1. 1 © 2010 TMIT NQF-Endorsed ® Safe Practices for Better Healthcare Safe Practice 1 Culture of Safety Leadership Structures and Systems Chapter 2: Improving Patient Safety by Creating and Sustaining a Culture of Safety

2. © 2006 HCC, Inc. CD000000-0000XX 2 © 2010 TMIT Slide Deck Overview Slide Set Includes:  Section 1: NQF-Endorsed ® Safe Practices for Better Healthcare Overview  Section 2: Harmonization Partners  Section 3:The Problem  Section 4: Practice Specifications  Section 5: Example Implementation Approaches  Section 6: Front-line Resources

3. 3 © 2010 TMIT NQF-Endorsed ® Safe Practices for Better Healthcare Overview Safe Practice 1 Culture of Safety Leadership Structures and Systems Chapter 2: Improving Patient Safety by Creating and Sustaining a Culture of Safety

4. 4 © 2010 TMIT 2010 NQF Safe Practices for Better Healthcare: A Consensus Report 34 Safe Practices Criteria for Inclusion Specificity Benefit Evidence of Effectiveness Generalization Readiness

5. 5 © 2010 TMIT Culture SP 1 2010 NQF Report

6. CHAPTER 7: Healthcare-Associated Infections Hand Hygiene Influenza Prevention Central Line-Associated Blood Stream Infection Prevention Surgical-Site Infection Prevention Daily Care of the Ventilated Patient MDRO Prevention Catheter-Associated UTI Prevention Information Management and Continuity of Care Medication Management Healthcare-Associated Infections Condition- and Site-Specific Practices Consent & Disclosure Wrong-site Sx Prevention Press. Ulcer Prevention VTE Prevention Anticoag. Therapy VAP Prevention Central Line-Assoc. BSI Prevention Sx-Site Inf. Prevention Contrast Media Use Hand Hygiene Influenza Prevention Pharmacist Leadership Structures and Systems Med. Recon. Culture CPOE Read-Back & Abbrev. Discharge Systems Patient Care Info. Labeling Diag. Studies Culture Meas., FB., and Interv. Structures and Systems Risk and Hazards Team Training and Skill Bldg. Nursing Workforce ICU Care Direct Caregivers Workforce CHAPTER 4: Workforce Nursing Workforce Direct Caregivers ICU Care CHAPTER 2: Creating and Sustaining a Culture of Safety (Separated into Practices]  Culture of Safety Leadership Structures and Systems  Culture Measurement, Feedback, and Intervention  Teamwork Training and Skill Building  Risks and Hazards CHAPTER 5: Information Management and Continuity of Care  Patient Care Information  Order Read-Back and Abbreviations  Labeling Diagnostic Studies  Discharge Systems  Safe Adoption of Computerized Prescriber Order Entry CHAPTER 6: Medication Management  Medication Reconciliation  Pharmacist Leadership Structures and Systems CHAPTER 8: Condition- and Site-Specific Practices Wrong-Site, Wrong-Procedure, Wrong-Person Surgery Prevention Pressure Ulcer Prevention VTE Prevention Anticoagulation Therapy Contrast Media-Induced Renal Failure Prevention Organ Donation Glycemic Control Falls Prevention Pediatric Imaging Informed Consent Life-Sustaining Treatment Disclosure CHAPTER 3: Consent and Disclosure Informed Consent Life-Sustaining Treatment Disclosure Care of the Caregiver Consent and Disclosure Care of Caregiver MDRO Prevention UTI Prevention Falls Prevention Organ Donation Glycemic Control Pediatric Imaging

7. 7 © 2010 TMIT Harmonization Partners Safe Practice 1 Culture of Safety Leadership Systems and Structures Chapter 2: Improving Patient Safety by Creating and Sustaining a Culture of Safety

8. 8 © 2010 TMIT Harmonization – The Quality Choir

9. 9 © 2010 TMIT The Patient – Our Conductor

10. © 2006 HCC, Inc. CD000000-0000XX 10 © 2010 TMIT The Objective Culture of Safety Leadership Systems and Structures  Ensure that healthcare organizations establish and nurture the leadership structures and systems that drive the values, behaviors, and performance necessary to create and sustain a healthcare culture of safety.

