MILESTONE: Senior Leader Education and Readiness
Things to Consider: Review your hospital’s attendance to the on-site Sr. Leader Education & Readiness sessions. 1. Did you have all the key senior leaders in the organization (CEO, COO, CNO, CFO, CMO, Board of Trustee member, Human Resources VP, Risk Managers VP, etc.) attend the sessions? 2. If not, how will you bring this information to them? 3. Has the Sr. Team discussed the results from the Readiness Assessment? 4. Are there opportunities to improve Adaptive Leadership in your organization? 5. If so, what will your senior leader team do to improve organizational adaptive capacity? 6. Who will review their roles with them?
WHAT (action)What needs to be done? / ADDITIONAL INFORMATION
or TOOLS NEEDED? / WHO should make this happen? / WHEN will this happen? / COMMENTS
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MILESTONE: Project Team Development
Things to Consider: 1. Did you have all key Project Team members of your organization attend the kick-off learning session on November 5, 2012? 2. If not, who else needs to be added? 3. How will get the information to them? 4. How will you fulfill the roles of the Project Team? How often are you going to meet?
WHAT (action)What needs to be done? / ADDITIONAL INFORMATION
or TOOLS NEEDED? / WHO should make this happen? / WHEN will this happen? / COMMENTS
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MILESTONE: Measurement of Just Culture Principles
Things to Consider: As part of this collaborative your hospital will administer two patient safety culture assessments via AHRQ’s Hospital Survey on Patient Safety Culture, at the beginning and at the conclusion of the collaborative. The survey will be electronic and done through the NC Quality Center. You will need to look at the timing of this and other organizational surveys. What are other metrics that your organization is currently collecting that you can use to measure progress?
WHAT (action)What needs to be done? / ADDITIONAL INFORMATION
or TOOLS NEEDED? / WHO should make this happen? / WHEN will this happen? / COMMENTS
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MILESTONE: Manager Training / Train-the-Trainer Model
Things to consider: This is on-site training (approximately 6 hours) with the goal of developing organizational capacity by educating managers on Just Culture concepts and on how to train Just Culture concepts. Participants to consider attending this session are clinical and non-clinical managers (nurse, physician, pharmacy, respiratory, lab, environmental services, dietary, medical records, etc). When will you schedule this? How will you expand to the rest of the organization? How will you develop on-going education for new managers?
WHAT (action)What needs to be done? / ADDITIONAL INFORMATION
or TOOLS NEEDED? / WHO should make this happen? / WHEN will this happen? / COMMENTS
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MILESTONE: Algorithm Practice
Things to Consider: Algorithm practice should be both internal and external (collaborative). Algorithm practice should be done with clinical and non-clinical staff and should be done on a frequent, regular basis. Consider eventual goal maybe to have multi-department (clinical and non-clinical) regular algorithm practice.
WHAT (action)What needs to be done? / ADDITIONAL INFORMATION
or TOOLS NEEDED? / WHO should make this happen? / WHEN will this happen? / COMMENTS
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MILESTONE: Physician Training
Things to Consider: Who will be your physician champions? How will you approach training? Will you include a physician in manager training? Will you bring this to peer-review? MEC? Department meetings Med staff meetings?
WHAT (action)What needs to be done? / ADDITIONAL INFORMATION
or TOOLS NEEDED? / WHO should make this happen? / WHEN will this happen? / COMMENTS
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MILESTONE: Policy / Procedure Alignment
Things to Consider: Review current policy and procedures (Patient Safety, Human Resources policies including corrective action and Grievance) and how they align with Just Culture? What is your event investigation process? Does it include the correct questions?
WHAT (action)What needs to be done? / ADDITIONAL INFORMATION
or TOOLS NEEDED? / WHO should make this happen? / WHEN will this happen? / COMMENTS
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MILESTONE: Staff Training
Things to Consider: How will train staff? Which tool will you use; Safe Choices, NC Quality Center presentation? Will you develop your own tools? Will you do this at an organizational level or at a local level?
WHAT (action)What needs to be done? / ADDITIONAL INFORMATION
or TOOLS NEEDED? / WHO should make this happen? / WHEN will this happen? / COMMENTS
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MILESTONE: Other______
WHAT (action)What needs to be done? / ADDITIONAL INFORMATION
or TOOLS NEEDED? / WHO should make this happen? / WHEN will this happen? / COMMENTS
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MILESTONE: Other______
WHAT (action)What needs to be done? / ADDITIONAL INFORMATION
or TOOLS NEEDED? / WHO should make this happen? / WHEN will this happen? / COMMENTS
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