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Learn It, Lead It, Live It: Strategies for Creating a Culture of Safety
Kathleen Vollman MSN, RN, CCNS, FCCM, FCNS, FAANClinical Nurse Specialist, Educator, Consultant
ADVANCING NURSING LLC, Northville [email protected]
©ADVANCING NURISNG LLC 2019
Disclosures for Kathleen Vollman
• Consultant-Michigan Hospital Association Keystone Center
• Subject matter expert for CAUTI and CLABSI, HAPI, C-Diff and Sepsis for CMS/HIIN
• Consultant and speaker bureau:– Sage Products LLC
• Will be addressing an off label use of a 2% CHG pre-op prep cloth
– Eloquest Healthcare– Urology division of Medline
Industries– Baxter Healthcare Advisory
Board
Objectives
• Discuss factors that contributed to quality and safety challenges from a nursing perspective
• Determine strategies to assess organizational and unit culture
• Identify organizational and unit infrastructure necessary to support a quality and safety culture
• Compare and contrast tools and techniques used on the front line to build a quality and safety culture and how to measure improvement
It is Time to Change!!
• HAC refers to a complication for which clinical risk mitigation strategies may reduce (but not necessarily eliminate) the risk of that complication occurring.
• 2017–18, admissions associated with hospital-acquired complications (HACs) cost the public sector $4.1 billion or 8.9% of total hospital expenditure.
Australian Commission on Safety and Quality in Health Care. The state of patient safety and q quality in Australian hospitals 2019. Sydney; ACSQHC, 2019.
HAC’s/HAI’s
Australian Commission on Safety and Quality in Health Care. The state of patient safety and q quality in Australian hospitals 2019. Sydney; ACSQHC, 2019.
HAIs are one of the most common complicationsaffecting hospital patients; they increase the risk of morbidity, mortality & readmission within 12 months
What If!!!
Australian Commission on Safety and Quality in Health Care. The state of patient safety and q quality in Australian hospitals 2019. Sydney; ACSQHC, 2019.
Safety and Quality
• Safety has to do with lack of harm. Quality has to do with efficient, effective, purposeful care that gets the job done at the right time.
• Safety focuses on avoiding bad events. Quality focuses on doing things well.
• Safety makes it less likely that mistakes happen. Quality raises the ceiling, so the overall care experience is a better one.
Understanding The Journey
NursingOrganizations
That’s not the way we do it here!!!
What is a Culture?
Represents a set of shared attitudes, values, goals, practice & behaviors that makes one unit distinct from the next
Pronovost, PJ et al. Clin Chest Med, 2009;30:169-179
Driving Components in a Work Culture
Reasons for Confusion & Disillusionment in Nursing
A narrow definition of health How we define autonomy Nursing’s unique contribution Absence of recognition for basic nursing care
activities
Vollman KM, Stewart KH. AACN Clin Issues. 1996;7(2):315-323.
A
Narrow
Definition
of
Health
Medicine’s Health Definition
The absence of disease and measured in terms of morbidity and mortality
Nightingale’s Health Definition
Health is not only to be well but to be able to use what ever power we have.
1st American Nurses Association’s Health Definition
A dynamic state of being in which the development and behavioral potential of an individual is realized to the fullest extent possible.
Social Policy Statement 1980
Lyon’s Health Definition
Health is the dynamic subjective quality of person-environment interaction which is expressed in a person’s composite evaluation of the somatic sense of self and functional ability.
Wellness & IllnessWellness & Illness
Wellness is comfortable somatic sensations accompanied by optimal functional ability whether we have a disease or not
Illness is uncomfortable somatic sensations or a decreased functional ability whether we have a disease or not
Autonomy
Means the self-directed diagnosis & treatment or it is a self determined and controlled action that does not require authorization from another
Confusing Autonomous Scope of Practice
Setting Judgments
AutonomousNursingScope of Practice
MedicalNursingScope of Practice
Florence Nightingale …
An expert in nursing’s autonomous scope of practice
Surveillance & monitoring of patient conditions for early detection of problems
Preventing complications
“I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all of these at the least expense of vital power to the patient”
Notes on Nursing (1860/1969 p. 8)
Florence Nightingale on:
The distinction between disease and illness
“… so deep-rooted and universal is the conviction that to give medicine is to be doing something or RATHER EVERYTHING; to give air, warmth, cleanliness, etc., is to do nothing.”