11. 11 © 2010 TMIT Safe Practice 1 Culture of Safety Leadership Systems and Structures Chapter 2: Improving Patient Safety by Creating and Sustaining a Culture of Safety The Problem

12. 12 © 2010 TMIT [http://cnsnews.com/news/article/58362]

13. 13 © 2010 TMIT [http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2008/Jul/Why-Not-the-Best--Results-from- the-National-Scorecard-on-U-S--Health-System-Performance--2008.aspx]

14. © 2006 HCC, Inc. CD000000-0000XX 14 © 2010 TMIT The Problem

15. © 2006 HCC, Inc. CD000000-0000XX 15 © 2010 TMIT The Problem Frequency  Leadership failure is one of the most frequent causes of sentinel events  One survey of hospital leaders found that only 61% of responding CEOs indicated that their governance boards have a quality committee  Studies reveal that failure in reliability and systems performance stems from inconsistent execution more than from failure of strategy [Bossidy, Execution: The Discipline of Getting Things Done; 2002; Jiang, J Healthc Manag 2008 Mar-Apr;53(2):121- 34; discussion 135.]

16. © 2006 HCC, Inc. CD000000-0000XX 16 © 2010 TMIT The Problem Severity  Harm resulting from inadequate performance of leadership structures and systems cannot be definitively quantified  Nevertheless, chronic failure of consistent execution plagues all industries  Severe shortfalls in performance are seen across organizations throughout the entire healthcare industry [Denham, J Patient Saf 2009 Dec;5(4)]

17. © 2006 HCC, Inc. CD000000-0000XX 17 © 2010 TMIT The Problem Preventability  Preventability of harm to patients and sustainable transformation to a higher state of reliability is directly related to governance board engagement and administrative execution  Having a governance board quality committee was associated with lower mortality rates for six common medical conditions  Hospital boards are more successful when they set specific aims to reduce harm [Wang, J Qual Patient Saf 2006 Nov;32(11):599-611; Conway, Jt Comm J Qual Patient Saf 2008 Apr;34(4):214-20; Jiang, J Healthc Manag 2008 Mar-Apr;53(2):121-34; discussion 135; Govier, Nurs Times 2009 May 12-18;105(18):24-7; Gowen, Health Care Manage Rev 2009 Apr-Jun;34(3):129-40; Jha, Health Aff (Millwood) 2010;29(1):published online 6 November 2009;10.1377/hlthaff.2009.0297]

18. © 2006 HCC, Inc. CD000000-0000XX 18 © 2010 TMIT The Problem [Institute for Healthcare Improvement, Protecting 5 Million Lives from Harm: Some is not a number. Soon is not a time, N.D.; Alexander, Hosp Top 2006 Winter;84(1):11-20; Pronovost, Jt Comm J Qual Patient Saf 2008 Jun;34(6):342-8; Denham, J Patient Saf 2009 Mar;5(1):42-52] Cost Impact  Significant costs can be direct, indirect, tangible, and intangible  Most common costs incurred are due to brand erosion and event management

19. 19 © 2010 TMIT Practice Specifications Safe Practice 1 Culture of Safety Leadership Systems and Structures Chapter 2: Improving Patient Safety by Creating and Sustaining a Culture of Safety

20. © 2006 HCC, Inc. CD000000-0000XX 20 © 2010 TMIT Additional Specifications

21. © 2006 HCC, Inc. CD000000-0000XX 21 © 2010 TMIT Safe Practice Statement Culture of Safety Leadership Structures and Systems  Leadership structures and systems must be established to ensure that there is organization-wide awareness of patient safety performance gaps, direct accountability of leaders for those gaps, and adequate investment in performance improvement abilities, and that actions are taken to ensure safe care of every patient served

22. © 2006 HCC, Inc. CD000000-0000XX 22 © 2010 TMIT Additional Specifications [Botwinick, Leadership Guide to Patient Safety, 2006] Awareness Structures and Systems  Structures and systems should be in place to provide a continuous flow of information to leaders from multiple sources about the risks, hazards, and performance gaps that contribute to patient safety issues

23. © 2006 HCC, Inc. CD000000-0000XX 23 © 2010 TMIT Additional Specifications [Reason, Managing the Risks of Organizational Accidents, 1997; Rider, Pediatrics 2002 May;109(5):752-7; Morath, Pediatr Clin North Am 2006 Dec;53(6):1053-65; Conway, Jt Comm J Qual Patient Saf 2008 Apr;34(4):214-20; Institute for Healthcare Improvement, IHI Improvement Map: Will: Patients & Families, 2009; Institute for Healthcare Improvement, IHI Improvement Map: Execution: Portfolio of Projects, 2009; Institute for Healthcare Improvement, IHI Improvement Map: Alignment and Coordination, 2009] Awareness Structures and Systems  Governance boards and senior administrative leaders should be regularly briefed on results of activities undertaken in relation to risk and hazards and culture measurement  Obtain direct feedback from patients about the performance of the organization  Patient safety risks, hazards, and progress toward performance improvement objectives should be addressed at every board meeting

