Culture of Safety Survey Safety culture is the product of individual and group beliefs values attitudes perceptions competencies and patterns of behavior that determine an organizations commitment to quality and patient safety ID: 682702
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Culture of Safety
Colquitt Regional Medical CenterSlide2
Culture of Safety Survey
“Safety culture is the product of individual and group beliefs, values, attitudes, perceptions, competencies and patterns of behavior that determine an organizations commitment to quality and patient safety.”
-The Joint CommissionSlide3
Culture of Safety Survey
Safety Survey is completed every 3 years
Most recent survey- May 2016
Survey was done in conjunction with Employee Engagement survey throughSlide4Slide5
Culture of Safety
“Exceptional” Areas of PerformanceSlide6
90% Positive Responses
6
th
consecutive Leapfrog “A”Hospitalist program genuinely committed to improving patient outcomes
Rated 4 star by CMS for HCAHPS
JC accredited Total Joint Replacement Program
CAP accredited Laboratory
CACR in CT, MR, Mammogram and PET/CT
ICANL in Nuclear Cardiology
ICAEL in Echocardiography
This organization provides high-quality care and service.Slide7
91% Positive Responses
Non-punitive error reporting
“Just Culture”
A process that recognizes that human error and faulty systems can cause a mistake, and encourages an investigation of what led to the error instead of an immediate rush to blame a person.
Event reporting system offering multiple reports, including anonymity
High compliance rates with barcode scanning
Communication & Compliance with JC NPSG
This organization makes every effort to deliver safe, error-free care to patients.Slide8
90% Positive Responses
EMR upgrade to
Meditech
6.1 and optimizationRobust fall programRounding from bedside to Administration
Bedside shift reporting to increase transparency of care
Leadership commitment to safety
We are actively doing things to improve patient safety.Slide9
90% Positive Responses
Open
discussion about
errorsStaff Nurse Advisory Council(SNAC) facilitates changes in nursing care
National Database Nursing Quality Indicators(NDNQI) participation with unit level results
Performance Improvement projects used to correct errors.
In my work unit, we discuss ways to prevent errors from happening again.Slide10
Culture of Safety
Areas of
OpportunitySlide11
69% Positive Responses
Plans to implement SBAR for communication
Staff Nurse Advisory Council(SNAC) with multidisciplinary representation
Communication between work units is effective in this organization.Slide12
37% Positive Responses
Encourage healthy lifestyles
Personal trainer available on units to take a 5 minute fitness break to de-stress
Rounding on staff by directors to identify problems and work towards solutions
The amount of job stress I feel is reasonable.Slide13
45% Positive Responses
Innovative schedules and benefits
Onsite interviews with nursing students to offer positions on site to increase workforce
Seeking to expand and improve the nurse extern program
Optimizing use of technology to facilitate efficiency
My work unit is adequately staffed.Slide14
57% Positive Responses
Open door policy throughout the organization
CEO forum/birthday celebrations monthly with input from employees actively solicited and acted upon.
Senior leader rounding on units to engage staff
Employee rounding by directors quarterly
Employees feel free to question the decisions or actions of those with more authority.Slide15
Culture of Safety Survey
At Colquitt Regional we are committed to
a culture
of safety. This commitment establishes a "culture of safety" that encompasses these key features
:
acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations
a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
organizational commitment of resources to address safety concerns Slide16
QAPI Data
UpdateSlide17
What is QAPI?
Quality assurance
is the specification of standards for quality of service and outcomes, and a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is
on-going and helps to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards.
Performance improvement
(also called Quality Improvement - QI) is the continuous study and improvement of processes with the intent to better services or outcomes, and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement
.
PI can make good quality even better.Slide18
Organizational Wide Indicators
Patient Flow
Readmissions
Hand hygienePatient ExperienceAiming for Zero HarmInfection Prevention
Surgical Site Infections, MRSA, CAUTI, CLABSISlide19
Departmental Indicators
Each department has department specific indicators. These are performance improvement projects that are specific to your department such as food temperatures in dietary, cleanliness in environmental services, LWBS in ED or distance of ambulation on 5
th
floor.
Know at least one of your departments indicatorsSlide20
Hand Hygiene
The single most effective means to prevent infections in the healthcare setting.Slide21
5 Moments for Hand Hygiene
Before patient contact
Before aseptic task
After body fluid exposure riskAfter patient contactAfter contact with patient surroundings
*remember before and after PPE removalSlide22
Hand Gel Versus Soap & Water
Gel for routine procedures
Gel in, gel out
Gel for episodes of careGel after removal of PPESoap & Water when hands are visibly soiled
Soap & Water after personal use of the toilet
Soap & Water before eating
Soap & Water when caring for C-diff patients
Soap & water after several gel applicationsSlide23
Hand Hygiene
Hand Gel- Once dispensed from applicator, rub in until completely dry
Soap & Water- Wash hands for 20 seconds
Sing the “Happy Birthday Song”