(emphasis added) Notes on Nursing, (1860/1969, pg. 9)
Self Directed Treatment Categories for Nursing
Hygiene-related activities Nutrition-related activities Elimination-related
activities Comfort-related activities Movement-related
activities Rest/activity relate
activities Learning and
development-related activities
Safety-related activities
Sense of normalcy-related activities
Interaction-related activities
Coping-related activities Physical environment-
related activities Alteration in ADL-related
activities
Recognition & Reprimand Structures within Acute Care Settings
• Recognition• Physiologic assessment • Completing medical treatments in a timely
fashion• Assisting physicians with activities
• Reprimand• Medication administration• Questioning content of medical orders
Behavior that is recognized and reinforced continues
Behavior that is ignored or not reinforced does not continue
Missed Nursing Care
• Any aspect of required patient care that is omitted (either in part or whole) or significantly delayed.
• A predictor of patient outcomes• Measures the process of nursing care
Kalish, R. et al. (2012) Am Jour Med Quality, 26(4), 291-299.
Hospital Variation in Missed Nursing Care
Kalish, R. et al. (2012) Am Jour Med Quality, 26(4), 291-299.
Patient Perceptions of Missed Nursing Care
Kalisch, B et al. (2012). TJC Jour Qual Patient Safety,38(4), 161-167.
Outcomes of Missed Nursing Care: A Systematic Review
• 14 studies connecting missed nursing care with at least 1 patient outcome• Patient Satisfaction ↓ • Lower quality of care reported by nurses with greater missed care • Clinical Outcomes
• Medication errors• CLA-BSI’s• Pneumonia• UTI’s• Pressure Injuries• Falls• Failure to rescue
Recio-Saucedo A, et al. J of Clin Nurs. 2018;27:2248-2259
5 nurse sensitive adverse events in 22 med-surg units added
1300 additional hospital days for 166 patients &
$ 600,000 in excess costs
Tchouaket E. JAN. 2017;73:1696
Reasons for Missed Nursing Care
Kalisch, BJ, et al. American Journal of Medical Quality. 2011; 26(4), 291–299Ball JE, et al. BMJ Quality and Safety 2014 Feb;23(2):116-25.
9.4% variance in missed nursing care
Qualitative Review• Interruptions/multitasking/task
switching• Fatigue & physical exhaustion• Cognitive biases• Lack of patient & family
engagement• Lack of physician resources• Leadership issues• Moral distress & compassion fatigue• Documentation load• Large proportion of new nurses on
unit• ComplacencyPractice environment correlates to missed nursing care
Rationing Care-How we Prioritize
• Highest priority activities for nurses• Those which are likely to have an immediate negative
impact• Administering meds• Medical directed treatments• Procedures-wound dressings, labs
• Lower priority activities for nurses• Those which show no immediate negative harm
• Ambulation• Oral hygiene• Emotional support• Teaching
Bail K, et al. International Journal of Nursing Studies. 2016;63:146-161
Rationing contributes to functional and cognitive decline
Fundamentals of Care Framework
The Fundamentals of Care Framework. Reprinted from Conroy, Feo, Alderman, and Kitson (2016)
• Fundamental care involves actions on the part of the nurse that respect and focus on a persons essential needs to ensure their physical & psychosocial wellbeing.
