AHRQ Tools and Resources to Prevent HAIs.

In early September, the AHRQ released a webpage highlighting research and resources related to the prevention of hospital acquired infections. This is an excellent site that links to tools and resources for both healthcare providers as well as healthcare consumers.

You can find the website here.

ThedaCare - "No Medication Errors in 2 years"??? via Lean

Fox News in Wisconsin recently interviewed the CEO of ThedaCare and discussed their Lean journey.

http://www.foxnews.com/search-results/m/25995300/what-is-thedacare.htm#q=thedacare

http://www.foxnews.com/search-results/m/25995305/what-works-what-doesn-t.htm#q=thedacare

http://www.foxnews.com/search-results/m/25995515/collaborative-care.htm#q=thedacare

Specifically, in these videos, you will hear the CEO talk about the Lean tools, the control boards, the improvement methodology, and the fact that their staff are empowered to solve the problems themselves rather than wait for a manager to solve the problem for them.

...a very interesting discussion.

Joint Commission issues Sentinel Event Alert Regarding Leadership

On 8-27-09, the Joint Commission released a Sentinel Event Alert regarding leadership and its commitment to safety.

You can find the entire alert here.
The press release can be found here.

Within the alert are 14 recommendations for the governing body, CEO, and senior managers:

1. Define and establish an organization-wide safety culture that includes a code of conduct for all employees, including contract workers.
2. Institute an organization-wide policy of transparency that sheds light on all adverse events and patient safety issues within the organization, thereby creating an environment where it is safe for everyone to talk about real and potential organizational vulnerabilities and to support each other in an effort to report vulnerabilities and failures without fear of reprisal.
3. Make the organization’s overall safety performance a key, measurable part of the evaluation of the CEO and all leadership.
4. Ensure that caregivers involved in adverse events receive attention that is just, respectful, compassionate, supportive and timely. Also, make sure they have the opportunity to fully participate in the investigation, risk identification and mitigation activities that will prevent future adverse events.
5. Create and communicate a policy that defines behaviors that are to be referred for disciplinary action; include the timeframe that the disciplinary action should take place.
6. Regularly monitor and analyze adverse events and close calls quantitatively and communicate findings and recommendations to leadership, the board and staff. Conduct root cause analyses of adverse events. Look for patterns in root causes that identify latent hazards and weaknesses in the defenses against errors—the holes in the slices of cheese—and make sure they are addressed.
7. Regularly hold open discussions with risk management, performance improvement, physician, nursing and pharmacy leaders, and with physicians and staff caring for patients, to develop a true, unvarnished view of the safety risks and barriers to safety facing patients and staff. Patient safety rounds at the point of care could provide the ideal opportunity for these discussions, which should focus on learning and improvement, not blame or retribution.
8. Prioritize and address safety risks and barriers to safety according to a timeline, with the highest priority items getting immediate attention. Make a visible commitment of time and money to improve the systems and processes needed to defend against hazards and minimize unsafe acts. For example, some organizations create an emergency patient safety fund.
9. Establish partnerships with physicians and align their incentives to improving safety and using evidence-based medicine.
10. Add a human element and a sense of urgency to safety improvement by having patients communicate their experiences and perceptions to board members, executive leadership, medical staff, and other key leadership groups; also solicit patient input into safety design.
11. When planning and implementing safety improvements, use the expertise of front-line staff who understand the risks to patients and how processes really work.
12. Regularly measure leadership’s commitment to safety using climate surveys and upward appraisal techniques (in which staff review or appraise their managers and leaders).
13. When leaders assess managers during the annual performance review, make sure they ask about the safety issues the manager encountered, how they were handled, and the impact their actions had on reducing unsafe conditions.
14. Communicate to staff when their work improves safety. Reward and recognize those whose efforts contribute to safety.

Personal Opinion: Although senior leadership has the responsibility for creating a structure that is conducive to improving patient safety, senior leadership is also the least effective group to actually improve patient safety. It is the bedside staff that can impact patient safety the most - if allowed to by senior leadership. Maybe this list should have included more recommendations for senior leadership to empower the bedside staff to proactively assess and redesign their work flow to minimize risk factors?