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Intermediate

The Essential Guide for Patient Safety Officers, Second Edition

December 2012. 160 pages.

  • An individual license is intended for single users only. This ebook cannot be shared, disseminated, downloaded, or posted for widespread or public use. 
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$69.00 - $79.00
Product Description

Product Description

Foreword by Gary Kaplan, MD, Chairman and CEO, Virginia Mason Health System, Seattle

The Essential Guide for Patient Safety Officers, Second Edition, copublished with the Institute for Healthcare Improvement (IHI), is a comprehensive and authoritative repository of essential knowledge on operationalizing patient safety. Patient safety officers must make sure their organizations create a safety culture, implement new safety practices, and improve safety-related management and operations. This updated edition of a JCR best seller, with many new chapters, will help them do that. Edited by Allan Frankel, MD; Michael Leonard, MD; Frank Federico, RPh; Karen Frush, MD; and Carol Haraden, PhD, this book provides:

  • Core knowledge and insights for patient safety leaders, clinicians, change agents, and other staff
  • Strategies and best practices for day-to-day operational issues
  • Patient safety strategies and initiatives
  • Tools, checklists, and guidelines to assess, improve, and monitor patient safety functions
  • Expert guidance on leadership’s role, assessing and improving safety culture, designing for reliability and resilience, ensuring patient involvement, using technology to enhance safety, and building and sustaining a learning system—and other essential topics

The work described in the book reveals growing insight into the complex task of taking care of patients safely as an intrinsic, inseparable part of quality care. To do this we need to create a systematic, integrated approach, and this book shows us how to do it.
—Gary S. Kaplan, MD, Chairman and CEO, Virginia Mason Medical Center, Seattle

Table of Contents

Table of Contents

Table of Contents
 
FOREWORD 
Gary S. Kaplan, MD 
 
CONTRIBUTORS 
 
INTRODUCTION: CREATING A ROAD MAP FOR PATIENT SAFETY 
Michael Leonard, MD; Allan Frankel, MD; Frank Federico, RPh; Karen Frush, BSN, MD; Carol Haraden, PhD 
 
CHAPTER ONE: THE ROLE OF LEADERSHIP 
Doug Bonacum, MBA, BS; Karen Frush, BSN, MD; Barbara Balik, RN, EdD; James Conway, MS
Establish, Oversee, and Communicate System-Level Aims
Identify Harm, Design and Implement Improvements, and Track/Measure Performance over Time
Assess the Culture for Safety and Act to Close Any Gaps
Understand the Science of Improvement and Reliability
Foster Transparency
Create a Leadership Promise
Engage Physicians, Nurses, and Other Clinicians 
Hire for What You Aspire to Become 
Involve Board Leadership in Safety
 
CHAPTER TWO: ASSESSING AND IMPROVING SAFETY CULTURE
Natasha Scott, MSc; Allan Frankel, MD; Michael Leonard, MD
What Is Safety Culture?
Linking Culture and Leadership
Why Is Safety Culture Important?
Assessing Safety Culture
Safety Culture Assessment Tools
Linking Safety Culture Assessment to Improvement
Conclusion
 
CHAPTER THREE: ACCOUNTABILITY AND THE REALITY OF THE HUMAN CONDITION
Allan Frankel, MD; Frank Federico, RPh; Michael Leonard, MD
Defining a Just Culture
Establishing an Accountability System
Why Is an Accountability System Important?
How to Create a Just Accountability System
Relentlessly Reinforce the Message
 
CHAPTER FOUR: RELIABILITY AND RESILIENCE
Roger Resar, MD; Frank Federico, RPh; Doug Bonacum, MBA, BS; Carol Haraden, PhD 
What Is Reliability? 
Why Do Organizations Struggle with Reliability? 
Designing for Reliability 
Addressing the Cultural Aspects of Reliability 
Pursuing Risk Resilience 
 
CHAPTER FIVE: SYSTEMATIC FLOW OF INFORMATION: THE EVOLUTION OF WALKROUNDS 
Allan Frankel, MD; Sarah Pratt, MPH 
Reflections 
A Guide to Conduct WalkRounds 
 
CHAPTER SIX: EFFECTIVE TEAMWORK AND COMMUNICATION 
Karen Frush, BSN, MD; Michael Leonard, MD; Allan Frankel, MD 
Why Is Effective Communication So Difficult in Health Care? 
Structures That Enhance Teamwork and Communication 
Training for Effective Teamwork and Communication
 
CHAPTER SEVEN: USING DIRECT OBSERVATION AND FEEDBACK TO MONITOR TEAM PERFORMANCE 
Allan Frankel, MD; Andrew P. Knight, PhD 
How to Use Direct Observation
Methods of Direct Observation
 
CHAPTER EIGHT: DISCLOSURE
Doug Bonacum, MBA, BS; James Conway, MS; Douglas Salvador, MD, MPH 
Disclosing Adverse Events
Leadership Commitment to Disclosure Is Critical
Other Items to Consider
How to Disclose
The Benefits of a Health Care Ombudsman/Mediator (HCOM) Program
Conclusion
 
