Building A High Reliability Culture For Patients And Health Care Workers

One of the recommendations for healthcare organizations to employ in an effort to reduce the number of errors is to advocate for voluntary error reporting nationally while conducting research and developing tools for patient safety. This way, information about errors can be gathered and prevented from reoccurring at health care sites and by health care providers. Voluntary error reporting will act as a warning of potential or actual errors and suggest ways to avoid them in the future.

The quality department has developed this manual to introduce new employees to the basic concepts of risk and quality management within the institution. This manual meets the institution’s initiative for continuous quality improvement within each department and the opportunity to mitigate areas of risk whenever possible. In order to accomplish this goal, it is important for the new employee to be able to identify what quality improvement and risk management mean within the institution. The institution believes that when employees are aware of these concepts, decision-making processes can be put in place to reduce risk and improve quality. This manual will also review the challenges that come from risk- and quality-management decisions especially in the health care setting. The new employee will be introduced to a variety of tools available to help assess potential problems, determine whether a change is needed and how to institute these changes through informed decision making. A clear understanding of how to use these tools will help the institution reach their goals of patient-centered care while providing a safe environment. Risk and quality management initiatives have the potential to save lives and save the institution money. The institution believes that successful risk and quality management is achieved only through employee awareness and incentives to provide a culture of safety.

"To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (Jointcommission.org, 2015). These requirements are regimented in the National Patient Safety Goals and are enforced via surveys and internal inspections to ensure that healthcare institutions abide by the safety mechanisms put in place to facilitate the optimal patient outcomes and environments.

In healthcare systems, there is a concept of fair and just culture. That concept is important to manage the risk. In any organization, errors can happen. But, the best first tool to understand the error is to report it when it happens. Reporting error in healthcare contributes to minimize the risk of recurring.

Traditionally, nursing shift-to-shift reports were organized methods of communication between only the oncoming and leaving nurse, designated to a location such as the central nursing station or nook of a hallway. Shift reports can be considered the foundation of how the day is going to plan out because it introduces the patient, diagnoses, complications, medications, consults, upcoming test and the entire plan of care. These reports are full of complicated and vital information and while set in certain locations that are vulnerable to interruptions, such as the nursing station, medical errors and miscommunication are more likely to be made. The Joint Commission’s 2009 and 2010 National Patient Safety Goals (Joint Commission, 2015) included two patient safety standards, first to encourage patients to be involved in their health care plan and second, to implement a standardized communication process for handoff reports between providers. Soon after in 2013, The Agency for Healthcare Research and Quality under the United States Department of Health and Human Services introduced a set of strategies to improve patient engagement along with safety and quality in patient care. Within these strategies the new method of nurse bedside shift report was developed, which suggests nurses to conduct shift-to-shift reports at bedside in the room of each patient, rather than out of the room. The benefits of this new method were

To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.

Patients want and expect to receive high quality care. Nurses want to provide the best care possible to their patients and like everybody else; want a pleasing job environment. Hospitals, on the other hand, are expected to provide a safe environment to patients, have enough nursing staff and remain profitable (Keller, Dulle, Kwiecinski, Altimier & Owens, 2013). The ultimate goal is to improve quality of care and patient safety across the United States; therefore, all the different interests of these major stakeholders should be taken into

To improve the quality, safety, efficiency, and effectiveness of patient care, applying research and evidence-based practice is necessary. In the Institute of Medicine’s report, Keeping Patient Safe: Transforming the Work Environment of Nurses, there is an emphasis on adequate nurse staffing (Hickey & Brosnan, 2012). Therefore, the quality improvement initiative is to focus on closing the gap between the core staffing and actual staffing in a six-week schedule.

From the top to the bottom, everyone is responsible to maintain safety throughout health care organizations. This is one of the fundamental reasons for having these six goals in an attempt to improve the quality in patient care (Finkleman, 2012). We must work consistently and collaboratively adhere to these goals in order to achieve quality improvement. Also, health care professionals need to understand the rationale for applying these concepts into their scope of practice. According to our lesson this week, (Chamberlain College of Nursing, 2016) “Quality Improvement is about inspiring change.” It is never easy to implement change because you are always going to face obstacles.

As the patient safety officer, I am involved in the frequent root cause analysis (RCA) that result in improvements due to a retrospective response to specific events. Likewise, I am involved in many patient safety and quality initiatives where information from occurrences is used to improve quality, such as the falls prevention program, hospital-acquired pressure ulcer prevention, medication safety to name a few. These are broader approaches for improvement using a collaborative, multidisciplinary effort directed at improving the quality throughout the organization rather than a specific reaction

Just culture is to update and improve patient safety from errors and mistakes based off the various behaviors chosen by the individual. Each individual has set values and expectations from each facility or institution. Within the nurses’ scope of practice, one must prevent harm, according to benefiance, to the patient. With just culture, this is used to implement new ideas to prevent further harm to future patients.

In today’s health care system, “quality” and “safety” are one in the same when it comes to patient care. As Florence Nightingale described our profession long ago, it takes work and vigilance to ensure we are doing the best we can to care for our patients. (Mitchell, 2008)

Collaborative relationship among members is critical to providing safe, high quality care in the hospital. While the governing body is ultimately responsible for the quality and safety of care at the hospital, the governing body, medical staff, and administration collaborate to provide safe, quality

An example of a current shift is the value placed on promoting the culture of safety. Culture of safety focuses on preventing or reducing medical errors and improving the overall quality of health care. While the thought of preventing injuries, death or unnecessary costs sounds simple, staff members who do not follow procedures put patients at risk. By monitoring a variety of outcomes such as infection rates or staff turnover, management can implement procedures to minimize the risk. Staff, whether they are on the front line or in leadership positions, should be able to discuss patient safety issues without the fear of retaliation. According to the Safety Attitudes and Safety Climate Questionnaire study by Bryan Sexton (2006), a high safety

Health care, in order to improve patient safety, needs to create awareness of potential threats and understand the factors associated with them which high-reliability organizations (HROs) called collective mindfulness (Spath, 2011, p. 36). HROs use five principles to achieve this, which they can be apply to health care.