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Engagement and Empowerment of Frontline Staff to Promote a Culture of Safety: A Safety Champion Program

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Title: Engagement and Empowerment of Frontline Staff to Promote a Culture of Safety: A Safety Champion Program


1
Engagement and Empowerment of Frontline Staff to
Promote a Culture of Safety A Safety Champion
Program
  • Jeanette Tanafranca, MSN, RN-BC
  • Safety Champion

2
Why do we need a Safety Champion program?
  • Health care is not safe.
  • During this 20 minute presentation
  • 5 7 patients across the U.S. will die due to
    medical error or infections
  • 85 113 patients will be hurt
  • 21 29 employees will experience a needle-stick
    injury

Improving Healthcare Using Toyota Lean Production
Methods R. Chalice, 2007Levinson, D. R. (2008).
Adverse events in hospitals overview of key
issues. Department of Health and Human Services,
Office of Inspector General. Retrieved at
http//oig.hhs.gov/oei/reports/oei-06-07-00470.pdf
IOM (1999). To err is human building a safer
health system. Retrieved at http//www.iom.edu/
Object.File/Master/4/117/ToErr-8pager.pdf Kohn,
L.T., Corrigan, J.M., and Donaldson, M.S. (Eds).
(2000). To err is human building a safer
health system. Committee on Quality of
Healthcare in America. Washington, DC National
Academy Press.
3

H A R M 50
  • Identify Top Causes of Harm
  • Enhance our Culture of Safety
  • 3. Improve the Quality and Clarity of Clinical
    Communications
  • 4. Redesign Care To Eliminate Harm

4
No Harm Campaign Extended 3 more years
5

Enhancing our Culture of Safety
Formal Team Training
Safety Champions
  • Safety Culture Global Indicators
  • Organizational commitment
  • Management Involvement
  • Employee Empowerment
  • Reward Systems (Just Culture)
  • Reporting Systems
  • HFHS Added
  • Partnerships with Patients and Families

Build Local Structure
Create Safe Environments
Establish a Common Language
HFHS Culture of Safety Building Blocks
Wiegmann, D.A., Zhang, H., von Thaden, T.,
Sharma, G. and Mitchell, A. (2002). A synthesis
of safety culture and safety climate research
(Technical Report ARL-02-3/FAA-02-2). Savoy, IL
Aviation Research Lab Institute of Aviation.
6
Impact of Safety Champion Program
7
Safety Champ vs. No Safety ChampCOS Engagement
Scores
  • Units with Safety Champions showed improvement
    for all
  • safety questions and engagement questions
    compared to units
  • without safety champions.

0.1 improvement meaningful 0.2 improvement
statistically significant
8
Safety Champion Program
  • Coming together is a beginning
  • Keeping together is progress
  • Working together is success.

Henry Ford
9
Program Objectives
  • To develop a network of multidisciplinary
    front-line safety experts
  • Create error wisdom at the front line
  • Support HFHS core values for patient safety and
    the No Harm Campaign build a culture of safety

First Safety Champions 6/2008
10
Who are Safety Champions?
  • Front line, multidisciplinary employees that act
    as a Voice and Face of Safety.
  • Have a genuine interest in safety
  • Model safe practices
  • Model HFHS Core Values for Patient Safety
  • Respected by peers
  • Are willing and able to communicate information
    (i.e. patient safety goals, personal safe
    practices, reporting) at department
    meetings/briefings/huddles
  • Are willing to embrace a leadership opportunity
  • Create a ripple effect

