2011 Areas for Improvement %60% %52%

Commitment to Patient Safety Commitment to Patient Safety Pullman Regional Hospital is committed to creating and sustaining a work environment where patient safety is consistently a top priority. This environment demonstrates a commitment to designing policies and processes to prevent errors, providing appropriate numbers of qualified staff, encourage event reporting, learning from errors, and commitment to continuous improvement. This environment of patient safety is demonstrated by these core principles: A safe reporting environment Individual Responsibility Leadership responsibility Appropriately understanding errors and effectively responding Timely and Effective response in the event of a significant error

Commitment to Patient Safety Pullman Regional Hospital is committed to creating and sustaining a work environment where patient safety is consistently a top priority. This environment demonstrates a commitment to designing policies and processes to prevent errors, providing appropriate numbers of qualified staff, encourage event reporting, learning from errors, and commitment to continuous improvement. This environment of patient safety is demonstrated by these core principles: A safe reporting environment – Staff feel safe to report when a near-miss or an error occurs The emphasis will be on learning from the error rather than assigning blame The focus will be primarily on improving processes and systems to prevent errors The outcome of the error does not determine the level of investigation, intervention, or disciplinary action Individual Responsibility – Each staff member is expected, regardless of role or title, to maintain patient safety standards and approach others when there is a question of patient safety. – Each staff member is responsible to consistently: follow safety policies and procedures, address safety issues immediately, communicate appropriately system flaws, near-misses, and errors Leadership responsibility – Leadership is responsible to: Role-model patient safety Design, implement, and evaluate safety practices and systems Educate and encourage staff to utilize patient safety practices Investigate all reported issues and improve processes and systems when they are found to be ineffective Set clear expectations for the use of patient safety systems Appropriately understanding errors and effectively responding – When an error occurs, there is a commitment to distinguish between systems errors and human errors and deal with each appropriately. – When dealing with human errors, leaders consistently utilize the following: Differentiate human error, at-risk behavior, and reckless behavior Appropriately utilize coaching, consoling, counseling, or discipline as a part of the Accountable Discipline process Maintain respect and privacy as much as possible for the affected individuals – When dealing with systems’ errors leaders will utilize continuous improvement skills and involve staff to make the appropriate improvements Timely and Effective response in the event of a significant error – When a significant error occurs, we consistently and immediately respond to take care of the patient and/or involved staff Reassign the staff involved to non-direct patient care duties for the remainder of the shift (recognizing they have been involved in a situation that may affect their ability to perform at their normal capabilities) Provide support appropriate to the employees’ needs

Just Culture Human ErrorAt-Risk BehaviorReckless Behavior Inadvertently doing other than what should have been done; a lapse in judgment or a mistake A choice that increases risk where risk is not recognized or is mistakenly believed to be justified Intentional risk-taking conscious disregard of a substantial or unjustified risk Manage through changes in: Processes Procedures Design Environment Manage through: Remove incentives for At-risk behavior Create incentives for healthy behaviors Increase situational awareness Manage through: Remedial Action Disciplinary Action Console Assist with making better choices, consider system redesign Educate Performance Improvement Coach Remove barriers to compliance with rule and procedures Promote incentives to desired behaviors Performance Improvement or Reminder 1 or 2 Discipline Demonstrate intolerance for reckless choices Reminder 2 Day of Decision Termination

Error investigation algorithm Was it the employee’s purpose to cause harm Given this, should the employee have known that they were taking a substantial and unjustifiable risk? Human Error Console Educate Make Systems changes Reckless Behavior Discipline appropriately Was the harm justified as the lesser of two evils? At-risk behavior Coach employee Remove systems’ barriers Did the behavior represent a substantial and unjustifiable risk Did the employee consciously disregard the substantial and unjustifiable risk Did the employee knowingly cause harm Did the employee choose the behavior? Yes No At-risk behavior Coach employee Remove systems’ barriers Human Error Console Educate Make Systems changes At-risk behavior Educate employee Remove systems’ barriers Human Error Console Educate Make Systems changes Human Error Console Educate Make Systems changes