Worker / Patient Safety: Steps in a Culture Change Mary Margaret Jackson Director, Performance Outcome Services Self Regional Healthcare

History of The “Journey” Idea conceived and grant sought Combining of six organizations with common bond of: – All JCAHO accredited and in South Carolina – All with same Worker Compensation & Liability carriers

Process Steps Gain organizational commitment Measure safety culture Form coordinator’s group Identify commonalities as well as individual needs Gain consensus on next steps Begin organizational work groups

Steps Continued Customize programs to the organization Develop individual and group measures / indicators Share successes and failures openly within the group Share with other S.C. organizations

Strategies / Activities Culture change takes a multi-pronged approach In some situations safety program reorganization needed Maintaining an internal focus and champion “Integrating” into current initiatives

Specific Activities Organizational identification of: – Red Rules – Behaviors at all levels that could best prevent error (“behavior based expectations” Used line staff who were first educated in concept and who next chose Self specific

Additional Activities Training in Root Cause Analysis & Common Cause Analysis Development of a “Scorecard” to consistently track results Enhancing communications organization- wide

Summary of the Key Activities Red Rules Behavior Based Expectations Accountabilities Scorecard

How are Red Rules picked? Choose those that focus employees on those rules that are most important to safety Choose those that clarify work expectations about processes critical to safety Choose those that make compliance with safety standards a routine activity

Getting Red Rules Implemented We are not there yet! Removal of barriers to successful compliance with a Red Rule Gain clear consensus on the “accountability” portion

What makes a good Red Rule? 1. Is the proposed Red Rule critical to patient and/or employee safety if not performed consistently and exactly? 2. Can the proposed Red Rule be applied throughout the hospital? 3. Is the proposed Red Rule specific enough so interpretation is not required? 4. Is it possible to directly observe/measure compliance? 5. Are you willing, as a leader, to endorse 100% compliance as the minimum standard for the proposed Red Rule?

First Steps on Action Sheet Gain organizational approval and support of "Red Rule Identify processes for Medical Staff acceptance and support with Red Rules Attach red rule accountability expectations and measures at all levels of the organization

Self’s Red Rules 1. I will always confirm patient identity using at least two hospital approved identifiers before any action. 2. I will always perform hand hygiene before and after every patient contact and as specified by my department. 3. I will always adhere to posted Personal Protective Equipment (PPE) requirements. 4. I will always wear my hospital ID badge while on duty.

Some of the Barriers Policy conflicts Staff knowledge Ability to observe and measure compliance Need to anticipate and have solutions for common human factors- such as “I forgot my badge”

What might the Red Rules Do? Unify staff on safety- 100% expectation for ALL! Gain better understanding of individual’s role in safety Build personal accountability Create formal accountability systems Hard to argue against

What about Behaviors? Already in use was “SELF PRIDE” S – Show Respect S – Show Respect E – Effective Communication E – Effective Communication L – Listen L – Listen F – Follow Through F – Follow Through P – Professionalism P – Professionalism R – Recognize Every Individual R – Recognize Every Individual I – Initiate and Inform I – Initiate and Inform D – Do The Job Right The 1st Time D – Do The Job Right The 1st Time E – Expect The Best E – Expect The Best

Translates into the Following: Use Repeat-Backs & Read-Backs and Seek Feedback Use Repeat-Backs & Read-Backs and Seek Feedback Ask Clarification Questions Ask Clarification Questions Identify Self, Department, Purpose Identify Self, Department, Purpose Hand-Off Effectively – 5 “P’s” – Patient, Plan, Purpose, Precautions, Problems Hand-Off Effectively – 5 “P’s” – Patient, Plan, Purpose, Precautions, Problems Follow Red Rules, Policies, Procedures Follow Red Rules, Policies, Procedures Practice Peer Checking & Coaching Using ARC (Ask, Request, Concern) Practice Peer Checking & Coaching Using ARC (Ask, Request, Concern) STAR – Stop, Think, Act, Review STAR – Stop, Think, Act, Review STOP when Unsure and Ask STOP when Unsure and Ask

How are Behaviors Introduced? Trainers developed Sessions grouped so communication improvements are emphasized Trainers carry “the message” Integrated into orientation and all safety training

What Other Things did the Six Facilities focus on? Training in Root Cause Analysis Introduction to increased use of Common Cause Analysis Identification of leading, lagging, and real time indicators of both patient and worker safety (Scorecard) Defining incident types and sharing results openly

Results

Results? It is a three year journey- at least! Re survey of culture next year Does it make a difference- you bet! Gives a framework for change