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Exit Survey
 
CULTURE 
• Beliefs, attitudes, and behaviors that support safe patient care
• Organizational leaders role model their beliefs and values
Not Implemented Planning to Implement Currently Implementing (in pockets) Implemented but not Hardwired Fully Implemented - part of culture
Just Culture Training for all staff
Just Culture Algorithm for responding to error
Implemented communication tool to stop the line/assert
Safety forums/meetings for leaders across the system to connect
Culture results are shared and acted on at all levels
 
 
LEADERSHIP
• Provides the skill and will to drive culture change.
• Data-driven and relentless about eliminating all-cause harm
• Committed to a culture of safety that welcomes change
Not Implemented Planning to Implement Currently Implementing (in pockets) Implemented but not Hardwired Fully Implemented - part of culture
Board involvement in patient safety and quality
Consistent senior leader rounding
Senior Leader "Adopt a unit Program"
Forum for staff to suggest and participate in improvement
substantial resources (time and money) devoted to continually develop our clinical and non-clinical leaders
 
 
TEAMS
• Instead of a team of experts, an expert team
• Mutual support of other team members within and across units – creates shared mental model
• Train and retrain for ordinary and extraordinary events
Not Implemented Planning to Implement Currently Implementing (in pockets) Implemented but not Hardwired Fully Implemented - part of culture
Teamwork and Communication Program
Daily Safety Huddles
Human Capital Strategy (correct staffing, correct hires, skill mix)
Process improvement strategies at the front line
in-situ Simulation or other ongoing teambuilding activities
 
 
LEARNING
• Promotes and embraces learning from errors and near misses.
• Easily spreading knowledge and best practices across the organization
Not Implemented Planning to Implement Currently Implementing (in pockets) Implemented but not Hardwired Fully Implemented - part of culture
Meaningful RCA process
Forum for reporting errors and learnings
Debriefing across organization
Simulation
Employee forums/ongoing training on patient safety
 
 
IMPLEMENTATION
• Uses reliable change management strategies
• Report mechanisms that are visible, transparent, easy to understand and well SHARED.
• Keeps long-term focus on most critical goals
Not Implemented Planning to Implement Currently Implementing (in pockets) Implemented but not Hardwired Fully Implemented - part of culture
Consistent process and track record for action planning and execution
System/Consistent process for Process Improvement across all departments
Measurement system for improvement patient safety
Leadership support through coaching and accountaility - uhhh
Forums for sharing success/learning/gaining feedback
 
 
PATIENTS
• Makes it a strategic priority that patients and families are always included as part of the team
• Safety and patient satisfaction viewed as interconnected indicators of high performance
Not Implemented Planning to Implement Currently Implementing (in pockets) Implemented but not Hardwired Fully Implemented - part of culture
Patients/Families are involved on advisory committees
Patient Safety and Satisfaction work and metrics are integrated
Patient Safety is consistently reinforced (mission, vision, leadership)
Partners in monitoring for compliance with safety practices.
Staff follow a standardized and effective method of sharing information when handing off patient.
Patient input is solicited and acted on
 
 
 
Other Major initiatives
   
 
 
 
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