1. 1 Building a Patient Safety Mentor Program Michele Campbell, RN, MSM, CPHQ FABC Corporate Director Patient Safety and Accreditation Christiana Care Health System

2. 2 Impetus for Safety Mentor Program Landmark Report Culture Survey Focus Groups/ Culture Debriefing Sessions Safety First Learning Report Data To Err is Human (IOM, 1999) Nonpunitive response to error Improvements made as a result of reporting Reluctance to report errors Reporting an error was difficult Volume and severity of events and near misses

3. 3 Goals: Safety Mentor Program Empower frontline staff to serve as ambassadors. Empower frontline staff to serve as ambassadors. Encourage peer-to-peer feedback and communication. Encourage peer-to-peer feedback and communication. Enhance and promote error reporting, including near misses. Enhance and promote error reporting, including near misses. Mitigate harm to our patients. Mitigate harm to our patients. Facilitate learning. Facilitate learning.

4. 4 Design of the Safety Mentor Program Formulate goals. Formulate goals. Gain organizational buy-in. Gain organizational buy-in. Define safety mentor role. Define safety mentor role. Identify educational and training needs. Identify educational and training needs. Determine frequency and content of meetings. Determine frequency and content of meetings. Develop and implement data collection plan/tools. Develop and implement data collection plan/tools. Plan how to evaluate innovation. Plan how to evaluate innovation.

5. 5 Considerations for Adopters Select mentors carefully. Select mentors carefully. Consider protected time for data collection. Consider protected time for data collection. Act on front-line input. Act on front-line input. Will it Work Here? A Decisionmaker’s Guide to Adopting Innovations http://www.innovations.ahrq.gov/resourc es/resources.aspx Will it Work Here? A Decisionmaker’s Guide to Adopting Innovations http://www.innovations.ahrq.gov/resourc es/resources.aspx http://www.innovations.ahrq.gov/resourc es/resources.aspx http://www.innovations.ahrq.gov/resourc es/resources.aspx

6. 6 Validation Of Our Success

7. 7 Improved reporting of medication-related near misses: Improved reporting of medication-related near misses:

8. 8 Validation Of Our Success Fewer events with major outcomes Fewer events with major outcomes Improvements in safety culture Improvements in safety culture – Dramatic decline in fear of disciplinary action – Perception of improved patient safety and learning

9. 9 Other Uses Of Quantitative and Qualitative Data Safe Practice Behavior Monitoring Safety First Learning Report Effectiveness of Safety Mentor meetings Focus Groups Observations Documentation Interview questions Ease of completion and navigation Agenda items Improvements and suggestions Qualitative feedback on safety project design and strategies

10. 10 Lessons Learned Assess baseline data to evaluate success. Assess baseline data to evaluate success. Select culture survey instrument strategically. Select culture survey instrument strategically. Resources impact selection of measures. Resources impact selection of measures. Safety mentors’ insights and perceptions promote learning. Safety mentors’ insights and perceptions promote learning. Recognize that safety culture is local, multidimensional, and still evolving. Recognize that safety culture is local, multidimensional, and still evolving. Sharing data at local and organizational levels can drive improvements. Sharing data at local and organizational levels can drive improvements.

11. 11 Limitations Variety of culture survey instruments utilized. Variety of culture survey instruments utilized. Paper surveys utilized. Paper surveys utilized. Skills and understanding of staff affected data integrity. Skills and understanding of staff affected data integrity. Real time peer-to-peer feedback depended on comfort level of staff. Real time peer-to-peer feedback depended on comfort level of staff. Pace of progress affected by turnover of front line staff who were safety mentors. Pace of progress affected by turnover of front line staff who were safety mentors.

12. 12 Next Steps in Our Journey Enhance “On Boarding” and formalize recognition. Enhance “On Boarding” and formalize recognition. Implement “Fair and Just Culture” concepts. Implement “Fair and Just Culture” concepts. Assess progress using results from 2009 (AHRQ) Hospital Survey on Patient Safety Culture. Assess progress using results from 2009 (AHRQ) Hospital Survey on Patient Safety Culture. Define frequency of measures for future validation of our success. Define frequency of measures for future validation of our success.