• These needs are met by developing a positive & trusting relationship with the person being care for as well as their families/carers
Feo R, et al. J of Clin Nurs. 2018;27:2285-2299
Reconnect With Our Professional Purpose
“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”
Florence NightingaleNotes on Hospitals: 1859
Advocacy = Safety
Protect The Patient From Bad Things
Happening on Your Watch
Interventional Patient Hygiene
• Hygiene…the science and practice of the establishment and maintenance of health
• Interventional Patient Hygiene….nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies
Incontinence Associated Dermatitis Prevention
Program
INTERVENTIONAL PATIENT HYGIENE(IPH)
Oral Care/ Mobility
VAP/HAP
Catheter Care
CA-UTI CLA-BSI
Skin Care/ Bathing/Mobility
HASISSI
Patient
Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154
Falls
PATIENT
CLEAN GLOVES
CLEAN GLOVES
HAND HYGIENE
HAND HYGIENE
INTERVENTIONAL PATIENT
HYGIENE(IPH):The Physical
Fundamentals of CareOral Care/
Mobility/Comfort
VAP/HAP
Medication Management
CA-UTI CLA-BSI
Skin Care/NutritionBathing/Mobility
SSI
Patient
Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154
PATIENT
CLEAN GLOVES
CLEAN GLOVES
HAND HYGIENE
HAND HYGIENE
VTECatheter Care
Falls
HASI
SSI
Adverse Drug Events/
Medication Errors
Attitude &
Accountability
Factors Impacting theability to Achieve QualityNursing Outcomesat the Point of Care
Achieving the Use of the Evidence
ValueVollman KM. Intensive & Critical Care Nursing, 2013 Oct; 29(5): 250-5
Preventing NV-HAP Through Evidence Based Fundamental
Nursing Care Strategies
Slides courtesy of Barbara Quinn
Why NV-HAP?: DO NO HARM
• HAP 1st most common HAI in U.S.• Increased morbidity 50% are not discharged back home• Increased mortality 18%-29%• Extended LOS 4-9 days• Increased Cost $28K to $109K• 2x likely for readmission <30 day
• Understudied, under-addressed• Focus has been on the other HAP VAP• Surveillance not required….yet
Kollef M.H. et.al. (2005). Chest. 128, 3854-3862ATS, (2005). AmJ Respir Crit Care Med. 171, 388-416.Lynch (2001) Chest. 119, 373S-384S.
Pennsylvania Dept. of Public Health (2010).
Pathogenesis Prevention
Germs in Mouth
• Dental plaque provides microhabitat• Bacteria replicate 5X/24 hrs
Aspirated into Lungs
• Most common route• 50% of healthy adults micro-aspirate
in sleep
Weak Defenses
• Poor cough• Immunosuppressed• Multiple co-morbidities
NV‐HAP SMCS Research Findings: 2010
Incidence:• 115 adults• 62% non-ICU• 50% surgical• Average age 66• Common comorbidities: CAD, COPD, DM, GERD
• Common Risk Factors: Dependent for ADLs (80%) CNS depressant meds (79%)
Quinn, B. et al. Journal of Nursing Scholarship, 2014. 46(1):11-19
Cost:• $4.6 million• 23 lives• Mean Extended LOS 9 days• 1035 extra days
SMCS HAP Prevention Plan
Phase 1: Oral Care
• Formation of new quality team: Hospital-Acquired Pneumonia Prevention Initiative (HAPPI)
• New oral care protocol to include non-ventilated patients
• New oral care products and equipment for all patients
• Staff education and in-services on products
• Ongoing monitoring and measurement– Monthly audits
Quinn B, et al. J of Nursing Scholarship, 2014, 46(1):11-19
Protocol – Plain & Simple
Patient Type Tools Procedure FrequencySelf Care / Assist
Brush, paste, rinse, moisturizer
Provide toolsBrush 1-2 minutesRinse
4 X / day
Dependent / Aspiration Risk
Suctiontoothbrush kit (4)
Package instructions 4 X / day
Dependent / Vent
ICU Suction toothbrush kit (6)
Package instructions 6 X / day
Dentures Tools +CleanserAdhesive
Remove dentures & soakBrush gums, mouthRinse
4X / day
NV-HAP Incidence 50 % Decrease from Baseline
0
2
4
6
8
10
12
14
16
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20
JAN
201
0
FEB
2010
MAR
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APR
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MAY
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2010
AUG
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SEP
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OC
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10
DEC
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3
Num
ber o
f non
-ven
tilat
or H
AP
case
s
Month/Year
Control chart for NV-HAP January 2010 to December 2013
UCL
LCL
Average
Oral CareBaseline
Return on Investment
60 NV-HAP avoided Jan 1 – Dec. 31 2013 $2,400,000 cost avoided- 117,600 cost increase for supplies $2,282,400 return on investment
•8 lives saved
NV-HAP 70% from baseline!
