Leadership Commitment
Provides leaders and the organization a pulse of the where we are with the Journey to HRO, opens communication between the frontline and leadership, contributes to a just culture, positively impacts employee morale and provides opportunity for recognition.
What is Leader Rounding?
The centralized electronic reporting system that is used by all VA employees to report near misses, good catches, and adverse events.
What is JPSR?
A simple test of change
What is a PDSA?
What is "Zero Harm"?
The individual responsible for reporting safety events, good catches or near misses in JPSR.
Who is everyone?
The #1 indicator of project success
What is an active and engaged sponsor?
The first question asked when an error or adverse event is reported instead of asking “who did it”
What is "what happened"?
The daily practice that can be used to identify problems or opportunities at the front line.
What is a safety huddle?
These are shared at the start of every meeting and highlight HRO Principles and Values through the sharing of a real life event.
What is a Safety Story?
It is defined as a slow and insidious deviation from an intended course or “normalized deviance”.
What is Drift?
The just culture response to console the parties involved and review the system for improvement to prevent future errors.
What is a leader's response to human error?
An atmosphere of trust where people are encouraged for providing essential safety-related information.
What is a Just Culture?
A simple tool for improvement that helps you uncover issues to get to the bottom of a situation.
The HRO Principle that gets to the root cause of a problem rather than settling for simple explanations.
What is reluctance to simplify?
What I see…What I’m concerned about…What I want
What are the 3Ws (Stop the Line)
The strategy used by leaders in a just culture to help make decisions about possible disciplinary action after an adverse event.
What is a risk-based strategy?
This practice provides an opportunity to communicate patient safety goals, establish a just culture and reinforce the importance and appreciation of reporting.
What are Safety Forums?
A tool that provides a venue for teams to problem solve and have clear active and visual communications about process concerns.
What is a Visual Management System?
Leader Rounding, Safety Huddles, Patient Safety Forums and Visual Management Systems
What are the Four Foundational HRO Practices?
An employee makes a potentially unsafe choice. Faulty or self-serving decision making may be evident, or short cuts or routine rule violations.
What is "At Risk Behavior"?
The step on the Decision Support Tool that asks "would 3 other employees with similar skills and knowledge do the same thing in similar circumstances?"
what is Step 2?
Focused daily meetings where teams identify, report and prioritize potential risks of the day and review past events for action, closure and learning.
What are safety huddles?
VAs improvement framework that focuses on eliminating waste and using data to drive improvement
What is Lean Six Sigma?
The HRO Value that says whenever we make a decision we should ask, “What does this have to do with helping a Veteran”?
What is “It’s About the Veteran”?
A model of accident causation that identifies layers of security or defenses used in risk analysis and risk management.
What is the swiss cheese model?