patients

Provide Feedback to Front–Line Staff This Institute for Healthcare Improvement Web page identifies tips and tools for how to communicate feedback: ​Feedback to the front-line staff is a critical component of demonstrating a commitment to safety and ensuring that staff members continue to report safety issues. If the leadership acts upon suggestions, staff members should know their voices were heard and should be recognized for their contributions, especially when the leadership’s response would otherwise be invisible from the front lines. Maintaining a consistent flow of information from senior leadership affirms that every safety initiative is important and not a fleeting “idea of the month.” http://www.ihi.org/resources/Pages/Changes/ProvideFeedbacktoFrontLineStaff.aspx http://www.ihi.org/resources/Pages/Changes/ProvideFeedbacktoFrontLineStaff.aspx

Provide Feedback to Front–Line Staff IHI Tips Use Patient Safety Leadership WalkRounds™ as an opportunity to provide feedback to staff, as well as to hear staff suggestions and ideas. Ensure that the feedback system reaches all staff members, including those who work on alternate shifts, on weekends, or intermittently. Develop a newsletter for communicating safety information, or add a page or column to an existing newsletter. Make sure some messages come directly from senior leaders. Recognize and thank staff members in front of their peers for their suggestions. Give feedback about each suggestion even if you can’t act on it: make sure the staff member who made the suggestion knows it was investigated and explain why you could not take action. Make responses timely — failure to provide prompt feedback will make staff members think you don’t listen or take action.

Conduct Safety Briefings ​​This Institute for Healthcare Improvement (IHI) Web page identifies tips and tools for how to conduct Safety Briefings: Safety briefings in patient care units are tools to increase safety awareness among front-line staff and foster a culture of safety. Based on concepts in aviation and other industries, briefings make safety- consciousness part of the routine, 24 hours a day and seven days a week. Safety briefings should be designed so staff members can conduct them without participation or guidance from the management. IHI Tips: Reinforce the non-punitive aspect of the discussion repeatedly, especially during the first few briefings. Keep the briefings short. Adjust the frequency and time of day if the staff asks you to. Collect detailed information about issues raised by staff. Institute weekly Patient Safety Leadership WalkRounds™ as well as the regular staff safety briefings for best results.

Safety Briefings Tool Health care organizations use Safety Briefings to help increase staff awareness of patient safety issues, create an environment in which staff share information without fear of reprisal, and integrate the reporting of medication safety issues into daily work. Over time, Safety Briefings help organizations create a culture of safety, reduce the risk of medication errors, and improve quality of care. The tool includes step-by-step instructions for conducting Safety Briefings, a data collection form, and a pre- and post-survey to evaluate the effectiveness of the tool. The Safety Briefing tool contains: Overview Background Using the Model for Improvement to Test Safety Briefings How to Conduct Safety Briefings Safety Briefing Data Collection Sheet Pre- and Post-Safety Briefing Evaluation Safety Briefings Tool

Safety Huddle Results Collection Tool Safety Briefings increase safety awareness among front-line staff and help an organization develop a culture of safety. To determine whether or not Safety Briefings are successful in accomplishing these goals, data must be collected to monitor progress. It is also important to collect data regarding the staff’s perception of the value of testing or implementing changes that affect their daily work. If staff do not perceive that a change has value or will bring improvement, the change will not be sustained. Iowa Health System tested the use of Safety Briefings (which it calls "Safety Huddles") to increase safety awareness and designed this tool to assist its staff with data collection during those tests. The tool can be used with the Safety Briefings but is not limited to that format. The tool enumerates data elements to collect during a test of Safety Briefings, including medication safety issues and "near miss" medication errors that are identified before they cause harm. http://www.ihi.org/resources/Pages/Tools/SafetyHuddleResultsCollectionTool.aspx http://www.ihi.org/resources/Pages/Tools/SafetyHuddleResultsCollectionTool.aspx

Safety Huddle Results Collection Tool This tool can be used to aggregate data collected during tests of Safety Briefings. When first testing Safety Briefings, it is important to gather information about staff perceptions of value. However, this information need not be collected at every Briefing, but only at the beginning and the end of the test. If an organization then decides to permanently implement Safety Briefings, other data collection tools may be used to track important information such as issues raised by staff and opportunities to improve safety. Review the tool prior to use, and modify it according to the needs of your organization and the actual test. Safety Huddle Results Collection Tool

Appoint a Safety Champion for Every Unit ​This Institute for Healthcare Improvement (IHI) Web page identifies tips and tools for how to Appoint a Safety Champion for Every Unit: Communicating information about patient safety is an important responsibility that should not always fall to managers alone. It is often better to have a staff member in this role. Having a designated safety champion in every department and patient care unit demonstrates the organization’s commitment to safety and may make other staff members feel more comfortable about sharing information and asking questions. Champions must have proper training, resources, and authority. http://www.ihi.org/resources/Pages/Changes/AppointaSafetyChampionforEveryUnit.aspx http://www.ihi.org/resources/Pages/Changes/AppointaSafetyChampionforEveryUnit.aspx

Appoint a Safety Champion for Every Unit IHI Tips: Seek volunteers from the staff; don’t assign the task to a reluctant staff member. Give the safety champion the power to come up with quick solutions to certain problems, such as getting equipment fixed or replaced. Remind staff members that the safety champion is their ally, not an informer or a disciplinarian. Train the safety champion in safety concepts such as Human Factors Engineering — the science of why people make mistakes. Bring safety champions from different units together regularly to share information. Check with staff members occasionally to see how well the safety champion is meeting their needs. http://www.ihi.org/resources/Pages/Changes/AppointaSafetyChampionforEveryUnit.aspx

Safety Leadership WalkRounds ​This Institute for Healthcare Improvement (IHI) Web page identifies tips and tools for how to conduct Safety Leadership WalkRounds: Senior leaders wishing to demonstrate their commitment to safety and learn about the safety issues in their own organization can do so by making regular rounds for the sole purpose of discussing safety with the staff. During the WalkRounds™, the communication should go two ways, with both the executives and the staff talking honestly and listening carefully. Many organizations have found Patient Safety Leadership WalkRounds™ especially effective in conjunction with Safety Briefings, which often provide material for executives to start discussions. http://www.ihi.org/resources/Pages/Changes/ConductPatientSafetyLeadershipWalkRounds.aspx http://www.ihi.org/resources/Pages/Changes/ConductPatientSafetyLeadershipWalkRounds.aspx

Safety Leadership WalkRounds IHI Tips: Get a commitment from senior executives for an hour every week. The WalkRounds™ may be rescheduled but never canceled. Involve all the senior executives in the organization, not just the chief executive officer. Keep discussions focused on safety; don’t dilute the safety message by trying to cover other topics. Communicate with managers so they understand why senior executives are visiting their departments. Make sure that senior executives follow up and provide feedback to staff about issues raised during the WalkRounds™. Institute regular safety briefings.  Pass along issues raised in the briefings (with names of the contributing staff members withheld) to the executives to talk about on their WalkRounds™. Take a digital camera. It has been wonderful for PowerPoint presentations to staff and quality council meetings. Pictures are worth a thousand words.  Prior to leaving the unit, have executive summarize the issues and ask staff to prioritize 2 to 3 items to be addressed. http://www.ihi.org/resources/Pages/Changes/ConductPatientSafetyLeadershipWalkRounds.aspx

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