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The information contained in these resources does not necessarily reflect the views of the Partnership for Patients, the Centers for Medicare and Medicaid Services, The United States Department of Health and Human Services, nor the United States government.

Culture Change
Title Description
Patient Safety and Quality: An Evidence-Based Handbook for Nurses Nurses play a vital role in improving the safety and quality of patient care—not only in the hospital or ambulatory treatment facility, but also in community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, AHRQ, with additional funding from the Robert Wood Johnson Foundation, prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality.
Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans to Enhance Safety The University of Texas M.D. Anderson Cancer Center implemented a multifaceted initiative, known as the Good Catch Program, to increase the reporting of events that could potentially harm patients, visitors, and staff (these events are often referred to as "near misses" or "close calls”). Nurses and other frontline providers are positioned to proactively identify, interrupt, and correct these events. Key elements include a change in terminology from negative to positive terms and phrases (e.g., from "close call" or "near miss" to "good catch"); friendly, team-based competition to promote reporting; an end-of-shift safety report; executive leadership–sponsored rounds and incentives; and a multidisciplinary workgroup to promote reporting. The program led to a dramatic initial increase in reporting of near misses and close calls, spurred development of action plans designed to address the common causes of potential errors, and contributed to numerous system changes. As these changes have occurred, the number of events that could potentially cause harm—and hence the number of reports—has declined, but reports still remain well above baseline levels.
Team Communication Improvement Initiatives Enhance a Hospital’s Culture of Safety, Leading to Improved Outcomes This case study details how Abington Memorial Hospital implemented TeamSTEPPS™ (Strategies and Tools to Enhance Performance and Patient Safety) with other initiatives with the goal of improving safety through team communications. As a result, the hospital has experienced significant improvements in patient outcomes and care processes since reinvigorating this effort in 2006.
Program to Promote Adherence to Standards of Professional Conduct Improves Staff Perceptions of Patient Safety Culture and Reduces Disruptive Clinician Behavior This case study details how Catholic Healthcare Partners, as a part of its Setting the Standard for Professional Behavior initiative, developed and embedded within the organization's patient safety program, a multipronged approach to addressing disruptive clinician behavior.
Comprehensive Program to Promote “Fair and Just Principles" Improves Employee Perceptions of How a Health System Responds to Errors This case study details how Aurora Health Care implemented a comprehensive program designed to promote a culture of safety through their "fair and just principles," which emphasizes a nonpunitive response to medical errors and near-misses, thus encouraging patient safety and error reporting.
Safety Mentors Create Culture to Reduce Adverse Events and Increase Error Reporting This case study details how safety mentors at Christiana Care Health System help staff implement best practice safety behaviors and reporting of errors and near-misses.
Hospital Survey on Patient Safety Culture This toolkit provides resources, comparative data, and a user guide relating to the AHRQ Hospital Survey on Patient Safety Culture.
Mistake Proofing the Design of Healthcare Processes This resource is featured on AHRQ's Healthcare Innovations Exchange. It includes practical examples on the use of process and design features to prevent medical errors or the negative impact of errors. It contains more than 150 examples of mistake proofing that can be applied to healthcare, in many cases relatively inexpensively.
Key Issues in Developing a Successful Hospital Safety Program This article discusses several key elements in developing a successful hospital safety program.
Making Just Culture a Reality: One Organizations Approach This article discusses how one hospital implemented Just Culture within their organization.
Crisis Management Simulation Course This online training course is available on AHRQ’s Health Care Innovations Exchange Web site. Crisis Resource Management (CRM) is a 7-hour course for Labor and Delivery (L&D) practitioners. It uses various strategies of crew resource management, a safe program developed by the aviation industry, to create realistic simulations designed to facilitate improvement of teamwork and communication skills in a real L&D crisis.
Curricula for Simulated Obstetric Emergency Response Drills & Safety (CORDS™) The CORDS Toolkit is available on the AHRQ’s Health Care Innovations Exchange Web site. It was designed to use military and aviation style simulation experiences to prepare Labor and Delivery staff for an obstetric emergency. The toolkit also includes information about the importance of communication and teamwork.
Patient Safety Primer: Teamwork Training Providing safe healthcare depends on highly trained individuals with disparate roles and responsibilities acting together in the best interests of the patient. The AHRQ Patient Safety Network explains this topic further and provides links for more information on what is new in teamwork training.
Patient Safety Through Teamwork and Communication Toolkit This toolkit includes an education guide and communication tools in addition to a plan for the education and integration of communication and teamwork factors into clinical practice.
TeamSTEPPS™ - Team Strategies and Tools to Enhance Performance and Patient Safety Developed jointly by the Department of Defense (DoD) and AHRQ, TeamSTEPPS™ is a resource for training healthcare providers in better teamwork practices. This training package capitalizes on DoD’s years of experience in medical and nonmedical team performance and AHRQ’s extensive research in the fields of patient safety and healthcare quality.
