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Building a Patient Safety Mentor Program (Text Version)

Slide Presentation from the AHRQ 2009 Annual Conference,

On September 16, 2009,Michele Campbell made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (863 KB).


Slide 1

Slide 1. Building a Patient Safety Mentor Program

Building a Patient Safety Mentor Program

Michele Campbell, RN, MSM, CPHQ FABC
Corporate Director
Patient Safety and Accreditation
Christiana Care Health System
 

 

Slide 2

Slide 2. Impetus for Safety Mentor Program

Impetus for Safety Mentor Program

Landmark Report:

  • To Err is Human (IOM, 1999)
Culture Survey:
  • Non-punitive response to error
  • Improvements made as a result of reporting
Focus Groups/Culture Debriefing Sessions
  • Reluctance to report errors
  • Reporting an error was difficult
Safety First Learning Report Data
  • Volume and severity of events and near misses

 

Slide 3

Slide 3. Goals: Safety Mentor Program

Goals: Safety Mentor Program

  • Empower frontline staff to serve as ambassadors.
  • Encourage peer-to-peer feedback and communication.
  • Enhance and promote error reporting, including near misses.
  • Mitigate harm to our patients.
  • Facilitate learning.

 

Slide 4

Slide 4. Design of the Safety Mentor Program

Design of the Safety Mentor Program

  • Formulate goals.
  • Gain organizational buy-in.
  • Define safety mentor role.
  • Identify educational and training needs.
  • Determine frequency and content of meetings.
  • Develop and implement data collection plan/tools.
  • Plan how to evaluate innovation.

 

Slide 5

Slide 5. Considerations for Adopters

Considerations for Adopters

  • Select mentors carefully.
  • Consider protected time for data collection.
  • Act on front-line input.
  • Will it Work Here? A Decisionmaker's Guide to Adopting Innovations http://www.innovations.ahrq.gov/resources/resources.aspx

 

Slide 6

Slide 6. Validation Of Our Success

Validation Of Our Success

Image: A graph of the total events reported is shown with and 17% increase in reporting.

 

Slide 7

Slide 7. Validation Of Our Success

Validation Of Our Success

  • Improved reporting of medication-related near misses:

Image: A graph of the "Increase in Medication Near Misses"

 

Slide 8

Slide 8. Validation Of Our Success

Validation Of Our Success

  • Fewer events with major outcomes
  • Improvements in safety culture
    • Dramatic decline in fear of disciplinary action
    • Perception of improved patient safety and learning

 

Slide 9

Slide 9. Other Uses Of Quantitative and Qualitative Data

Other Uses Of Quantitative and Qualitative Data

Safe Practice Behavior Monitoring

  • Observations
  • Documentation
  • Interview questions

Safety First Learning Report

  • Ease of completion and navigation

Effectiveness of Safety Mentor meetings

  • Agenda items
  • Improvements and suggestions

Focus Groups

  • Qualitative feedback on safety project design and strategies

 

Slide 10

Slide 10. Lessons Learned

Lessons Learned

  • Assess baseline data to evaluate success.
  • Select culture survey instrument strategically.
  • Resources impact selection of measures.
  • Safety mentors' insights and perceptions promote learning.
  • Recognize that safety culture is local, multidimensional, and still evolving.
  • Sharing data at local and organizational levels can drive improvements.

 

Slide 11

Slide 11. Limitations

Limitations

  • Variety of culture survey instruments utilized.
  • Paper surveys utilized.
  • Skills and understanding of staff affected data integrity.
  • Real time peer-to-peer feedback depended on comfort level of staff.
  • Pace of progress affected by turnover of front line staff who were safety mentors.

 

Slide 12

Slide 12. Next Steps in Our Journey

Next Steps in Our Journey

  • Enhance "On Boarding" and formalize recognition.
  • Implement "Fair and Just Culture" concepts.
  • Assess progress using results from 2009 (AHRQ)�Hospital Survey on Patient Safety Culture.
  • Define frequency of measures for future validation of our success.
Current as of February 2009
Internet Citation: Building a Patient Safety Mentor Program (Text Version). February 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/news/events/conference/2009/campbell/index.html

 

The information on this page is archived and provided for reference purposes only.

 

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