Learning Systems
The best way to improve patient safety is:
Learn from our mistakes
What industry experiences much higher rates of worker injury?
Healthcare experiences more worker injuries than manufacturing, construction, rail transportation, and nuclear power.
What are some examples of Tactics to Improve the Care Experience?
Hourly Patient Rounding, Huddles, Service Recovery Program, Post Discharge Phone Calls, Promotion of Team, and Bedside Shift Report
What are some feelings patients want to have about their treatment in a high reliability organization?
They want caregivers to minimize their suffering, address their clinical needs, return them to health or slow its decline.
What happens everyday at 0900?
Safety Huddle where we review the days since serious safety events and workplace injuries and share safety stories and a good catch.
Two Major Components of Learning Systems
1. Root Cause Analysis
2. Daily Leader Practices such as Learning Boards/Huddles
What are the cumulative organizational costs due to Employee Injuries?
Workers Compensation costs, Turnover costs, cost of overtime to replace workers who are injured and productivity losses.
What is a good 1st step for organizations to have High Reliability?
Organizations should be more transparent about their goals, initiatives, activities, and performance so that leaders may begin to identify areas of redundancy and areas of alignment.
What are some additional feelings that patients want to have about a HRO?
The care they receive will be safe and free from harm that could worsen their condition and hope they encounter a compassionate environment that supports their healing rather than one that has innefficiencies that could compound their suffering.
HRO's should invest in what type of training for leaders?
NWTHS invested in this training to train leaders around high reliability principles, safety science, process improvement methodology, and cause analysis.
What is the Goal of Learning Systems?
Allow Organizations to Monitor performance so they can improve care delivery and respond quickly to safety lapses.
What are the 4 Components of a Workforce Safety Management System?
Commitment, Culture, Safety Promotion, and Local Learning
What is a good 2nd step for organizations to have High Reliability?
Adopt a set of shared metrics and goals that include key measures of safety, quality, experience of care, and engagement. Such metrics drive collaborative performance while also reinforcing a set of shared principles.
HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems
HRO's adopt what specific methodology to conduct cause analysis?
Risk regularly conducts RCA's (Root Cause Analysis) to determin system and process issues not to assign blame.
First 5 Components of Effective Learning Systems
Harm Measures, Injury Measures, Culture Measures, Climate Measures, Engagement Measures
What are some key training elements of Workforce Safety?
Deescalation Training, Self-Defense, Safe Patient Handling, Practices for using safety equipment (Needle Safety, PPE, Etc.)
What is the HEART acronym for Nursing Practice?
Holistic, Evidence-based practice and research, Advocates, Resourcefulness, and Teamwork. HEART allowed nurses to tie improvement efforts back to their own professional goals and desired outcomes.
Difference between Patient Satisfaction and Patient Experience
Pt SATISFACTION is the emotional assessment of the care they received. Pt EXPERIENCE addresses everything that directly or indirectly affects patients across the continuum of care, including relief of their suffering, physical discomfort, and anxiety
How do HRO's deal with workplace injuries?
We adopted a fair and just culture where workers feel safe to report hazards or injuries without feel of repercussion.
Last 5 Components of Effective Learning Systems
Cause Analysis, Common Cause Analysis, Self-Assessment, Independent Assessment, Operating Experience
How does Just Culture apply to workforce safety?
Without a fair and just culture, worker won't feel safe to report hazards or injuries for fear of repercussion.
For a Highly Reliable Organization to improve patient experience, organizations must address what two classes of suffering?
Inherent Suffering and Avoidable Suffering. Efforts should focus on mitigating or reducing the impact of inherent suffering and on preventing avoidable suffering.
What are the Compassionate Connected Care Model's 4 key elements of optimum care to meet patient needs?
Culture, Clinical Excellence, Caring Behaviors, and Operational Efficiency
What key elements of training do we have for Hazard Prevention?
Deescalation training, safe patient handling programs, and practices for using safety equipment.