Consensus-based Interventions

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Consensus-Based Interventions

Tools identified by a panel of experts as important; but may or may not have been rigorously tested in perinatal patients.

• Action Planning for Safer Culture Assessment
  Applies to: All Enabling Factors | Teamwork & Collaboration | Communication & Information Exchange | Incident Reporting | Fair Rewarding & PunishmentAHRQ provides a list of 10 questions to help organizations prepare for starting patient safety and quality initiatives. To begin an initiative like assessing Safer Culture, these questions can be a helpful guide to consider the type and scope of your assessment. Answers to these questions can be added to the Action Plan Template (attached below) to create steps for completing your Safer Culture assessment goals.Additional link: Action Planning Questions
• AHRQ Toolkit for Improving Perinatal Safety
  Applies to: All Enabling FactorsThe Agency for Healthcare Research and Quality (AHRQ) developed this toolkit “to improve the patient Safer Culture of labor and delivery (L&D) units and decrease maternal and neonatal adverse events resulting from poor communication and system failures”. The toolkit is built on three program pillars: 1) Teamwork and Communication Skills, 2) Perinatal Safety Strategies, and 3) In Situ Simulation Training.
• Anonymous Event Reporting System / Incident Reporting
  Applies to: Organizational Enabling Factors | Individual Enabling Factors | Incident ReportingThe purpose of the anonymous event reporting system is to allow any hospital employee to report any harmful or unsafe episode to a patient or staff member. Having this technology available shows the support to error and incident reporting while maintaining confidentiality. It also serves as a method to help leaders learn from a unit’s mistake.
• Code of Professionalism
  Applies to: Organizational Enabling Factors | Group Enabling Factors |Teamwork & Collaboration | Fair Rewarding & PunishingImplementing a multidisciplinary Code of Professionalism can improve the Safer Culture in a hospital. When physicians and staff are held to the same standards by leadership, it can lead to improvements in an organization’s Safer Culture and can serve as the foundation for delivery of safer care.
• High-Reliability Organization Principles (HRO) / Just Culture

Applies to: All Enabling Factors | Fair Rewarding & Punishing | Communication & Information Exchange

High reliability means consistent excellence in quality and safety across all services maintained over long periods of time. The Joint Commission created a framework for healthcare organizations to use to accelerate their progress in achieving the goal of zero harm. This framework focuses on three domains of change: leadership commitment to zero harm, organizational Safer Culture (all staff can speak about the negative things that can affect the organization), and an empowered workforce (one that addresses improvement opportunities found by employees to drive significant and lasting change).

Additional links:  The Joint Commission for Transforming Healthcare
High Reliability Healthcare Maturity Model

 

• Increasing Physician Presence in Units
  Applies to: Organizational Enabling Factors | Group Enabling Factors |Teamwork & Collaboration | Communication & Information ExchangeThere are various methods to improve patient safety by increasing the amount of time senior physicians are present and available on the unit, depending on the size of the unit. One suggestion is to have an on-call attending physician 24 hours, 7 days a week. If that is not an option to your facility, perhaps increasing the number of hours the attending physician is on the unit or designate a senior resident to be assigned only to a specific unit for the day. Having the most experienced physicians available to nurses and resident physicians for a longer amount of time, or more often, will create opportunities to ask questions and prevent errors. This will also provide for more teachable moments for residents and nurses, creating group cohesion and increasing confidence in one another as well as self-confidence.

Obstetrics Patient Safety Committee / Quality Councils
Applies to: Organizational Enabling Factors | Group Enabling Factors |Teamwork & Collaboration | Communication & Information Exchange | Fair Rewarding & Punishing

Patient safety committees and quality councils are created to improve safety and quality assurance. They can include former patients, providers, or a combination of these two groups. Meetings take place weekly or monthly, depending on the topics addressed and the committee members’ availability.