Launch Safety as a Core Value

This Roadmap and how safety for staff, patients, and in processes will become a defining aspect of the hospital’s identity and a principal consideration in future decision-making is presented and discussed.

With acceptance of this direction, a formal commitment is made through a publicly affirmed pledge to prioritize safety for staff, patients, and in operational processes. This collective assurance confirms the institution’s firm dedication to upholding the highest standards of safety throughout the hospital.

Prepare the Culture at the Hospital for Success

Establish Principles for Interactions

Change, which is often difficult, is unavoidable for hospitals following this Roadmap. All interactions and interfaces within the hospital will be conducted with respect – both in language and behaviors – to foster a positive work environment that supports safety. Feedback will be constructive, avoiding criticism and blame. Communications will be timely, clear, and concise. A positive environment promotes safety and staff well-being while also bolstering resilience during challenging periods.

Establish Expectancies for Ongoing Professional Development and Education

Everyone will participate in ongoing professional development and education. Knowledge and skills that are needed by everyone at the hospital, like safety and communication skills, will be learned collectively. This will mix usually separated groups like physicians, nurses, pharmacists, housekeeping, top management, and more in the same learning courses. This not only opens communication and strengthens relationships, but it also builds trust between leadership and staff, boosts productivity, and supports conflict resolution. Some staff groups and departments will get specific enrichment related to their specialty. All providers will get training that includes standardized patient hand over reports and documenting care while nurses who work in the PACU and other areas of critical care will get courses that include adult and pediatric advanced life support. All housekeeping staff will get training that includes handling biohazardous material while those who work in critical care areas will get training that includes donning and doffing personal protection equipment (PPE) because they may need to clean the rooms of patients with contagions like Covid19.

Establish Expectancies for Variable Learning Approaches  

Workplace learning among adults is different than that of children. Adult learners bring an array of skills, knowledge, and experience to the instructional sessions. This covers accurate and inaccurate knowledge as well as instances of justified skepticism. Additionally, participants may find themselves distracted by their duties, overwhelmed, or simply tired during sessions, which can present challenges to effective learning.

Active learning methods such as - moderated discussions, problem-based learning, role playing, stories, group projects, gaming, simulations, and workshops play a key role in this Roadmap. Learners who are actively engaged in the course - rather than solely listening to lectures - tend to remain focused, effectively absorb the material, and find the learning experience enjoyable. Active learning blends the expertise of experienced staff with the innovative ideas of others unlocking the full potential of staff and ideas.

Identify and Rank all Targets at the Hospital

Targets are points in care where there is staff, patient, or process risk that can be decreased. It is often places where most injuries occur. Targets include processes, like airway management during anesthetic care, and situations, like an instrument sterilizer that frequently needs fixed, and more.

Every Department Identifies Three High-Risk Targets - That Need Fixed

Each department including obstetric and pediatrics units, biomedical engineering, PACU nursing, pharmacy, housekeeping, pre-hospital care, and perioperative care identifies three targets where the risk of harm is the highest. Even when there is a directed project in a specific department this step will identify - sometimes hidden - targets that need immediate attention or those that may interfere with the project.

Targets are Merged and Ranked

Department targets are merged then ranked from highest to lowest risk. This creates an all-inclusive list of targets and avoids omissions. A master list is finalized after adjusting the ranking of some targets on the merged list in accordance with the Roadmap's design rules. This modification prioritizes corrections in time-sensitive and critical areas of care and in profit centers.

Select Targets to be Corrected First

Three targets, from the top of the master list, are selected to be fixed or corrected. This limited scope is enough to maintain engagement and is not overwhelming. This method centers everyone on the systematic reduction in risk and avoids divergent fixations on low priority, trendy, or random goals.

Gather Information About the Targets

Root Causes of the Safety Risks at the Targets are Identified

A root cause analysis (RCA) of each target is completed. This plays a crucial role in finding solutions to problems. This is vital to fixing the issue and preventing recurrence.

Identify the Points of Care (POC) Surrounding the Targets

The root causes of targets are often complex and involve issues with items located in multiple locations and actions that should take place in several places and at various times. In this step these times and places are identified.

Identify: POC Where Items - Connected to the Target - are Kept

Target corrections require ongoing item preparedness at POC. Because items are used and restocked across different POCs, all of these must be identified. For example, if the goal is to ensure that medication at the point of care (POC) in the nursery meets standards, it is important to involve the pharmacy department’s POC, as this is where medications are sourced and stored.

Identify: Times and Places Where Actions - Related to Target - Should Occur

Actions are needed at POC for safety. For example, the medication in the nursery should be checked before each shift and restocked at the end of shifts and before there is an outage. Here these times and places are identified.