CHAPTER NINE: ENSURING PATIENT INVOLVEMENT AND FAMILY ENGAGEMENT 
Mary Ann Abrams, MD, MPH; Gail Nielsen, BSHCA, FAHRA, RTR; Karen Frush, BSN, MD; Barbara Balik, RN, EdD 
Ways to Partner with Patients
Addressing Patient Literacy
Summary
 
CHAPTER TEN: USING TECHNOLOGY TO ENHANCE SAFETY 
Jeffrey P. Brown, MEd; Jackie Tonkel, BSBA; David C. Classen, MD, MS
Current State of Health Care Information Technology
Looking Forward: Patient Safety and HIT—The IOM Report
Challenges in Improving Safety with HIT
Health Care Is a Sociotechnical Endeavor
Component-Centered Versus System-Based Safety Management
Considerations for System-Based Safety Management
Maximizing the Benefits of HIT
Conclusion
 
CHAPTER ELEVEN: MEASUREMENT STRATEGIES 
Robert C. Lloyd, PhD
The Context for Health Care Measurement
The Quality Measurement Journey
 
CHAPTER TWELVE: CARE PROCESS IMPROVEMENT 
Allan Frankel, MD; Carol Haraden, PhD; David Munch, MD 
The Model for Improvement
Lean Methodology
Six Sigma
Tools for Use in Performance Improvement
Failure Mode and Effects Analysis
Root Cause Analysis
 
CHAPTER THIRTEEN: BUILDING AND SUSTAINING A LEARNING SYSTEM—FROM THEORY TO ACTION
Allan Frankel, MD; Michael Leonard, MD
Introduction
Organizational Physicians
The Four Organs of Learning
The Four Organs of Culture
Assessing and Treating the Organization
Summary
 
INDEX
Contributors

Contributors

About the Editors

 
Michael Leonard, MD, is a founder and managing partner of Safe and Reliable Healthcare, an organization that strives to improve patient safety and clinical quality. He is faculty for the Institute for Healthcare Improvement in Cambridge, Massachusetts. Leonard earned his doctor of medicine from the University of Missouri-Columbia School of Medicine.
 
Allan Frankel, MD, also a managing partner at Safe and Reliable Healthcare and has been faculty at the Institute for Healthcare Improvement Open School for 20 years. Frankel earned his doctor of medicine from Boston University School of Medicine.
 
Frank Federico, RPh, is vice president and senior safety expert at the Institute for Healthcare Improvement. He is faculty for the Patient Safety Executive Development Program as well as vice-chair of the Joint Commission Patient Safety Advisory Group.
 
Karen Frush, BSN, MD, is chief patient safety officer for the Duke University Health System as well as vice president at LifePoint Health. She is an associate professor of the pediatrics and an assistant professor at the Duke University School of Nursing. Frush graduated from the University of Pittsburg School of Nursing and she earned her doctor of medicine from Duke University School of medicine.
 
Carol Haraden, PhD, is vice president at the Institute for Healthcare Improvement. She has close to 30 years of experience in health care improvement. She was a consultant at No Bristol Trust, a national health service trust.
 
Gary S. Kaplan, MD, is CEO of Virginia Mason Health System and is a member of the Board of Directors at the National Patient Safety Foundation. He is chair of the board of directors for the Institute for Healthcare Improvement. Kaplan is a clinical professor at the University of Washington. He earned his doctor of medicine from the University of Michigan.

About the Authors

  • Doug Bonacum, MBA, is vice president, quality, safety, and resource management at Kaiser Permanente
  • Barbara Balik, RN, EdD, is faculty, Institute for Healthcare Improvement. She is also a consultant at Pascal Metrics in Washington, DC
  • James Conway, MS, is adjunct faculty at Harvard School of Public Health in Boston and principal at Pascal Metrics.
  • Natasha Scott, MSc, is director of scientific instruments, applied science at Pascal Metrics.
  • Sarah Pratt, MPH, is vice president of client services at Pascal Metrics.
  • Andrew P. Knight, PhD, is assistant professor of organizational behavior at Washington University in St. Louis
  • Douglas Salvador, MD, MPH, is associate chief medical officer and patient safety officer at Maine Medical Center in Portland, Maine
  • Mary Ann Abrams, MD, MPH, works at Iowa Health System in Des Moines, Iowa
  • Gail Nielsen, BSHCA, FAHRA, RTR, is director of learning and innovation leading the Center for Clinical Transformation Iowa Health System and faculty for the Institute for Healthcare Improvement
  • Jeffrey P. Brown, Med, is senior cognitive psychologist at Cognitive Systems Engineering Group in Cognitive Solutions Division at Applied Research Associates in Fairborn, Ohio
  • Jackie Tonkel, BSBA, is vice president of Consulting at Pascal Metrics
  • David C. Classen, MD, MS, is chief medical information officer at Pascal Metrics
  • Robert C. Lloyd, PhD, is executive director of performance improvement at the Institute for Healthcare Improvement
  • David Munch, MD, is senior vice president and chief clinical officer at Healthcare Performance Partners, Inc., in Gallatin, Tennessee
 

 

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