Hospital Patient Safety Publication

SIH – Southern Illinois Healthcare’s Commitment to Patient Safety

Achieving Exceptional Patient Safety Redefining the Culture of Patient Safety

Southern Illinois Healthcare is committed to promoting an organizational culture that values safety in an environment of learning and open communication. To achieve this goal, SIH has established a Just Culture workplace for all of its employees. This Just Culture environment will apply across the system. SIH believes that the establishment of such a Just Culture work environment will encourage employees to:

1) focus on safety issues; 2) identify and report all events, “near-misses” and hazardous conditions; and 3) promote and implement performance improvement processes across the organization.

While the identification, analysis and prevention of events and patient safety issues are at the heart of this program, SIH also expects this program to enhance the safety of employees, medical staff members and visitors to the hospital. Therefore, SIH expects and requires all employees to fully participate in achieving the goals of this program.

Patient Safety Program SIH is committed to reducing the number of adverse events resulting from medical treatment, identifying the cause of adverse outcomes and developing processes that will minimize patient safety risk. Employees and medical staff working toward creating a safer environment are encouraged to submit suggestions.

Patient Safety Is Your Call Event and near-miss reporting are critical components in improving patient safety. If you are aware

A Just Culture focuses on a system failure; however, employees are held accountable for their actions.

Employees are not subject to disciplinary action when making or reporting events/injuries/near misses except when: 1) the employee repeatedly fails to participate in the detection and reporting of events/injuries/near misses and the system based prevention remedies; 2) there is reason to believe criminal activity or criminal intent may be involved in the making or reporting of an event/injury; 3) intentional false information is provided in the reporting, documenting or follow up of an event/injury;

of an event, please report the information via Remote Data Entry or call Patient Relations.

MHC: 618-549-0721 x 65203 Herrin: 618-942-2171 x 35254 SJMH: 618-684-3156 x 55506 System: 618-457-5200 x 67035 CMA: 618-549-5361 x 25205

4) intentional acts resulting in harm or potential for harm or actions that demonstrate a willful disregard for patient safety and/or facility and system policies and procedures; or 5) if it becomes evident that employee competency is the root cause for a pattern of events, after education and counseling, this situation will be treated as an employee

You will be asked to provide the following:

competency issue through normal disciplinary procedures.

• • • •

Patient Name Patient Room Number Date and Time of Event Detailed Description of Event

Providing your name is optional

“Talking the Talk” of Patient Safety A key step to improve patient safety is to change our language Dear Southern Illinois Healthcare Employee: Our core mission and vision is to provide excellent patient care. To achieve our mission, patient safety must be priority one. That is why Southern Illinois Healthcare, at every level, is fostering a positive culture that integrates patient safety into every aspect of our work.

To “hard wire” the process, we must remove the misperception that providing patient safety means focusing on blame. Instead, we will concentrate our efforts on identifying areas of opportunity for change and education. This requires your participation as you share your observations and suggestions with your supervisors so we may improve the safety of our patients.

The pages of this brochure will provide you with valuable information about our patient safety initiative and how you can play a role in its success. Please read this brochure carefully and, if you have any questions or suggestions, share them with your supervisor.

Southern Illinois Healthcare is a quality organization that continues to grow and improve thanks to the people who work here. As with every other aspect of this organization, the strength and success of our patient safety initiatives lie in you. That is why I ask for your support and devotion as we continuously improve our patient safety together.

Sincerely,

The words we use must reinforce that events are about the failure of systems, not people. By changing our language, we are helping to create a culture where we can discuss and analyze events openly, objectively and honestly.

OLD TERM: Isolated Event

NEW TERM: System/Process Here are some concepts that can help redefine our culture for patient safety.

WHY: An adverse event results from latent failures or weaknesses in a system. These failures or weaknesses are cumulative and interactive. Therefore, an adverse event is not an isolated happening. These weaknesses can go

OLD TERM: Accident

unnoticed within a system for a long time, only coming to our attention when they combine with other factors to

NEW TERM: Event

overcome the system’s defenses.

WHY: Event describes a breakdown in a system, which is complex and needs analysis.

Accident suggests that only one factor, usually noted as human error, is the cause.

OLD TERM: Blame

NEW TERM: Accountable OLD TERM: “Thank goodness I caught that in time!”

WHY: Health care professionals are accountable for their work. They have a responsibility to increase and maintain their

NEW TERM: Near-Miss

knowledge and competence. In addition, they must understand how systems work, and how people are the human

WHY: What you “caught” today, you or someone else may not catch tomorrow.

components of systems that sometimes contribute to failure, as well as create safety. Blame is often used to find an excuse

A near-miss must be reported and examined to determine that next time it does not

or “bad apple,” rather than to achieve a greater understanding of the failure to predict and prevent future events.

cause a serious adverse outcome.

OLD TERM: Non-Punitive

NEW TERM: Just Culture WHY: A Just Culture is one where personnel feel comfortable and compelled to report failures and near-misses, thus creating the opportunity to learn from mistakes. This culture fosters the analysis of systems failure while acknowledging that an individual’s actions may be at the root of the event. A Just Culture is a method of assigning

Rex P. Budde, President/CEO

consequences for an unsafe act in a fair way. This method is based on an understanding of a person’s accountability and responsibilities relative to the event. The Just Culture is not a blamefree culture. It tries to provide a consistent guide to determine: 1) when a person is truly at fault

George O'Neill, SIH Board Chair

for a specific act and 2) reasonable consequences to that individual that will best serve the individual’s and organization’s interests in the long run.

OLD TERM: Whose fault is it?

NEW TERM: Why did it happen?

WHY: When we ask “Why did it happen?” we are trying to uncover the facts surrounding the event. Asking “Whose fault is it?” immediately seeks to place blame instead of focusing on examining the situation.