Working Toward A Safer Culture For All Patients

This week I invited Carolyn Candiello, Vice President, Quality and Patient Safety, to write a guest blog post highlighting the organization's upcoming Safety Attitude Survey.

We all heard over and over in this most recent election about the importance of getting out to vote!   Next week we will begin our second annual Safety Attitude Survey.  I am very excited about this year’s survey and am looking forward to learning how we can continue to improve our safety culture.  I am also interested to see if our scores reflect the good work our staff has done over the past 18 months to reduce serious safety events and infections.     I hope everyone in our patient care units will take the time to “vote”!

When we conducted our survey last year, we learned that in those units with the lowest perception of teamwork there was a higher incidence of patient harm. We also learned that nurses and doctors working on the same unit can have a different perspective of patient safety and teamwork.  We learned that some of our staff felt that it was not easy to talk about errors and that we didn’t always address behaviors fairly.

Christina Welch, Clinical Unit Coordinator of Unit 58,
demonstrates the Quantos reporting tool.

In response to the survey, each unit reviewed their findings and implemented action plans aimed at specific improvement.    In addition, we initiated several organization-wide changes.   For example, our survey revealed that we did not have a good mechanism to report safety events. Since the survey, we have implemented our on-line incident reporting tool, Quantros, which allows for ease of reporting.  The increase in reporting and the quality of the reporting has allowed us to identify trends that block holes in our system.  The Quantros tool is located on the InfoWeb - look for the Patient Safety button on the homepage.  As a reminder, staff should report any incidence of patient harm, near misses or unreliable care. 

Quantos reporting on the InfoWeb

We also heard that it was difficult to discuss errors and there was inconsistency in our responses. We have since adopted a philosophy of a Just Culture were we console human error, coach at risk behavior and appropriately discipline reckless behavior.  We also continue to learn from our errors and share our learning throughout the organization.  Staff are involved in root cause analysis and participate in identifying permanent solutions to prevent an error from re-occurring.

A great example of learning from our experiences has been in our efforts to reduce falls.  Earlier this year, we noticed an increase in patient falls.   In response, a a multi-disciplinary improvement team  was appointed whose aim is to reduce falls and prevent injury.    So far, we have seen significant improvement (see the FY2013 system goals).    But also, we are seeing a culture change.  Units are measuring the time between falls.  Now, when a fall occurs, everyone takes notice.   The team does a post-fall huddle and looks for ways to prevent a similar occurrence.    Having everyone engaged and in action to prevent falls is powerful.

The Safety Attitude Survey will be conducted across all patient care units within the organization.  This is a confidential survey that focuses specifically on staff perception of clinical safety in their unique work setting.  The 33 questions focus on teamwork, safety, leadership, stress, working conditions, and learning.   While some of the questions are similar to the employee opinion survey, this questionnaire is designed to provide direct feedback around the clinical safety climate.  Responses to the survey are completely confidential and will be processed electronically by Pascal Metrics.

Staff who will participate in the survey will receive a  “token” and a link for the survey from their manager—this will be a similar process to the employee opinion survey.  Gilchrist Hospice employees will receive a paper survey.  Results of the survey will be shared throughout the organization in early 2013.  I look forward to sharing them with you and seeing where we have made improvements since last year.

When you receive the token or paper survey, please take the time to “vote”—our patient’s safety depends on it.