0
2
4
6
8
10
12
14
16
18
20
JAN
201
0FE
B 20
10M
AR 2
010
APR
201
0M
AY 2
010
JUN
201
0JU
L 20
10AU
G 2
010
SEP
2010
OC
T 20
10N
OV
2010
DEC
201
0M
AY 2
012
JUN
201
2JU
L 20
12AU
G 2
012
SEP
2012
OC
T 20
12N
OV
2012
DEC
201
2JA
N 2
013
FEB
2013
MAR
201
3AP
R 2
013
MAY
201
3JU
N 2
013
JUL
2013
AUG
201
3SE
P 20
13O
CT
2013
NO
V 20
13D
EC 2
013
JAN
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4FE
B 20
14M
AR 2
014
APR
201
4M
AY 2
014
JUL
2014
AUG
201
4SE
P 20
14O
CT
2014
NO
V 20
14D
EC 2
014
Num
ber o
f non
-ven
tilat
or H
AP
case
s
Control chart for non-ventilator HAP January 2010 to December 2014
UCL
LCL
Mean
Oral care for all adult pts
Started oral care prior to surgery
Quinn B, Presented at AACN NTI, Houston, Tx, 2017
Pharmacy starts PPI protocol
NGT standards revised
Baseline
Documentation
Mandatory Education for Nurse Assistants
Driving Components in a Work Culture
Number 1 Respected Profession
So Why Don’t We Feel Respected?
NursingGallup Poll: 82% Honesty & Ethical Rating
Reclaiming Professional Respect
What Behaviors or Communications Make You Feel the Recipient of Respect?
Work EnvironmentQuality of Care You Provide to Patient & Families
Feeling of Respect or Not being Respected Bournes DA, et al. Nursing Science Quarterly, 2009;22(1):47-56
• Respected• Feeling listen to• Feeling revered for their
knowledge• Feeling trusted• Feel part of the group• Being acknowledged• Sense of belonging/contributing• Persons look out for each other
and their support• Fairness• Free to speak• Opportunities to excel
• Not Being Respected• Disregarded• Not revered• Not trusted• Not supported• Not recognized• Closed conversation• Speaking in a tone that is
demeaning• Ideas and opinions not
considered a value priority• Unsafe, guarded,
pressured, put down
Respect
Self Respect
Self Respect
Internal Dialogue External Dialogue
Culture of Respect
• Develop effective methods for responding to episodes of disrespectful behavior
• Initiating cultural changes needed to prevent the episodes
• Disrespectful behavior must be addressed consistently and transparently
• Organization set up a code of conduct and it must be enforced
• Culture of respect requires building a shared vision
Leape LL, et al. Academic Medicine, 2012;87(7):853-858
The Road to Respect
I spoke.You listened.I felt valued and honored.You shared your opinion.I trusted your wisdom.The circle of respect was complete.We saw in each other’s eyes are common humanity.Now, moving to a zone of mutual affirmation, we felt safe to trust and learn and nurture in the give-and-take of life.
