A Safety Champion Program: Engaging and Empowering Front line staff to promote a culture of safety

1. 0
Engagement and Empowerment of
Frontline Staff to Promote a Culture
of Safety:
A Safety Champion Program
Jeanette Tanafranca, MSN, RN-BC
Safety Champion
2011

2. 1
Why do we need a
Safety Champion program?
During this 20 minute presentation:
• 5 – 7 patients across the U.S. will
die due to medical error or
infections
• 85 – 113 patients will be hurt
• 21 – 29 employees will
experience a needle-stick injury
Improving Healthcare Using Toyota Lean Production Methods R. Chalice, 2007Levinson, D. R. (2008). Adverse events in hospitals: overview of key
issues. Department of Health and Human Services, Office of Inspector General. Retrieved at: http://oig.hhs.gov/oei/reports/oei-06-07-00470.pdf
IOM (1999). To err is human: building a safer health system. Retrieved at: http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf
Kohn, L.T., Corrigan, J.M., and Donaldson, M.S. (Eds). (2000). To err is human: building a safer health system. Committee on Quality of Healthcare in
America. Washington, DC: National Academy Press.
Health care is not safe.

3. 2
1. Identify Top Causes of Harm
2. Enhance our Culture of Safety
3. Improve the Quality and Clarity of Clinical
Communications
4. Redesign Care To Eliminate Harm
H
A
R
M
50%

4. 3
No Harm Campaign
Extended 3 more years
Combined Harm Rate HFHS Hospitals by Hospital
20
30
40
50
60
70
80
Jan-08
Mar-08
May-08
Jul-08
Sep-08
Nov-08
Jan-09
Mar-09
May-09
Jul-09
Sep-09
Nov-09
Jan-10
Mar-10
May-10
Jul-10
Sep-10
Nov-10
Jan-11
Mar-11
May-11
Jul-11
Rateper1000Days
HFH Clinton Twshp Warren West Bloomfield Wyandotte All

5. 4
Establish a Common Language
Create Safe Environments
Build Local Structure
Formal
Team Training
HFHS Culture of Safety Building Blocks
Safety
Champions
Safety Culture Global Indicators
• Organizational commitment
• Management Involvement
• Employee Empowerment
• Reward Systems (Just Culture)
• Reporting Systems
HFHS Added:
• Partnerships with Patients and
Families
Wiegmann, D.A., Zhang, H., von Thaden, T., Sharma, G. and Mitchell, A. (2002). A synthesis of safety culture
and safety climate research (Technical Report ARL-02-3/FAA-02-2). Savoy, IL: Aviation Research Lab Institute
of Aviation.
Enhancing our Culture of Safety

6. 5
Impact of Safety Champion
Program
2006 - 2010 Comparison of Percent Favorable:
(4 - Agree and 5 - Strongly Agree)
76
62 59
34
81 82
68
83
79
70
58
77
74
53
65
74
73
80
0
10
20
30
40
50
60
70
80
90
100
Mgt actions
show safety is
a priority
We are
encouraged to
speak up
I would feel
safe as a
patient here
Lots of nurse
doctor
teamwork
Clinical
disagreements
resolved well
Communication
breakdown
leading to care
delays rareCulture of Safety Question
%
2006 2008 2010 AHRQ 75th Percentile 2010 AHRQ 90th Percentile 2010
N=15,767 N=15,683 N=16,566 N=10,407 N=10,994 N=10,994

7. 6
Safety Champ vs. No Safety Champ
COS & Engagement Scores
Units with Safety Champions showed improvement for all
safety questions and engagement questions compared to units
without safety champions.
0.09
0.14 0.22
0.19
0.14
0.3
-0.1
-0.05
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
ManagementActions
EncouragedtoSpeak
Up
FeelSafeasaPatient
atHFHSfacility
Lotsofteamwork
betweennursesand
doctors
Disagreements
resolvedwell
Communication
breakdowns
uncommon
C05 C06 C07 C08 C09 C10
DifferenceBetween2010and2008Mean
Scores
COS Question
Safety Champion vs. No Safety Champion (Clinical Units)
Improvement 2010 vs. 2008
NO Safety Champ
Safety Champ
Engagement Scores Improvement 2010 vs. 2008
Safety Champ vs. No Safety Champ (Clinical Units)
0.08
0.15
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
Q12 GMEAN
12 Engagement Questions GMEAN
DifferenceBetween2010and
2008GMEANScores
No SafetyChampion
SafetyChampion
0.1 improvement = meaningful
0.2 improvement = statistically significant

