Building a Patient Safety Mentor Program (Text Version)

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

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Slide 1

Building a Patient Safety Mentor Program

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

 

Slide 2

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

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

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

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

Validation Of Our Success

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

 

Slide 7

Validation Of Our Success

• Improved reporting of medication-related near misses:

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

 

Slide 8

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

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

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

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

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.