Suci Noor Hayati, S.Kep.,Ners.,M.

Kep
1

Health care is not safe.

During this 30 minute presentation:
5 7 patients across the U.S. will
die due to medical error or
infections
85 113 patients will be hurt
21 29 employees will experience
a needle-stick injury

Improving Healthcare Using Toyota Lean Production Methods R. Chalice, 2007Levinson, D. R. (2008). Adverse events in hospitals: overview of key
issues. Department of Health and Human Services, Office of Inspector General. Retrieved at: http://oig.hhs.gov/oei/reports/oei-06-07-00470.pdf
IOM (1999). To err is human: building a safer health system. Retrieved at: http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf
Kohn, L.T., Corrigan, J.M., and Donaldson, M.S. (Eds). (2000). To err is human: building a safer health system. Committee on Quality of Healthcare in
America. Washington, DC: National Academy Press.

1. Identify Top Causes ofHHarm

A
2. Enhance our Culture ofRSafety
M

3. Improve the Quality and Clarity of Clinical

Communications
50%
4. Redesign Care To Eliminate Harm
3

Enhancing our Culture of Safety

Safety Culture Global Indicators

Komitmen organisasi
Pemberdayaan Karyawan
Reward Systems (Just Culture)
Sistem pelaporan
Kemitraan dengan pasien dan
keluarga

Formal

Team
Build Local

Training

Safety
Champions
Structure

Create Safe Environments

Establish a Common Language

HFHS Culture of Safety Building Blocks
Wiegmann, D.A., Zhang, H., von Thaden, T., Sharma, G. and Mitchell, A. (2002). A synthesis of safety culture
and safety climate research (Technical Report ARL-02-3/FAA-02-2). Savoy, IL: Aviation Research Lab
5
Institute of Aviation.

Units with Safety Champions showed improvement for all

safety questions and engagement questions compared to units
without safety champions.

0.1 improvement = meaningful

0.2 improvement = statistically significant

Coming together is a beginning;

Keeping together is progress;
Working together is success.
Henry Ford

Untuk mengembangkan
jaringan keselamatan
pasien dengan multidisplin

Create error wisdom at

the front line

Mendukung nilai nilai

keselamatan pasien untuk
mendukung budaya
keselamatan

First Safety Champions 6/2008

Front line, multidisciplinary employees that act as a Voice and

Face of Safety.

Memiliki minat yang tulus dalam keselamatan pasien

Merupakan role model dalam keselamatn pasie
Dihormati oleh rekan
Bersedia dan mampu mengkomunikasikan informasi (tujuan keselamatn
pasien, pelaporan) dalam pertemuan departemen, briefing, atau obrolan
Bersedia untuk merangkul setiap peluang

10

Program Start: June, 2008

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Penelitian tentang faktor manusia telah menunjukkan bahwa

karyawan yang sangat terampil , profesional, dan memiliki
motivasi rentan terhadap kesalahan karena keterbatasan
manusia yang melekat

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Memory- we generally store only partial

A Simple Example of the Limits of Memory
descriptions of things to be remembered,
13
Image
Source:http://www.dcity.org/braingames/pennies/
descriptions
that are sufficiently precise to
work
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Quarterly Forums: Identify top causes of harm, Culture of Safety, Just

Culture,Error Reporting & Error Prevention, Speak Up, Speak Out: Creating
Safe Environments, Getting LEAN with Hand Hygiene, Healthcare Equity and
Culturally Competent care, Emergency Preparedness and Patient Safety.

2 Minute Tutorials: How Tos

Great Catch Stories

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2 patient identifier projects

Accurate
and form
Voluntary
reporting
Revised SBAR
for patient
hand-offs
reporting
system.for hospital
Selecting equipment
Post-fall survey.
management program
Project
Handicapped parking assistance
Bladder health and collaborative project
Handwashing projects
Medication review process
Mammogram process review
Medication dispensing projects
A3s-Needlestick prevention
More..

through our

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Process 7,000 medications orders per day

Dispense 17,000 medication doses per day
Recognize human limitations and have made 49
system improvements since joining the program

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378 Safety Champions (multidiscplinary, multiple business

units)

100% would recommend program

>95% favorable with class and forum surveys
95% share toolkits and newsletters
88% believe they have made an impact on the culture of
safety for their units

80% participate in safety improvement work

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Safety Champion

I am a
because I do my best to live the Henry Ford
Experience of caring about people by helping
to make sure they are safe,on a daily
basis..Ruth

Patient Safety means......" putting forth a

conscience effort to protect our patients and
employees by minimizing risk and
adhering to all set standards while providing
the highest quality care in the safest work
environment possible!!!!
Dawn Dombek-Bailey, CHSP

all
Safety Champions
Can and

I make a difference in the lives of

persons who enter HFHS properties.
MaryAnn L. Northcote, CPP, CHSP

Do Make a Difference
in
I want to be proactive in
Patient Safety means.delivering the highest
spreading
wellness to individuals
quality care thatPatient
is reliable and coordinated
for the by
Safety
Being
that are in my reach. Injury
patients we serve each day..Judy Caretti-Rourke
prevention is a key component in
Proactive,
Minimizing
Risk,
I am a Safety
Champion because......the
helping our loved ones and others
environment I work in and the people I serve are
in our community stay safe and
Creating
Safe
Environments
important
to me LesaBorden
Sanford RN,
healthy..Katie Horn
BSN
I make a
Because
itsSafety
Important
to the
I am a safety
champion
Patient
means being proactive in creating and maintaining
difference to
because I CAN and
Lives
of ALL. everyone that comes in
safe
environments
DO make a difference
one person at a
time". Stephanie B.
Anderson, RN, MSN

I am a safety champion because

contact with me in the

for our patients who depend on us
Henry Ford Health
when they are most vulnerable.
system..Latonya Phillips
Judy Czerepowicz, CHSP
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Thank You to all Safety Champions for making a difference.

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The boss drives group members, the leader

coaches them
The boss says I, the leader says We
The boss know how its done, the leader
shows how
Be the boss or leader??????
Absolutely Be a good leader

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