Jeanette Tanafranca, MSN, RN-BC Safety Champion

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

2. 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 • Health care is not safe. 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.

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

4. No Harm Campaign Extended 3 more years

5. Enhancing our Culture of Safety Formal Team Training 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 Build Local Structure Create Safe Environments Establish a Common Language HFHS Culture of Safety Building Blocks 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.

6. Impact of Safety Champion Program

7. Safety Champ vs. No Safety ChampCOS & Engagement Scores Units with Safety Champions showed improvement for all safety questions and engagement questions compared to units without safety champions. • 0.1 improvement = meaningful • 0.2 improvement = statistically significant

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

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

12. Safety Champion Program Program Start: June, 2008

13. Core Courses • I. Patient Safety 101 • II. Introduction to the Safety Champion Role (Human Factors) 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

14. Which is the One Cent U.S. Coin? 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. A Simple Example of the Limits of Memory Image Source:http://www.dcity.org/braingames/pennies/

15. Safety Champion Program

17. Safety Champion Program

18. 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

19. Safety Champion Program

20. Process Improvement • Accurate and Voluntary reporting through our reporting system. • Project survey.

21. 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 BloomfieldImpact of Safety Champion Program

22. HFH Inpatient PharmacyImpact 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. Safety Champion Program

24. 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

26. 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 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 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 Patient Safety means….delivering the highest quality care that is reliable and coordinated for the patients we serve each day..Judy Caretti-Rourke I am a Safety Champion because......the environment I work in and the people I serve are important to me“ LesaBorden Sanford RN, BSN   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 I CAN and DO make a difference one person at a time". Stephanie B. Anderson, RN, MSN 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

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

28. 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