1st Achieve “Item Preparedness” Goals at POC

Safety is critically dependent on correct and timely actions which are critically dependent on having items ready and available at POC. Item preparedness at POC is a first step here. Even the most skilled providers cannot mask-ventilate apneic patients without a self-inflating bag and a proper sized mask.

Preparedness helps skilled providers perform well in routine situations and ensures readiness for unexpected events. It also decreases the amount of time “helpers” spend looking for things during time sensitive emergency care. Even when providers’ skills have gaps, item preparedness is essential because it allows others to assist and manage the situation effectively.

Identify “Item Preparedness” Goals at Each POC  

Achieving and sustaining item preparedness at POC requires a clear understanding of the goals. The goals are international standards or higher and are collected from various sources in the global community.

Make and Perform Assessment Measuring Item Preparedness

Per design rules of this Roadmap, the items at each POC, like the nursing station in the nursery, are divided into groups of related items, like monitoring items and medications or patient assessment items and care items. These groups are on the assessment and for each group there is a % preparedness score. The assessment is performed by going to each POC, looking for the items, and recording what was found. The groups are also on the assessment report that, per design rules, shows the amount of each item that should be at the site or the goals, what was found at the site during the assessment, and what is needed to reach the goal. The goal is to use the assessment process as a constructive experience, showing starting points, goals, and what is needed to achieve them.

The “In-Between-Time” Project Deflation is Proactively Mitigated

The time between the assessment and corrections or the in-between-time is a critical period where almost everything about a project and the momentum to continue – is at great risk of deflation. Here the “in-between time deflation” is announced in advance and proactively mitigated. The courses and workshops that started earlier in the Roadmap continue. They include topics like communications, crisis communications, safety principles and how to apply them in the workplace, hospital policies, protocols, and strategic plan, professionalism, accountability, and others that improve safety at the hospital. They also include topics relating to standardization, organization, checklist use and other skills that will be needed during the correction to make it easier and more familiar. Other events that take place during this time to strengthen the collective safety net at the hospital include fire drills, simulations to prepare for catastrophic events like mass casualty or intruder, and more.

Item Preparedness at POC - Related to the Target - are Corrected

After the data is analyzed, the correction plan is made and implemented. The correction plan may include getting items, creating an inter-department “sharing’ plan, caring for items, standardizing POC sites, making checklists, updating job duties, adding security and oversite and adjusting other tools that make the correction efficient and easy. Oversite ensures safety and equal workloads among staff.

2nd Achieve “Action” Goals at Points of Care

Identify “Action” Goals at POC Related to the Target

With essential items needed for safety in place at POC, individuals and groups must now align their actions with safety requirements. These are collected from the international community.

Make Assessment Measuring “Actions” at POC   

This assessment measures the performance of tasks and how they compare to international standards. Per design rules of this Roadmap, the action goals – at a binary level – are on the assessment and measured. For instance, following the placement of a tracheal tube, the provider’s actions should include auscultating breath sounds over the patient's 1. left and 2. right chest, as well as the 3. abdomen. Measuring the performance of these three actions and not vaguely “verified placement of the tracheal tube” identifies specific actions that are needed for safety and supports exact corrections. Another example includes measuring the performance of the task “attempted to ventilate a patient before placing a tracheal tube.” This measurement is important because, after determining that a patient cannot be ventilated, subsequent procedures are significantly altered, and early awareness of this condition enhances safety. Actions are arranged in groups that are connected, like the induction of anesthesia. Scores are calculated for each group.

Perform Assessment Measuring Actions at POC  

As with the “Item Preparedness” evaluation the goal here is to use the “Action” assessment process as a constructive experience, to support ongoing development with coaching and constructive dialogue afterwards while still showing starting points and goals.

Strengthening General Skills During the “In-Between-Time”

During the period between the assessment and corrections, general skills are practiced and standardized, protocols are reviewed, and simulations are conducted to reinforce skills.

Actions at POC related to the target are corrected

After the data is analyzed, the correction plan is made and implemented. The correction plan may include reviewing, updating, or implementing protocols, offering skills workshops, simulations, and other enrichments, changing processes, updating job descriptions and supporting these with printed material, posters and other things. This step is completed with verification of proficiency of providers and staff.

Debriefing of Target Correction and Celebration

After the correction there is a debriefing, an Ebenezer stone is placed, and there is a celebration! Correcting a target is a massive achievement and is worthy of a celebration.

New Target - or Advancement - is Selected for Correction

Targets are selected for correction until all safety and quality goals are met. At this point the hospital is ready to advance and expand. The steps and tools in this Roadmap can be modified to do this.