8. 7
Safety Champion Program
“Coming together is a beginning;
Keeping together is progress;
Working together is success.”
Henry Ford

9. 8
Program Objectives
• To develop a network of
multidisciplinary front-line
safety experts
• Create ‘error wisdom’ at the
front line
• Support HFHS core values
for patient safety and the No
Harm Campaign – build a
culture of safety
First Safety Champions 6/2008

10. 9
Who are Safety Champions?
• Front line, multidisciplinary employees that act as a “Voice” and
“Face” of Safety.
– Have a genuine interest in safety
– Model safe practices
– Model HFHS Core Values for Patient Safety
– Respected by peers
– Are willing and able to communicate information (i.e. patient safety goals,
personal safe practices, reporting) at department
meetings/briefings/huddles
– Are willing to embrace a leadership opportunity
– Create a ripple effect

11. 10
Conceptual Framework
Adapted from Dr. Patricia Benner’s Stages of Clinical Competence

12. 11
Safety
Champion
Program
11
Core
Courses
Patient Safety 101
Introduction to the
Safety Champion Role
-Human Factors
Communication
Monthly Toolkits
Bi-Monthly
Newsletters/Great
Catch
Facebook
Process
Improvement
Reporting
Strategies
Projects
Sharing
Learning
Quarterly
Forums
2 Minute
Tutorials
Professional
Development
IHI Open School
Conferences
Program Start: June, 2008

13. 12
12
Human factors research has shown that even highly skilled,
motivated professionals are vulnerable to error due to
inherent human limitations – really ‘good’ people will make
mistakes
Core Courses
I. Patient Safety 101
II. Introduction to the
Safety Champion Role
(Human Factors)

14. 13
13
Which is the One Cent U.S. Coin?
A Simple Example of the Limits of Memory
Memory- we generally store only partial
descriptions of things to be remembered,
descriptions that are sufficiently precise to work
at the time something is learned but may not work
later on when new experiences are encountered.
Image Source:http://www.dcity.org/braingames/pennies/

15. 14
Safety
Champion
Program
14
Core
Courses
Patient Safety 101
Introduction to the
Safety Champion Role
-Human Factors
Communication
Monthly Toolkits
Bi-Monthly
Newsletters/Great
Catch
Facebook
Process
Improvement
Reporting
Strategies
Projects
Sharing
Learning
Quarterly
Forums
2 Minute
Tutorials
Professional
Development
IHI Open School
Conferences

16. 15

17. 16
Safety
Champion
Program
16
Core
Courses
Patient Safety 101
Introduction to the
Safety Champion Role
-Human Factors
Communication
Monthly Toolkits
Bi-Monthly
Newsletters/Great
Catch
Facebook
Process
Improvement
Reporting
Strategies
Projects
Sharing
Learning
Quarterly
Forums
2 Minute
Tutorials
Professional
Development
IHI Open School
Conferences

18. 17
Sharing & Learning
• Quarterly Forums: Identify top causes of harm, Culture of Safety, Just
Culture,Error Reporting & Error Prevention, Speak Up, Speak Out: Creating
Safe Environments, Getting LEAN with Hand Hygiene, Healthcare Equity and
Culturally Competent care, Emergency Preparedness and Patient Safety….
• 2 Minute Tutorials: “How To’s”
• Great Catch Stories
17