24. © 2006 HCC, Inc. CD000000-0000XX 24 © 2010 TMIT Additional Specifications Accountability Structures and Systems  Structures and systems should be established to ensure that there is direct accountability of the governance board, senior administrative management, midlevel management, physician leaders, and front-line caregivers to close certain performance gaps and to adopt certain patient safety practices

25. © 2006 HCC, Inc. CD000000-0000XX 25 © 2010 TMIT Additional Specifications [Botwinick, Leadership Guide to Patient Safety, 2006; Denham, J Patient Saf 2007 Dec;3(4):214-26; Denham, J Patient Saf 2009 Mar;5(1):42-52; Institute for Healthcare Improvement, IHI Improvement Map: Will: Connect Leaders to the Front Line, 2009; Institute for Healthcare Improvement, IHI Improvement Map: Set Direction: Aims, 2009; The Joint Commission, Issue 43: Leadership committed to safety, 2009; Joint Commission Resources, 2010 Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook, 2010] Accountability Structures and Systems Cont’d  An integrated patient safety program should be implemented throughout the healthcare organization  Appoint a Patient Safety Officer who is the primary point of contact for questions about patient safety, patient safety education, and the deployment of system changes  Governance and senior management should have direct accountability for safety in the organization

26. © 2006 HCC, Inc. CD000000-0000XX 26 © 2010 TMIT Additional Specifications [Botwinick, Leadership Guide to Patient Safety, 2006; Denham, J Patient Saf 2007 Dec;3(4):214-26; The Joint Commission, Issue 43: Leadership committed to safety, 2009; Joint Commission Resources, 2010 Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook; 2010] Accountability Structures and Systems Cont’d  The Patient Safety Officer should have direct and regular communication with governance leaders and senior administrative management  Leaders should establish and support an interdisciplinary patient safety improvement committee(s) or equivalent structure(s)  Organizations should report adverse events to the appropriate external mandatory and voluntary programs

27. © 2006 HCC, Inc. CD000000-0000XX 27 © 2010 TMIT Additional Specifications [Institute for Healthcare Improvement, IHI Improvement Map: Ideas: Innovation & Knowledge Management, 2009; The Joint Commission, Issue 43: Leadership committed to safety, 2009; Joint Commission Resources, 2010 Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook, 2010] Structures- and Systems-Driving Ability  Capacity, resources, and competency are critical to the ability of organizations to implement changes in their culture and in patient safety performance  Regular assessment of resource allocations to key systems should be undertaken to ensure performance in patient safety

28. © 2006 HCC, Inc. CD000000-0000XX 28 © 2010 TMIT Additional Specifications [Institute for Healthcare Improvement, IHI Improvement Map: Execution: Reliable Processes, 2009; Institute for Healthcare Improvement, IHI Improvement Map: Foundation: Build Capability for Execution & Improvement, 2009; Institute for Healthcare Improvement, IHI Improvement Map: Ideas: Scanning, 2009] Structures- and Systems-Driving Ability Cont’d  Specific budget allocations for initiatives that drive patient safety should be evaluated  Human resource issues should be addressed with direct input from the Risks and Hazards safe practice  Quality systems and structures should be adequately funded, actively managed, and regularly evaluated  Budgets for technologies that can enable safe practices should be regularly evaluated

29. © 2006 HCC, Inc. CD000000-0000XX 29 © 2010 TMIT Additional Specifications [Institute for Healthcare Improvement, Will: Measure, Oversee, & Communicate Transparency, 2009] Action Structures and Systems  Structures and systems should be put in place to ensure that leaders take direct and specific actions  Performance Improvement Programs – Leaders should document the actions taken to verify that the remedial activities are implemented, are effective, and cause no unintended harm

30. © 2006 HCC, Inc. CD000000-0000XX 30 © 2010 TMIT Additional Specifications [Institute for Healthcare Improvement, Getting Started Kit. Governance Leadership “Boards on Board” How to guide, 2008; Institute for Healthcare Improvement, IHI Improvement Map: Foundation: Governance & Improvement, 2009; Institute for Healthcare Improvement, IHI Improvement Map: Foundation: Operating Values, 2009; Joint Commission Resources, 2010 Comprehensive Accreditation Manual: CAMH for Hospitals: The Official Handbook, 2010] Action Structures and Systems Cont’d  Regular Actions of Governance that confirm acknowledged values, supply team training, and increase governance board competency in patient safety  The actions of the CEO and senior leaders should be informed, monitored, and directed by an engaged governance leadership on a regular basis