11
Conceptual Framework
  • Adapted from Dr. Patricia Benners Stages of
    Clinical Competence

12
Safety Champion Program
Program Start June, 2008
13
Human factors research has shown that even highly
skilled, motivated professionals are vulnerable
to error due to inherent human limitations
really good people will make mistakes
14
Which is the One Cent U.S. Coin?
Memory- we generally store only partial
descriptions of things to be remembered,
descriptions that are sufficiently precise to
work at the time something is learned but may not
work later on when new experiences are
encountered.
A Simple Example of the Limits of Memory
Image Sourcehttp//www.dcity.org/braingames/penni
es/
15
Safety Champion Program
16
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17
Safety Champion Program
18
Sharing Learning
  • Quarterly Forums Identify top causes of harm,
    Culture of Safety, Just Culture,Error Reporting
    Error Prevention, Speak Up, Speak Out Creating
    Safe Environments, Getting LEAN with Hand
    Hygiene, Healthcare Equity and Culturally
    Competent care, Emergency Preparedness and
    Patient Safety.
  • 2 Minute Tutorials How Tos
  • Great Catch Stories

19
Safety Champion Program
20
Process Improvement
2 patient identifier projects Revised SBAR form for patient hand-offs Selecting equipment for hospital Post-fall management program Handicapped parking assistance Bladder health and collaborative project Handwashing projects Medication review process Mammogram process review Medication dispensing projects A3s-Needlestick prevention More..
  • Accurate and Voluntary reporting through our
    reporting system.
  • Project survey.

21
HF West BloomfieldImpact of Safety Champion
Program
  • Safety Champions reviewed employee injury data
    and identified that lift injuries are in the top
    3 (2010-2011).
  • Conducted a survey that employees stated that
    lifts were a number one concern of what injury
    they felt would happen in their area.
  • Conducted A3s on sharp containers and the
    inappropriate use of biohazard bags.   
  • An EOC audit showed a spike in finding the
    biohazard bags used inappropriately
  • SC Team conducted additional education and weekly

22
HFH Inpatient PharmacyImpact of Safety Champion
Program
  • Process 7,000 medications orders per day
  • Dispense 17,000 medication doses per day
  • Recognize human limitations and have made 49
    system improvements since joining the program

23
Safety Champion Program
24
Safety Champion Successes
  • 378 Safety Champions (multidiscplinary, multiple
    business units)
  • 100 would recommend program
  • gt95 favorable with class and forum surveys
  • 95 share toolkits and newsletters
  • 88 believe they have made an impact on the
    culture of safety for their units
  • 80 participate in safety improvement work

25
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26
I am a Safety Champion because I do my best to
live the Henry Ford Experience of caring about
people by helping to make sure they are safe,on
a daily basis..Ruth
Patient Safety means......" putting forth a
conscience effort to protect our patients and
employees by minimizing risk  and adhering to all
set standards while providing the highest quality
care in the safest work environment possible!!!!
 Dawn Dombek-Bailey, CHSP
Safety Champions Can and Do Make a Difference in
Patient Safety by Being Proactive, Minimizing
Risk, Creating Safe Environments Because its
Important to the Lives of ALL.
-HFHS Safety Champions
I make a difference in the lives of all persons
who enter HFHS properties.  MaryAnn L. Northcote,
CPP, CHSP
I am a safety champion because I want to
be proactive in spreading wellness to individuals
that are in my reach.  Injury prevention is a key
component in helping our loved ones and others in
our community stay safe and healthy..Katie Horn
 
Patient Safety means.delivering the highest
quality care that is reliable and coordinated for
the patients we serve each day..Judy
Caretti-Rourke
I am a Safety Champion because......the
environment I work in and the people I serve are
important to me LesaBorden Sanford RN, BSN  
I make a difference to everyone that comes in
contact with me in the Henry Ford Health
system..Latonya Phillips
I am a safety champion because I CAN and DO make
a difference one person at a time". Stephanie B.
Anderson, RN, MSN
Patient Safety means being pro-active in creating
and maintaining safe environments for our
patients who depend on us when they are most
vulnerable.  Judy Czerepowicz, CHSP
27
Thank You to all of the HFHS Safety Champions for
making a difference.
28
Contact Information
  • Jeanette Tanafranca, MSN, RN-BC
  • Office of Clinical Quality and Safety
  • One Ford Place, Detroit, MI 48202
  • 313.874.7181
  • jtanafr1_at_hfhs.org
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