Yasmin Morais 2006
Culture Assessment is Critical
Assessment of Safety & Work Culture-Organization & Unit
• SAQ (Safety Attitudes Questionnaire)• Teamwork• Safety• Working conditions• Job satisfaction• Stress recognition• Perception of upper management• Perception of unit management
Strive for 80%, if > 60% SAQ scores correlates to decreases in clinical outcomes
AACN Healthy Work Environment Assessment tool-Unit Level
• Skilled communication• True collaboration• Effective decision making• Appropriate staffing• Meaningful recognition• Authentic leadership
Unit Culture Assessment
Tweeners
PositronsNegatoids
If you Permit it you Promote it
Understanding The Journey
Nursing Organizations
Health Care QualityDonabedian Framework
STRUCTURE PROCESS OUTCOME
Having the right things in place
Doing the right things
Having the right things happen
Quality of care is represented by an entire systemic integration from structure to process and to outcome,
but not by one or the other independently
Organizational & Unit Structures that Supported the Empowerment
Shared Governance Model
Continuous Quality Improvement Model
Professional Practice Model/Clinical Ladder
Unit Based Leadership Model
Educational Support
Foundational Principles to Maximize Staff Empowerment
• The Unit is the center of a shared governance model..the locus of control is at the point of service
• Staff need mentoring and leadership coaching• Shared leadership means the clinical and administrative
lead of the unit are part of the unit practice/governance council
• Defined accountability of all members• Sufficient time in meetings to formulate ideas and plan
work (unit meeting 4hrs)
Example Structure:Unit Based Accountability Teams
• Every patient care unit in hospital or group practice• Composition: Medical Director, Nurse manager, Clinical
Nurse Specialist, System Performance Improvement Leader
• Responsibilities:• Establish clinical/quality goals for unit• Responsible for unit outcomes---unit dashboard
• Clinical and operation measures• Quality• Patient Safety and safety culture• Patient satisfaction• Employee satisfaction
One of the reasons people don’t achieve their dreams is that they desire to change
their results without changing their thinking
John C. Maxwell
A Large Part of Your Success in Driving Change Occurs Around the
Ability to Lead or Influence
Leadership in Driving Change• The essence of leadership is influence over
others. But, influence is not unidirectional.• You do not need a formal title to be a leader• Understanding power relationships and
influence strategies in organizations is essential to drive change and effective team work
http://accurate.clemson.edu/becker//prtm320/notes/power320.pdf
“If your actions inspire others to dream more, learn more, do more, and become more, you are a
Leader”
John Quincy Adams
Understanding How You Influence
Legitimate Power– Authoritative
power derived from a job, position, or status and held as belonging to the person in such a position.
Expert Power– Based on a
person’s expertise, competence, and information in a certain area.
Power is the engine that drives the ability to influence
Referent Power― Based on a
high level of identification with, admiration of, or respect for the power holder/leader.
Potential Reactions to Individual Sources of Power
• Coercive Power
• Reward Power
• Legitimate Power
• Expert Power
• Referent Power
Resistance
Compliance
Commitment
“Setting an Example is Not the Main Means of Influencing Others….It
is the Only Means”Albert Einstein
The Most Powerful Force of Human Behavior is Social Influence
Changing the Routine
• Implementation science: study of methods to promote uptake of clinical research findings and make them the new routine• Identification of need• Team Assembly• Tools & Methods• Implementation• Measuring success
Murphy DM, et al. APIC. 2012;40:296-303Babine RL, et al. J of Nursing Management, 2016;24:39-49
Models/Frameworks Used to Guide Change
Iowa Model
John Hopkins Translating Evidence into Practice Model
Process = Strategies for Creating a Safety Culture
CUSP
Huddles
Crucial Conversations
PDCA
Multidisciplinary Rounds
Learn From a Defect
Comprehensive Unit-Based Patient Safety Program (CUSP)
• Assess culture of safety (SAQ & AHRQ)• Educate staff on science of safety
http://www.safetyresearch.jhu.eduhouse staff orientation
• Identify defects• Learn from one defect per quarter• Assign executive to adopt unit• Implement team/communication tools• Reassess culture annually
www.aone.org/hret/programs/cusp.html
CUSP in Partnership with Technical Interventions for Improvement
• CUSP + VAP• CUSP + CAUTI• CUSP + CLA-BSI
HAI Progress Reports 2014-2016↓ VAP’s by 32%↓ CLABSI by 31%↓ VTE by 21%↓ ADE by 15%↓ C. difficile by 11%
Patient Advocacy/Safety Related to Clinical Practice
• Nurses knowledge of the Evidence based care• Ability to deliver the care to the right patient at the right time,
every time it is needed• The ability to communicate patient concerns in a concise,
data driven manner and take appropriate action• Understanding the chain of command when faced with
resistance and that we are the patients voice
What Supports Our Ability to Advocate & Use the Evidence?
• Leadership support• Evidence-based knowledge• Experience• Effective communication• Respectful communication and being respected
• Goes both ways• If we as nurse don’t know or believe something different than
the doctors order what should we do?• Understanding that it’s worth it!!!!!
