High Reliability and Culture of Safety Toolkit
Patient safety is a priority in healthcare. This guide is to assist in promoting a highly reliable staff and maintain a culture of safety throughout the facility with tools to guide them including a video demonstration, education, monitoring assessments, podcasts, articles, webinars and numerous resources. This education, along with interventions, allows staff to provide reliable care to every patient while minimizing risks and placing safety first.High Reliability Organizational Toolkit
It is important to incorporate certain characteristics into your organization which are associated with improved outcomes in other industries where safety is paramount. This section is organized into the five key characteristics of highly reliable organizations and contains tools and other resources to help you strive toward incorporating these characteristics into your organization’s culture.
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Reluctance for Simple Explanations- RCA Matrix
A matrix designed by The Joint Commission to identify specific areas that need to be investigated during a RCA of a sentinel event.
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Reluctance for Simple Explanations- FMEA
A quick reference to use when conducting an FMEA. This resources guides you through steps, probability and severity ranking and development of plans for improvement of a process.
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Reluctance for Simple Explanations- Impact of Staff-Led Safety Walk Rounds
An article to support the benefits of leadership rounds in safety.
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Preoccupation with Failures- Best Practices Checklist as Gap Analysis
A gap analysis designed to assist organizations at evaluating current practices against best practices in their journey to being highly reliable.
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Preoccupation with Failures- Reliability: Developing a Culture for Patient Safety and Experience
An informative powerpoint presentation from IHI discussing how to develop a culture of safety that supports patient care.
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Defer to Expertise- Facility Survey on Patient Safety
Sample culture of safety survey from AHRQ.
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Defer to Expertise- Sentinel Event Alert
Sentinel Event Alert Issue #57 from The Joint Commission discussing culture of safety.
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Resiliency- Leadership Template
A sample guide for leaders to improve the culture of safety.
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Resiliency- Monthly Meeting Model
A sample guide to conducting monthly meetings with employees that support culture of safety.
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Resiliency- Skillset Matrix
A worksheet for the Leadership Team to evaluate gaps in skills.
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Best Practices Checklist as Gap Analysis- Handoff Sample Tools
A selection of sample handoff communication tools.
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Best Practices Checklist as Gap Analysis- Importance of Debriefing
A list of points to remember during a debriefing with a patient.
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Best Practices Checklist as Gap Analysis- Tips to Bedside Reporting
Great tips for staff to improve bedside reporting of patient care.
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Best Practices Checklist as Gap Analysis- Scripts for Bedside Reporting
Tool that discusses the value of bedside reporting plus sample scripts staff can customize and use in real time.
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Best Practices Checklist as Gap Analysis- Best Practice - Braden Scale
A evidence-based tool to aid in consistent, standardized staging of pressure ulcers.
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Best Practices Checklist as Gap Analysis- Best Practice - Morse Scale
A sample tool to help identify patients at high risk for falls while in the hospital.
Characteristics of High Reliability Organizations (HROs)
Highly reliable organizations tend to display certain characteristics in their processes and systems that make them exceptionally successful in meeting goals and avoiding errors. This section provides more information on the key traits that these organizations share and how to set off on your organization's own jouney toward high reliability.
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Webinar: The Journey to Becoming an HRO
This webinar is meant to increase your knowledge related to characteristics that Highly Reliable Organizations exhibit and help you understand some best practices that can be incorporated into your organizations’ culture.
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High Reliability: The Gold Standard in Healthcare
A collection of resources from The Joint Commission Center for Transforming Care that provides the framework for organizing an organization's journey toward high reliability. The framework focuses on three areas: leadership commitment, safety culture and an empowered workforce.
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AHRQ High Reliability
High reliability organizations display certain characteristics. This information on AHRQ's PSNet site describes the five characteristics of highly reliable organizations.
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NCPS Approach to Achieving High Reliability
Description of each characteristic of high reliabilty organizations provided by the VA National Center for Patient Safety.
Best Practices of Highly Reliable Organizations
Tools and information that are helpful in developing processes to support the journey to high reliability. Organizations that implement similar processes are displaying characteristics of highly reliable organizations.
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10 Patient Handoff Communication Tools
Article that provides a list of 10 ideas to improve communication with patient handoffs.
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IHI: Patient Safety Leadership WalkRounds™
A tool developed to facilitate leadership walk rounds. The tool gives suggestions on the types of questions leaders should ask staff, who should be involved and where the rounds should be conducted.
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Daily Huddle Component Kit
Step-by-step instruction from AHRQ on how to develop a process for daily huddles.
Creating an Organizational Culture of Safety
Creating an organizational culture of safety is a daunting task that requires patience, persistence and consistency. This section provides a collection of resources to help guide the organization in creating an environment committed to a Just Culture.
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Safety Culture and Leadership: A View from The Joint Commission
This slide presentation from The Joint Commission discusses how to develop a culture of safety in your organization.
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Just Culture Sample Policy
This sample policy addresses organizational commitment to Just Culture.
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Webinar: Creating Organizational Change Using Your Culture of Safety Survey Results
This webinar communicates best practices for administering surveys, debriefing results, formulating action plans and monitoring cultural change with readily available, open resource material from AHRQ, IHI and other quality/patient safety organizations.
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Develop a Culture of Safety
A step-by-step guide from IHI on how to create a culture of safety within the organization. This resource provides information on the role of the patient safety officer, how to address adverse events when they occur and various types of programs that can be created to facilitate the process.