Pillars, Principles, Values
THESE experience fewer than anticipated accidents or harm events despite operating in a highly complex and high-risk environment
What are HIGH RELIABILITY ORGANIZATIONS
THIS HRO concept describes why attendance is tracked for EOC rounds.
What is:
Demonstrates Leadership Commitment, culture of safety, continuous process improvement. Accountability is also a key HRO concept. (Any of the above is a right answer)
TRUE or FALSE: During a weekly test of the generators, you discover a malfunctioning breaker that needs to be replaced. This needs to be reported to your Leadership Team as well as the VISN Safety Officer.
What is TRUE?
Insuring all the right people are at the table when designing a new sterile compounding room demonstrates THIS HRO value/principle
What is DEFERENCE TO EXPERTISE,
or RESPECT FOR PEOPLE,
or SENSITIVITY TO OPERATIONS,
or ITS ALL ABOUT THE VETERAN
VHA's true North -- who we serve
What is VETERANS
The HRO principle that means empowering and valuing knowledge and diversity
What is DEFERENCE TO EXPERTISE
Performance of EOC rounds directly relates to patient and staff safety. True or False.
What is TRUE
An EMS (environmental management services) worker discovers an unlocked medication room and a patient standing nearby. This should be entered into the patient safety event reporting system (JPSR). True or False.
What is TRUE
BONUS: How is this a patient safety event?
Developing SOPs (standard operating procedures) or standard work demonstrates THIS
What is STANDARDIZATION
BONUS: Why is standardization important?
According to Directive, THIS person is responsible for ensuring a safe and healthful work environment for all employees, volunteers, and others who perform work under direct supervision of VHA management
What is FACILITY DIRECTOR
The 3 pillars of HROs include all of the following BUT:
1. Culture of Safety
2. Just Culture
3. Continuous Process Improvement
4. Leadership Commitment
What is JUST CULTURE?
While on rounds, you notice that the inner Sally Port door on the locked inpatient mental health ward is not working. You don't recall seeing a work order for this--this is the second time you haven't been notified of this potentially imminent safety hazard. Your response to this situation demonstrates THIS HRO value.
What is DUTY TO SPEAK UP
The time within which the VISN Director must be notified for any work-related employee fatality, amputation, loss of an eye, or inpatient hospitalization of one or more VHA staff or contract employee.
What is WITHIN 8 HOURS
BONUS: What formal reporting for this incident must be done?
After an employee complaint about unsafe working conditions, you complete an investigation and provide your response to the employee. The employee then claims retaliation. The employee is lacking THIS, which likely led to their claim.
What is PSYCHOLOGICAL SAFETY
Our greatest resource
What is OUR STAFF
Instead of finger pointing at WHO, stopping to ask WHY and HOW, as well as getting to the root cause, demonstrate THIS HRO value.
What is RELUCTANCE TO SIMPLIFY
On rounds in the CLC, it is noted that the floors are particularly shiny--they look great. However, one nurse points out that she's had two patient falls in the last two days thought due to the shiny floors. What is the best course of action to take that demonstrates an HRO action:
Compliment the EMS staff for doing a great job on the floors
Meet with EMS staff to ask about the wax recently put on the floors. Is it new/different?
Send an email to the EMS Supervisor to ask if you can attend a huddle next week so you can talk about consequences of floor wax, or changes in product.
What is:
All of the above
Meeting daily amongst a work unit to discuss potential safety hazards, identify situations that require a process improvement, and to discuss staffing or other issues for the day.
What are SAFETY HUDDLES
The Associate Director visits the GEMS manager and asks to be given a tour of the hazardous drug disposal program, to better understand the location of the black bins, their labeling, and chain of custody. This situation demonstrates which HRO concept.
What is:
DEFERENCE TO EXPERTISE
LEADERSHIP COMMITMENT
GEMBA WALK
LEADER ROUNDING
Being good stewards of our financial, human, and equipment resources satisfies THIS group.
What is TAXPAYERS, VETERANS, VACO
PDSA (Plan-Do-Study-Act) is an example of THIS.
What is CONTINUOUS PROCESS IMPROVEMENT
You enter the OR suite to perform rounds and notice a power strip connecting two pieces of anesthesia equipment. The doctor in the room is noted for having an abrasive, non-collegial, and confrontational personality. You use THIS HRO TOOL to inform the physician of the daisy-chaining infraction that must be immediately remedied. Surprisingly, he complies.
What is THE 3 W'S Tool
WHAT I see...
WHAT I'm concerned about...
WHAT I want...
What I see is that there are 2 pieces of equipment connected by a power strip, daisy chained together.
What I'm concerned about is the potential power implications that could result in a bad outcome if they occur during a patient procedure.
What I'd like is for you to reposition the equipment and power supplies so that daisy chaining is not needed.
A biomedical engineering employee is headed to radiology to perform maintenance on the MRI machine. Upon arriving to Zone 4 of the MRI area, only one radiology staff person is present and they are tending to a patient in the CT area. Knowing where he is going, the biomedical staff person decides to not bother the staff person and enters Zone 4 independently and immediately feels a "tug" around his waist. He quickly discovers his belt has metal in the buckle and it is pulling him into the MRI magnet.
What type of reporting must be done for this incident. Choose all that apply.
OSHA notification
Rapid Response
JPSR report
DBRS report
OIG notification
VISN notification
eComp completion
Issue brief
Joint Commission notification
Other
What is:
A dashboard displaying a red-yellow-green status of all facility fire extinguishers, when they are due for inspection and servicing, and their location on the campus is an example of which of the 4 HRO FOUNDATIONAL PRACTICEs.
What is VISUAL MANAGEMENT SYSTEMS
BONUS: What is another example of a visual management system?
Ultimately, we engage in HRO behaviors and practices for WHOM
What is FOR ALL OF US