George Bernard Shaw
“Our lives begin to end the day we become silent
about things that matter”
Martin Luther King Jr.
Effective Communication and Teamwork Requires:
• Structured Communication
• Assertion/Critical Language
• Psychological Safety
• Effective Leadership
• SBAR (Situation-Behavior-Assessment-Recommendation), structured handoffs,
• Key words, CUS, the ability to speak up and stop the show, STAR (stop, think, act & review)
• An environment of respect
• Flat hierarchy, sharing the plan, continuously inviting other team members into the conversation, explicitly asking people to share questions or concerns, using people’s names
Manser T. Acta Anaesthesiol Scand, 2009;53:143-151
Communication Training
Communication Strategies
• Tools to help structure communication for Safety• CUS Words: I am Concerned, I am
Uncomfortable, This is not Safe• ARCC:
• Ask a question to gently prompt the other person of a potential safety issue.
• Request a change to make the person fully aware of the risk.
• Voice a concern if the person is resistant.• Finally, use the chain of command if
Tools and Strategies to Improve Communication and Teamwork
• Huddles• Learn from a defect• Daily rounds/goals• Pre-procedure briefing• Morning Briefing
Huddles• Enable teams to have frequent but short briefings
so that they can stay informed, review work, make plans, and move ahead rapidly.
• Allow fuller participation of front-line staff and bedside caregivers, who often find it impossible to get away for the conventional hour-long improvement team meetings.
• They keep momentum going, as teams are able to meet more frequently.
Metrics Don’t Change Until You Have Been Successful
Learn from a Defect Tool• Designed to rigorously
analyze the various components and conditions that contributed to an adverse event and is likely to be successful in the elimination of future occurrences.
• Tool can serve to organize factors that may have contributed to the defect and provides a logical approach to breaking down faulty system issues.
Huddle Issues Requiring In-Depth Review Gets the Full Drill Down
Multidisciplinary/Interdisciplinary Rounds with Daily Goals
• Purpose: Improve communication among care team and family members regarding the patient’s plan of care• Goals should be specific and measurable• Documented where all care team members have access• Checklist used during rounds prompts caregivers to focus
on what needs to be accomplished that day to safely move the patient closer to transfer out of the ICU
• Use of checklists result in knowledge of the plan of care among clinicians, a culture of teamwork & safety and clinical, financial and service outcomes
• Evidence of reduced mortality in ICU’s that use daily multidisciplinary rounds (Kim MM. et al Arch Intern Med. 2010;170(4):369-376)
Halm MA. AJCC, 2008;17:577-580
RN Starts Round with Vital SignsThen Integrates The Checklist
The Silent Treatment, April 20
Helpful Hints to an Empowered Practice
• Encourage staff to be a part of unit governance council or on projects or task forces to solve clinical issues with the evidence
• Start up a journal club or participate…help them learn to read evidence
• Strategies to impact value of practice
It Takes a Village
Measurement is Key
Nurse Sensitive Care Indicators
• Death among surgical patients with treatable serious complication
• Pressure ulcer prevalence• Falls prevalence• Falls with injury• Restraint prevalence (vest
& limb only• UTI rate/ICU• Blood stream infections
(BSI) from invasive catheters (ICU and high risk nursery)
• Ventilator-associated pneumonia (VAP and high risk nursery)
• Smoking cessation for AMI
• Smoking cessation counseling for heart failure and pneumonia
• Skill mix• Nursing care hours per
day• Voluntary turnover• Nursing Environment
IndexNursing Quality Forum 2004
Additional Measures
• Non-ventilator hospital acquired pneumonia• Employee satisfaction• Retention of qualified experience staff• Staff Empowerment
• Culture and healthy work environment tools• Participation in process improvement & committees• Presentations-posters and podiums• Actively engaged in problem solving
“Quality is never an accident. It represents the wise choice of many
alternatives.”
Willa Foster
Health Care Quality Outcomes
Positive Patient
Outcomes
Satisfied Patients & Families
Positive Safety Culture
Engaged & Satisfied
Employees
Cost Efficient Care
Evidence Based Care
Accountable Leadership