“Use data to shed light, not heat.”

Source: Reinertsen JL et al 2007.

Needs Analysis

1. Observational techniques2. Questioning techniques3. Event-based analyses

From Safety at the Sharp End by Flin, O’Connor, and Crichton

Makary/Coordination Question

“Problem personnel are dealt with constructively by our (local/senior) management”

Average: 32% positive Average: 21% positive

0102030405060708090

100

11 16 18 22 25 30 33 33 34 38 40 4150

59

Problem personnel - Local managment

BC operating rooms

Perc

enta

ge o

f pos

itive

resp

onse

s

0102030405060708090

100

6 9 10 10 12 17 20 22 23 24 25 2740

47

Problem personnel - Senior managment

BC operating rooms

Perc

enta

ge o

f pos

itive

resp

onse

s

Practicalities of surveys

• Participation matters• Debrief• Dig deeper• Small-scale surveys work too

Never Events&

Good Catches

Sentinel Event

Sentinel events are defined as "an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof."

Table. Never Events, 2011

The National Quality Forum's Health Care "Never Events" (2011 Revision)

BC PSLS Clinical Process or Procedure Events

Surgical events Treatment, Procedure, or Intervention Events

Surgery or other invasive procedure performed on the wrong body part

Incorrect site, body part or side

Surgery or other invasive procedure performed on the wrong patient

Incorrect patient

Wrong surgical or other invasive procedure performed on a patient

Incorrect treatment, process or procedure

Unintended retention of a foreign object in a patient after surgery or other procedure

Missing or retained object or incorrect surgical count or no surgical count

Intraoperative or immediately postoperative/postprocedure death in an American Society of Anesthesiologists Class I patient

AHRQ website: permission from the National Quality Forum

Joint CommissionWrong-site surgeries

209

• Communication• Patient Management• Clinical Performance

Themes at your site

• Patient Safety Learning System• Root Cause Analysis in Surgery• Checklist compliance or observation• Culture survey or Gallup poll• Anything that gives you a glimpse into the

need

Table discussion: needs analysis

• What are you seeing? Positive and Negative• What are three things that you could focus on

at your site?Example: – Debriefing phase of checklist – Teamwork between disciplines– Pockets of disrespect– Some nurses find it hard to speak up– Frustrations with equipment needs