TeamSTEPPS™ - Readiness Assessment Tool This Assessment Tool can help an organization understand its level of readiness to initiate TeamSTEPPS™ program.
TeamSTEPPS™ - Rapid Response Systems (RRS) Training Module This evidence-based module will provide insight into the core concepts of teamwork as they are applied to the rapid response system. This online training module contains an electronic Instructor Guide and training slides that include a high-quality video vignette of teamwork as it relates to RRS.
Appoint a Safety Champion for Every Unit Having a designated safety champion in every department and patient care unit demonstrates the organization's commitment to safety and may make other staff members feel more comfortable about sharing information and asking questions. This IHI Web site identifies tips for appointing a safety champion.
Conduct Patient Safety Leadership WalkRounds™ Senior leaders can demonstrate their commitment to safety and learn about the safety issues in their own organization by making regular rounds to discuss safety issues with frontline staff. The IHI Web site discusses the benefits of management making regular rounds and provides links to tools available for download.
Decision Tree for Unsafe Acts Culpability The decision tree for unsafe acts culpability is a tool available for download from IHI's Web site. Users can consult this decision tree when analyzing errors or adverse events that have occurred within the organization. This tool can help identify how human factors and systems issues can contribute to adverse events. This decision tree is particularly helpful when working towards a non-punitive approach in an organization.
IHI: Plan-Do-Study-Act (PDSA) Worksheet The Plan-Do-Study-Act (PDSA) Worksheet is a useful tool for documenting a test of change. The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the results (Study), and determining what modifications should be made to the test (Act).
Patient Safety Primer: Root Cause Analysis Root Cause Analysis (RCA) is a structured method used to analyze adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in healthcare. AHRQ Patient Safety Network explains this topic further and provides links for more information on what is new in RCA.
VA National Center for Patient Safety: NCPS Root Cause Analysis Tools Since 1999, NCPS has developed tools, training, and software to facilitate patient safety and RCA investigations. This guide functions as a cognitive aid to help teams in developing a chronological event flow diagram and a cause and effect diagram.
Conduct Safety Briefings This IHI Web site identifies tips and tools for conducting safety briefings. Safety briefings in patient care units are tools to increase safety awareness among frontline staff and foster a culture of safety.
Provide Feedback to Frontline Staff This tip sheet for how to provide feedback to frontline staff is available on the IHI Web site. Feedback to frontline staff is a critical component of demonstrating a commitment to safety and ensures that staff members continue to report safety issues.
SBAR Technique for Communication: A Situational Briefing Model The SBAR technique provides a framework for communication between members of the healthcare team about a patient's condition. This downloadable tool from the IHI Web site includes two documents. The document "SBAR Report to Physician About a Critical Situation" is a worksheet/script that a provider can use to organize information when preparing to communicate with a physician about a critically ill patient. The document "Guidelines for Communicating With Physicians using the SBAR Process" explains how to carry out the SBAR technique in detail.
A Leadership Framework for Culture Change in Healthcare [PDF, 1022KB] This article describes the process by which Ascension Health changed its culture to enable it to successfully address its call to action—and effect transformational (rather than incremental) change.
Getting Boards on Board: Engaging Governing Boards in Quality and Safety This article discusses 6 things all boards should do to improve quality and reduce harm in their organizations.
Getting Started Kit: Governance Leadership "Boards on Board" How to Guide This resource from IHI offers a how-to-guide, presentation, tools, and resources for obtaining board support for patient safety.
Patient Safety Leadership WalkRounds This tool provides key elements for successful implementation of WalkRounds™ and sample formats and questions to ask staff.
Communication Failure: Who's In Charge? This case study outlines communication failure as a patient safety issue within a healthcare team.
Case and Commentary: Fumbled Handoff This case study discusses how a fumbled handoff contributes to potential patient safety issues.
Case and Commentary: Triple Handoff This case study outlines how to effectively manage multiple handoffs to avoid patient safety events.
TeamSTEPPS Tools This toolkit contains the curriculum and associated tools and resources for the TeamSTEPPS program.
Discharge Fumbles This case study outlines patient safety issues that can occur from an uncoordinated discharge process.
SBAR Communication Technique This toolkit provides tools and resources on the SBAR (Situation-Background-Assessment-Recommendation) technique, created by clinical staff at Kaiser Permanente in Colorado. This technique provides a framework for communication between members of the health care team about a patient's condition.
A Leadership Framework for Culture Changes in Healthcare [PDF, 1022KB] This article is the second of a series that charts the journey of one health care system, Ascension Health, towards the clinical transformation of inpatient care—and no preventable injuries or deaths.

Other Useful Tools and Resources

Other Useful Tools and Resources
Title Description
Hospital Survey on Patient Safety Culture: 2011 User Comparative Database This Web site contains the 2011 User Comparative Database Report for the Hospital Survey on Patient Safety Culture.

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