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Department of Defense (DoD)Patient SafetyImprovement Guide
Prepared for:
TRICARE Management ActivityDoD Patient Safety Programhttp://dodpatientsafety.usuhs.mil/
Prepared by:
Westat, Rockville, MDMartha Franklin, M.A.Laura Milcetich, M.P.H.Theresa Famolaro, M.P.S.Joann Sorra, Ph.D.
Contract # 233-02-0087Task Order # HHSP23300700002T
March 2009
 
 
DoD PATIENT SAFETY IMPROVEMENT GUIDE
 
i
 
T
ABLE OF
C
ONTENTS
 
Chapter Page
Executive Summary............................................................ iiiPurpose of This Guide......................................................... 11 Survey Background & MHS Results..................................... 32008 MHS Results............................................................... 42 Seven Steps of Action Planning........................................... 7
Step # 1: Understand Your Survey Results............................... 7
 
Step # 2: Communicate and Discuss the Survey Results............ 8
 
Step # 3: Develop Focused Action Plans.................................. 8
 
Step # 4: Communicate Action Plans and Deliverables............... 9
 
Step # 5: Implement Action Plans........................................... 10
 
Step # 6: Track Progress and Evaluate Impact.......................... 10
 
Step # 7: Share What Works.................................................. 11
3 Patient Safety Improvement Practices................................ 12Event Reporting and Nonpunitive Culture........................... 12
 
1.
 
Educating Staff About Medical Events and Event Reporting..... 13
 
2.
 
Maintaining an Open Door Policy About Reporting................. 15
 
3.
 
Making Event Reporting Convenient and Easy....................... 16
 
4.
 
Creating a Nonpunitive Reporting Environment..................... 17
 
5.
 
Providing Feedback and Communicating Lessons Learned...... 19
Handoffs and Transitions.................................................... 20
 
1.
 
Using Handoff Communication Tools................................... 20
 
2.
 
Identifying and Improving Handoffs and Transitions.............. 22
Teamwork........................................................................... 23
 
1.
 
Cross Training and Use of Universal Protocols....................... 23
 
2.
 
Implementing a New Way of Doing Rounds.......................... 23
 
3.
 
Implementing TeamSTEPPS™............................................ 24
Management Support for Patient Safety............................. 25
 
1.
 
Ensuring Leadership Support............................................. 25
 
2.
 
Establishing a Patient Safety Program Manager.................... 26
 
 
DoD PATIENT SAFETY IMPROVEMENT GUIDE
 
ii
 
C
ONTENTS(
CONTINUED
)
Chapter Page
3 Staff Engagement/Ownership............................................. 28
 
1.
 
Establishing Formal Patient Safety Committees..................... 28
 
2.
 
Spreading Ownership Through a Peer-to-Peer Approach......... 29
 
3.
 
Recruiting Facility Experts as Patient Safety Champions......... 29
 
4.
 
Involving Staff From All Levels........................................... 30
 
5.
 
Rewarding Participation in Patient Safety Tasks.................... 31
Raising Staff Awareness of Patient Safety..........................
 
31
 
1.
 
Conducting Short “Pulse” Surveys....................................... 31
 
2.
 
Conducting Leadership Rounds........................................... 31
 
3.
 
Orientation and Other Staff Training................................... 32
Other Improvement Initiatives........................................... 34References.......................................................................... 35
Appendix
A Department of Defense (DoD) 2008 Tri-Service Surveyon Patient Safety................................................................ 36B Department of Defense (DoD) Resources........................... 44
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