Table of Contents
Table of Contents
FOREWORD
Gary S. Kaplan, MD
CONTRIBUTORS
INTRODUCTION: CREATING A ROAD MAP FOR PATIENT SAFETY
Michael Leonard, MD; Allan Frankel, MD; Frank Federico, RPh; Karen Frush, BSN, MD; Carol Haraden, PhD
CHAPTER ONE: THE ROLE OF LEADERSHIP
Doug Bonacum, MBA, BS; Karen Frush, BSN, MD; Barbara Balik, RN, EdD; James Conway, MS
Establish, Oversee, and Communicate System-Level Aims
Identify Harm, Design and Implement Improvements, and Track/Measure Performance over Time
Assess the Culture for Safety and Act to Close Any Gaps
Understand the Science of Improvement and Reliability
Foster Transparency
Create a Leadership Promise
Engage Physicians, Nurses, and Other Clinicians
Hire for What You Aspire to Become
Involve Board Leadership in Safety
CHAPTER TWO: ASSESSING AND IMPROVING SAFETY CULTURE
Natasha Scott, MSc; Allan Frankel, MD; Michael Leonard, MD
What Is Safety Culture?
Linking Culture and Leadership
Why Is Safety Culture Important?
Assessing Safety Culture
Safety Culture Assessment Tools
Linking Safety Culture Assessment to Improvement
Conclusion
CHAPTER THREE: ACCOUNTABILITY AND THE REALITY OF THE HUMAN CONDITION
Allan Frankel, MD; Frank Federico, RPh; Michael Leonard, MD
Defining a Just Culture
Establishing an Accountability System
Why Is an Accountability System Important?
How to Create a Just Accountability System
Relentlessly Reinforce the Message
CHAPTER FOUR: RELIABILITY AND RESILIENCE
Roger Resar, MD; Frank Federico, RPh; Doug Bonacum, MBA, BS; Carol Haraden, PhD
What Is Reliability?
Why Do Organizations Struggle with Reliability?
Designing for Reliability
Addressing the Cultural Aspects of Reliability
Pursuing Risk Resilience
CHAPTER FIVE: SYSTEMATIC FLOW OF INFORMATION: THE EVOLUTION OF WALKROUNDS
Allan Frankel, MD; Sarah Pratt, MPH
Reflections
A Guide to Conduct WalkRounds
CHAPTER SIX: EFFECTIVE TEAMWORK AND COMMUNICATION
Karen Frush, BSN, MD; Michael Leonard, MD; Allan Frankel, MD
Why Is Effective Communication So Difficult in Health Care?
Structures That Enhance Teamwork and Communication
Training for Effective Teamwork and Communication
CHAPTER SEVEN: USING DIRECT OBSERVATION AND FEEDBACK TO MONITOR TEAM PERFORMANCE
Allan Frankel, MD; Andrew P. Knight, PhD
How to Use Direct Observation
Methods of Direct Observation
CHAPTER EIGHT: DISCLOSURE
Doug Bonacum, MBA, BS; James Conway, MS; Douglas Salvador, MD, MPH
Disclosing Adverse Events
Leadership Commitment to Disclosure Is Critical
Other Items to Consider
How to Disclose
The Benefits of a Health Care Ombudsman/Mediator (HCOM) Program
Conclusion
CHAPTER NINE: ENSURING PATIENT INVOLVEMENT AND FAMILY ENGAGEMENT
Mary Ann Abrams, MD, MPH; Gail Nielsen, BSHCA, FAHRA, RTR; Karen Frush, BSN, MD; Barbara Balik, RN, EdD
Ways to Partner with Patients
Addressing Patient Literacy
Summary
CHAPTER TEN: USING TECHNOLOGY TO ENHANCE SAFETY
Jeffrey P. Brown, MEd; Jackie Tonkel, BSBA; David C. Classen, MD, MS
Current State of Health Care Information Technology
Looking Forward: Patient Safety and HIT—The IOM Report
Challenges in Improving Safety with HIT
Health Care Is a Sociotechnical Endeavor
Component-Centered Versus System-Based Safety Management
Considerations for System-Based Safety Management
Maximizing the Benefits of HIT
Conclusion
CHAPTER ELEVEN: MEASUREMENT STRATEGIES
Robert C. Lloyd, PhD
The Context for Health Care Measurement
The Quality Measurement Journey
CHAPTER TWELVE: CARE PROCESS IMPROVEMENT
Allan Frankel, MD; Carol Haraden, PhD; David Munch, MD
The Model for Improvement
Lean Methodology
Six Sigma
Tools for Use in Performance Improvement
Failure Mode and Effects Analysis
Root Cause Analysis
CHAPTER THIRTEEN: BUILDING AND SUSTAINING A LEARNING SYSTEM—FROM THEORY TO ACTION
Allan Frankel, MD; Michael Leonard, MD
Introduction
Organizational Physicians
The Four Organs of Learning
The Four Organs of Culture
Assessing and Treating the Organization
Summary
INDEX