| Primary Author: | Cynthia A. Oster, PhD, MBA, APRN, CNS-BC, ANP |
| Co-Principal Investigators/Collaborators: | Kathleen Bradley |
| Organization: | Porter Adventist Hospital |
Abstract
Background
Practitioners often perceive care delivered as “excellent” whereas a regulatory agency expects “perfect” care. “A perfect storm is a convergence of independent events that form an environment never experienced before” (Fields, 2006). Three prevailing winds or barriers to exemplary blood and blood product administration practice, “failure to see,” “failure to move,” and “failure to finish” converged to create the perfect storm that threatened our culture of excellence (Kerfoot, 2010).
Purpose
The purpose of this project is to demonstrate how to achieve and sustain an organizational culture of personal and professional accountability within the global context of a healthcare system by transforming quality monitors to enculturate a no-fail exemplary practice environment.
Materials & Methods
Evidence supporting “perfect” blood product administration practice was collected during a 24 week period. An organizational culture of transparency broke through staff “failure to see” the need for change. Clinical audits mitigated “failure to move” by making the “perfect” clinical practice destination clear for all departments. Audits created movement to ensure staff adhered to the “no failure” regulatory and professional blood administration standards related to consent, verification, documentation, teaching and adverse reactions (Patel, 2010). Fatigue inherent to “failure to finish” was diminished through motivating and energizing champions of change placed to reinforce, encourage and reward professional accountability.
Results
Sixteen patient care areas audited 100% (n = 2638 units) of blood products administered for adherence to regulatory standards between June 11 and December 1, 2010. “No failure” or “perfect” care was no deviation from regulatory standard without exception. “Perfect” care was hardwired and enculturated into clinical practice by week 18.
Conclusion
A “perfect storm” environment brought about redesign of leadership roles, performance measures and professional accountability. Utilization of a detailed audit strategy led to a no-fail practice culture and global improvements in blood administration safety throughout a healthcare system.
© Improvement Science Research Network, 2011