31. © 2006 HCC, Inc. CD000000-0000XX 31 © 2010 TMIT Additional Specifications Action Structures and Systems Cont’d  Leaders at all levels and in all clinical areas should be continuously and actively engaged in the pursuit of patient safety  Governance and senior administrative leaders should establish the systems and structures needed to ensure that medical leaders have regular and frequent opportunities to provide direct input to patient safety programs

32. 32 © 2010 TMIT Example Implementation Approaches Safe Practice 1 Culture of Safety Leadership Systems and Structures Chapter 2: Improving Patient Safety by Creating and Sustaining a Culture of Safety

33. © 2006 HCC, Inc. CD000000-0000XX 33 © 2010 TMIT Example Implementation Approaches

34. © 2006 HCC, Inc. CD000000-0000XX 34 © 2010 TMIT Example Implementation Approaches [Denham, J Patient Saf 2009 Dec;5(4); Denham, J Patient Saf 2009 Mar;5(1):42-52; Kanter, SuperCorp, 2009]  Governance boards and senior administrative leaders should be briefed on Safe Practice 1 through 4 to understand how tightly linked they are and how many of the activities overlap  A systematic strategy should be employed to establish the systems, structures, and resource requirements for implementation  Governance boards and senior administrative leaders should become personally involved in patient safety

35. © 2006 HCC, Inc. CD000000-0000XX 35 © 2010 TMIT Example Implementation Approaches Strategies of Progressive Organizations  Some organizations have declared that governance board members will spend equal time on financial issues and quality/safety issues in their meetings and activities  Others have established an external multidisciplinary committee that reviews all incidents  Certain organizations have taken entire leadership teams through training in other industries and countries to learn leadership and performance improvement methods

36. © 2006 HCC, Inc. CD000000-0000XX 36 © 2010 TMIT Example Implementation Approaches [Kanter, Change Masters, 1983; Covey, The SPEED of Trust: The One Thing That Changes Everything, 2006; Nance, Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care, 2008; Gladwell, Outliers: The Story of Success, 2008; Institute for Healthcare Improvement, IHI Improvement Map: Will: Patients & Families, 2009l] Strategies of Progressive Organizations Cont’d  High-performing organizations understand three critical issues that impact execution:  Execution is integral to strategy  The leader must be engaged in the execution of the strategy  The leader has a direct impact on the behaviors of the employees

37. 37 © 2010 TMIT Front-line Resources Safe Practice 1 Culture of Safety Leadership Systems and Structures Chapter 2: Improving Patient Safety by Creating and Sustaining a Culture of Safety

38. 38 © 2010 TMIT

39. 39 © 2010 TMIT The 3 Ts of Leadership Engagement: Truth, Trust, and Teamwork Charles Denham

40. 40 © 2010 TMIT http://www.jointcommission.org/PatientSafety/SpeakUp/ Available in Spanish

41. © 2006 HCC, Inc. CD000000-0000XX 41 © 2010 TMIT NQF & TMIT National Webinar Series Leadership and Leadership Principles for Safety (Safe Practices 1-4)  Charles R. Denham, MD – Leadership and Culture Practices: New Roles for Leaders  Peter B. Angood, MD – Important National Highlights Regarding Leadership and Culture  James Conway, MS – Bringing Boards On-board: Critical Issues in 2009  Dan Ford, MBA – Patient Perspective on Medication Management Safe Practices  Go to: http://www.safetyleaders.org/pages/idPage.jsp?ID=4942 (July 16, 2009)

42. © 2006 HCC, Inc. CD000000-0000XX 42 © 2010 TMIT Leadership Lessons for Pharmacy, Nursing, and Hospital Leaders  William George, MBA – 7 Lessons for Leading in Crisis  Charles Denham, MD – Welcome and Review of Specifications for Safe Practice 1, Leadership Structures and Systems  Hayley Burgess, PharmD – Review of Specifications for Safe Practice 18, Pharmacist Leadership Structures and Systems  Peter Angood, MD – National Perspective on Leadership Issues  Go to: http://www.safetyleaders.org/pages/idPage.jsp?ID=4945 (August 25, 2009) NQF & TMIT National Webinar Series

43. © 2006 HCC, Inc. CD000000-0000XX 43 © 2010 TMIT TMIT National Webinar Series Safe Practice 1: Creating and Sustaining a Culture of Safety  Charles Denham, MD  Ann Rhoades, MBA  Allan Frankel, MD  Michael Leonard, MD  Dan Ford, MBA  Go to: http://www.safetyleaders.org/pages/idPage.jsp?ID=4648 (July 13, 2007)