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Resources

Tools to Enhance your "Culture of Safety"

STRATEGIES FOR LEADERSHIP: A TOOLKIT FOR IMPROVING PATIENT SAFETY

During the past two years, the AHA has encouraged hospitals and health systems to develop a culture of safety - a culture that focuses on actively evaluating all aspects of care delivery in an effort to prevent errors. As part of the AHA's continuing efforts to improve patient safety, we've teamed up with the Department of Veterans Affairs National Center for Patient Safety (VA NCPS) to offer hospitals the Strategies for Leadership A Toolkit for Improving Patient Safety. Developed by the VA NCPS, these are tools you can use to identify where errors can occur in the delivery of care and help you take corrective steps to avoid patient harm.

The Strategies for Leadership A Toolkit for Improving Patient Safety effectively does just that. The toolkit's focus is on helping hospitals prioritize and systematically evaluate aspects of care delivery that may be at high-risk for causing patient harm or have been associated with an adverse event or close call. The VA NCPS tools are based on more than 30 years of research in the aviation, aerospace and nuclear power fields, and are used in all 163 of the VA's health care facilities. These tools will help you conduct proactive risk assessments and root causes analyses.

The toolkit includes an instructional video and CD-ROM and workbooks with case examples and worksheets. In addition, to help you with the difficult tasks during a root cause analysis, there's a set of triage cards outlining all the key questions that need to be asked during such an analysis.

Because improving patient safety is a top priority for America's hospitals, the AHA will continue to share with hospitals and health systems a variety of tools and resources to help you in your quest for improving quality.

MORE INFORMATION ON THE PATIENT SAFETY TOOLKIT
Developed by the VA NCPS, the patient safety toolkit are tools you can use to identify where errors can occur in the delivery of care and help you take corrective steps to avoid patient harm. These tools are to be used in two ways: prospectively - before harm might occur, and retrospectively - after a close call or harm occurs.

Proactive Risk Assessment. The VA-developed Healthcare Failure Mode and Effect Analysis (HFMEA™) looks at a process, identifies where errors may occur and takes steps to eliminate or minimize future occurrences. The video, "Basics of Healthcare Failure Mode and Effects Analysis™," explains the five-step HFMEA™ process. When performed properly, HFMEA™ meets the JCAHO Hospital Accreditation Manual leadership standard LD.5.2. In addition to the video, the toolkit includes a workbook featuring worksheets and diagrams to help your team prioritize potential risks to patients and assess interventions.

Root Cause Analysis. Since the advent of the JCAHO Sentinel Event Policy, hospitals have been doing a root cause analysis (RCA) when specific adverse events have occurred. However, there are many questions regarding those instances where an RCA is not required. How does a hospital decide whether an event or close call warrants an RCA? Which event or close call should be targeted by a hospital as an immediate priority? How can a hospital ensure that it has addressed all of the relevant factors in an RCA?

To address these questions, the VA NCPS created two tools. The Safety Assessment Code (SAC) Matrix helps hospitals prioritize adverse events and close calls based on both actual and potential outcomes. Incidents are assigned a severity category (catastrophic, major, moderate or minor) and a probability category (frequent, occasional, uncommon or remote). The resulting SAC score determines which incidents require a root cause analysis, thereby assisting hospitals in appropriately allocating patient safety resources.

The second tool, VA NCPS Triage Cards™, helps hospitals effectively deal with difficult tasks during an RCA. The cards are a series of questions that prompt your team to identify human factors and systems issues that may have contributed to a close call or adverse event. The cards will also prompt the team to answer three questions: What happened? Why did it happen? and What do we do to prevent it from happening in the future?

The toolkit contains an instructional video on HFMEA™, a training CD-ROM for the SAC matrix and triage cards, a set of VA NCPS Triage Cards™ and workbooks for HFMEA™ and SAC.

The Strategies For Leadership Toolkit for Improving Patient Safety

Item # 166926 $350 (AHA members pay $200)

If you wish to purchase a supply of the VA NCPS Triage Cards™, contact the Chesapeake Health Education Program at dcannon@chepinc.org.

VA NCPS Triage Cards™, bundles of 15 cards and a triage card training CD-ROM -- $250
Bundles of 30 and 3 triage card training CD-ROMs -- $450

Several tools have been developed for you as part of the AHA's Improving Patient Safety initiative.

Strategies for Leadership: An Organizational Approach to Patient Safety - This tool, developed by Nancy Wilson, MD, at VHA, Inc., provides a systematic method to evaluate current processes and systems and to measure ongoing progress in establishing a safer organization. The Malcolm Baldrige National Quality Program categories are used as the framework within which to identify critical safety functions. It was mailed to all chief executive officers in May 2001. Additional copies can be ordered in groups of ten ($15 for AHA members; $30 for non-members) through AHA Order Services (800-242-2626; order #166925).

Click here to download this tool as a PDF file.

Strategies for Leadership: Hospital Executives and Their Role in Patient Safety
This tool was developed by James B. Conway, chief operations officer at the Dana-Farber Cancer institute in Boston, MA. It was developed specifically for executives' personal use and reflection on their efforts to develop a culture of safety. It was mailed to all chief executive officers in early March 2001. Additional copies can be ordered in groups of ten ($10 for AHA members; $20 for non-members) through AHA Order Services (800-242-2626; order #166924).

Click here to download this tool as a PDF file.

ADDITIONAL RESOURCES

Institute for Healthcare Improvement

Let's Talk: Communicating Risk and Safety in Health Care
This conference was held in May 2000 in St. Paul Minnesota and was built on the highly successful 1996 and 1998 Annenberg conferences on patient safety, held at the Annenberg Center for Health Sciences in Rancho Mirage, California. These conferences were seminal events in the genesis of the study of patient safety, and marked the beginning of the widespread recognition that health care error must be recognized and reduced. For conference summaries, highlights, and tape ordering information, visit www.mederrors.org.

Elements of a Culture of Safety: Patient Safety is Our Top Priority
Pennsylvania Patient Safety Collaborative

Click here to downloadable this PDF file.

MHHP Patient Safety brochure, Redefining the Culture for Patient Safety
The Minnesota Hospital and Healthcare Partnership (MHHP) has produced a patient safety brochure, Redefining the Culture for Patient Safety. This brochure has been enthusiastically received by hospitals and promises to be a useful tool for hospitals throughout the country. It describes the main concepts of how accidents occur, and how by changing our language, we can help create a culture where accidents are discussed and analyzed openly, objectively and honestly, without fear of blame or personal retribution. Brochures are 10 cents each, plus shipping and handling, and quantities are available in groups of 100 only. To order, contact Johni Johnston at MHHP, (651) 641-1121; or jjohnston@mhhp.com

ISMP Medication Safety Contest Winners
Congratulations to the winners of the ISMP Medication Safety Contest, which calls for entries in four medication safety categories:

  • a job description for a medication safety practitioner; Covenant Health Systems in Lubbock, TX, submitted the winning entry for a medication safety nurse specialist job description.
  • a policy for a non-punitive, system-based error reporting program; Frederick Memorial Hospital in Frederick, MD, sent in the winning entry for a non-punitive reporting program.
  • a medication safety exam or program for new staff; Allina Hospitals and Clinics in Minneapolis, MN, won for their entry of a medication safety orientation program.
  • and a survey to solicit information about the culture of reporting. Allina Hospitals and Clinics also submitted the winning entry for a patient safety culture assessment.

Visit www.ismp.org for more information.

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