Safety First: Using a Perfect Storm to Change the Quality Performance Culture

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Hdl Handle:
http://hdl.handle.net/10755/202293
Type:
Presentation
Title:
Safety First: Using a Perfect Storm to Change the Quality Performance Culture
Abstract:
(41st Biennial Convention) Background Practitioners often perceive care delivered as “excellent” whereas a regulatory agency expects “perfect” care.  “A perfect storm is a convergence of independent events that form an environment never experienced before” (Fields, 2006). Three prevailing winds or barriers to exemplary blood and blood product administration practice, “failure to see,” “failure to move,” and “failure to finish” converged to create the perfect storm that threatened our culture of excellence (Kerfoot, 2010).  Materials and Methods Evidence supporting “perfect” blood product administration practice was collected during a 24 week period.  An organizational culture of transparency broke through staff “failure to see” the need for change.  Clinical audits mitigated “failure to move” by making the “perfect” clinical practice destination clear for all departments.  Audits created movement to ensure staff adhered to the “no failure” regulatory and professional blood administration standards related to consent,  verification, documentation, teaching and adverse reactions (Patel, 2010).  Fatigue inherent to “failure to finish” was diminished through motivating and energizing champions of change placed to reinforce, encourage and reward professional accountability. Results Sixteen patient care areas audited 100% (n = 2638 units) of blood products administered for adherence to regulatory standards between June 11 and December 1, 2010. “No failure” or “perfect” care was no deviation from regulatory standard without exception.  “Perfect” care was hardwired and enculturated into clinical practice by week 18. Conclusions A “perfect storm” environment brought about redesign of leadership roles, performance measures and professional accountability.  Utilization of a detailed audit strategy led to a no-fail practice culture and global improvements in blood administration safety throughout a healthcare system.
Keywords:
Patient Safety; Quality Outcomes; Performance
Repository Posting Date:
11-Jan-2012
Date of Publication:
4-Jan-2012
Sponsors:
Sigma Theta Tau International

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleSafety First: Using a Perfect Storm to Change the Quality Performance Cultureen_GB
dc.identifier.urihttp://hdl.handle.net/10755/202293-
dc.description.abstract(41st Biennial Convention) Background Practitioners often perceive care delivered as “excellent” whereas a regulatory agency expects “perfect” care.  “A perfect storm is a convergence of independent events that form an environment never experienced before” (Fields, 2006). Three prevailing winds or barriers to exemplary blood and blood product administration practice, “failure to see,” “failure to move,” and “failure to finish” converged to create the perfect storm that threatened our culture of excellence (Kerfoot, 2010).  Materials and Methods Evidence supporting “perfect” blood product administration practice was collected during a 24 week period.  An organizational culture of transparency broke through staff “failure to see” the need for change.  Clinical audits mitigated “failure to move” by making the “perfect” clinical practice destination clear for all departments.  Audits created movement to ensure staff adhered to the “no failure” regulatory and professional blood administration standards related to consent,  verification, documentation, teaching and adverse reactions (Patel, 2010).  Fatigue inherent to “failure to finish” was diminished through motivating and energizing champions of change placed to reinforce, encourage and reward professional accountability. Results Sixteen patient care areas audited 100% (n = 2638 units) of blood products administered for adherence to regulatory standards between June 11 and December 1, 2010. “No failure” or “perfect” care was no deviation from regulatory standard without exception.  “Perfect” care was hardwired and enculturated into clinical practice by week 18. Conclusions A “perfect storm” environment brought about redesign of leadership roles, performance measures and professional accountability.  Utilization of a detailed audit strategy led to a no-fail practice culture and global improvements in blood administration safety throughout a healthcare system.en_GB
dc.subjectPatient Safetyen_GB
dc.subjectQuality Outcomesen_GB
dc.subjectPerformanceen_GB
dc.date.available2012-01-11T11:20:32Z-
dc.date.issued2012-01-04en_GB
dc.date.accessioned2012-01-11T11:20:32Z-
dc.description.sponsorshipSigma Theta Tau Internationalen_GB
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