19. 18
Safety
Champion
Program
18
Core
Courses
Patient Safety 101
Introduction to the
Safety Champion Role
-Human Factors
Communication
Monthly Toolkits
Bi-Monthly
Newsletters/Great
Catch
Facebook
Process
Improvement
Reporting
Strategies
Projects
Sharing
Learning
Quarterly
Forums
2 Minute
Tutorials
Professional
Development
IHI Open School
Conferences

20. 19
Process Improvement
• Accurate and Voluntary reporting through
our reporting system.
• Project survey.
19
•2 patient identifier projects
•Revised SBAR form for patient hand-offs
•Selecting equipment for hospital
•Post-fall management program
•Handicapped parking assistance
•Bladder health and collaborative project
•Handwashing projects
•Medication review process
•Mammogram process review
•Medication dispensing projects
•A3s-Needlestick prevention
•More…..

21. 20
• Safety Champions reviewed employee
injury data and identified that lift injuries
are in the top 3 (2010-2011).
– Conducted a survey that employees
stated that lifts were a number one
concern of what injury they felt would
happen in their area.
• Conducted A3s on sharp containers and
the inappropriate use of biohazard
bags.
– An EOC audit showed a spike in finding
the biohazard bags used inappropriately
– SC Team conducted additional education
and weekly
HF West Bloomfield
Impact of Safety Champion Program

22. 21
HFH Inpatient Pharmacy
Impact of Safety Champion Program
• Process 7,000 medications orders per day
• Dispense 17,000 medication doses per day
• Recognize human limitations and have made 49
system improvements since joining the program

23. 22
Safety
Champion
Program
22
Core
Courses
Patient Safety 101
Introduction to the
Safety Champion Role
-Human Factors
Communication
Monthly Toolkits
Bi-Monthly
Newsletters/Great
Catch
Facebook
Process
Improvement
Reporting
Strategies
Projects
Sharing
Learning
Quarterly
Forums
2 Minute
Tutorials
Professional
Development
IHI Open School
Conferences

24. 23
Safety Champion Successes
• 378 Safety Champions (multidiscplinary, multiple business units)
• 100% would recommend program
• >95% favorable with class and forum surveys
• 95% share toolkits and newsletters
• 88% believe they have made an impact on the culture of safety for
their units
• 80% participate in safety improvement work
23

25. 24
24

26. 25
I am a Safety Champion
because I do my best to live the Henry Ford
Experience of caring about people by helping
to make sure they are safe,…on a daily
basis..Ruth
Patient Safety means......" putting forth a
conscience effort to protect our patients and
employees by minimizing risk and
adhering to all set standards while providing
the highest quality care in the safest work
environment possible!!!!
Dawn Dombek-Bailey, CHSP
I make a difference in the lives of all
persons who enter HFHS properties.
MaryAnn L. Northcote, CPP, CHSP I am a safety champion because
I want to be proactive in
spreading wellness to individuals
that are in my reach. Injury
prevention is a key component in
helping our loved ones and others
in our community stay safe and
healthy..Katie Horn
I am a safety champion
because I CAN and
DO make a difference
one person at a
time". Stephanie B.
Anderson, RN, MSN
Patient Safety means….delivering the highest
quality care that is reliable and coordinated for the
patients we serve each day..Judy Caretti-Rourke
I make a
difference to
everyone that comes in
contact with me in the
Henry Ford Health
system..Latonya
Phillips
I am a Safety Champion because......the
environment I work in and the people I serve are
important to me“ LesaBorden Sanford RN,
BSN
Patient Safety means being pro-
active in creating and maintaining
safe environments
for our patients who depend on us
when they are most vulnerable.
Judy Czerepowicz, CHSP
Safety Champions Can and Do
Make a Difference in Patient Safety by
Being Proactive, Minimizing Risk,
Creating Safe Environments Because
its Important to the Lives of ALL.
-HFHS Safety Champions

27. 26
Thank You to all of the HFHS Safety Champions for making a difference.

28. 27
Contact Information
Jeanette Tanafranca, MSN, RN-BC
Office of Clinical Quality and Safety
One Ford Place, Detroit, MI 48202
313.874.7181
jtanafr1@hfhs.org
27