5.1.16 Safety inspection by the management

1 Aim and purpose

Collect information from employees about danger points
Taking action on the basis of messages from staff
Direct response to safety problems by those responsible for management
Promote safety awareness among employees through visible management commitment to the topic.
Addressing employees in management positions on the topic of safety
Remind employees of the importance of patient safety in the overall mission of the organization

2 Scope of application

Put together a management team for the inspection: Head of the organization, QM coordinator and/or RM manager, safety specialists, head of technology. The area must be defined before the inspection. The area should be notified prior to the inspection.

3 Description

3.1 Preparation

Define areas Set dates at an early stage. Observe daily routines in the areas. Determine the flow chart: who will be interviewed? What is being looked at? Involve senior staff in the department Distribute "Attitude to safety culture" questionnaire

3.2 Procedure

Formal introduction to employees. Explain that the management wants to find out about safety problems and hazards. To do this, employees must understand that it is not their mistakes that are being asked about, but the dangers that threaten to cause them to make mistakes. Explain that the management feels responsible for preventing such dangerous situations. Areas can be:

• Dangers of medication
• Disruptions in communication
• Team problems
• Distraction
• Inefficiency
• Documentation problems

Announce that the employees will receive feedback on what will happen regarding their comments. Finally, thank everyone for their time. Explain that the information will be analyzed and action will be taken to address the risks. We will also inquire how the measures are received by them. Refer to the "Adverse events" reporting system

3.3 Analysis of the data

All recorded hazards are classified according to frequency of occurrence, severity of impact on patients and recognizability (enter risk indicators). Make suggestions for remedial action Have the management decide on measures Summarize the results in a report and send it to the departments that took part in the inspection. Evaluate the "Questionnaire on attitudes to safety culture" survey

3.4 Tracking

Report on the measures and their implementation throughout the hospital (in-house information) Enter measures in the list of corrective measures and have them followed up by the QM coordinator.

4 Documentation

Create a report form Note the date, time, locations and participants in the inspections Note all messages Note observations The report should be given to the QM group to follow up on the findings. The report should be included in the management review.

5 Resources

5.1 Time required

An inspection takes approx. 1 hour, participants 6 managers, participation of employees depending on the size of the department (approx. 2 hours), follow-up approx. 1 hour. Consultation and decisions are the normal task of the management. Estimated time required for an inspection: approx. 10 working hours. Each department or clinic should be visited once in the course of a year.

6 Responsibility

Organization: QM coordinator Participation: Hospital management, department management, QM coordination, safety specialists, head of technology Decision on prioritization, initiation of measures: Management Follow-up: QM coordinator Communication of results and measures: Press office

7 Notes and comments

8 Applicable documents

8.1 Literature

Frankel А, Graydon-Baker Е, Neppl С, Simmonds Т, Gustafson М, Gandhi ТК. "Patient Safety Leadership WalkRounds." Joint Commission Joumal of Quality and Safety. 2003, Vol 29(1), 16-26.

Leonard М, Frankel А, Simmonds Т, Vega КВ. Achieving Safe and ReliaЫe Healthcare: Strategies and Solutions. Chicago: Health Administration Press, 2004.

Gandhi ТК, Graydon-Baker Е, Barnes JN, Neppl С, Stapinski С, Silverman J, Churchi11 W, Johnson Р, Gustafson М. "Creating an integrated patient safety team." Joint Commission Joumal of Quality and Safety. 2003, Vol 29(8), 383-90

8.2 Terms

Attachments

Annual planning for inspections
Announcement letter for inspection
List of questions for the inspection
Report form for inspection
Questionnaire "Attitude towards safety culture"