Building a Patient Safety Mentor Program

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) (Plugin Software Help).


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. February 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/campbell/index.html