Using safety coaches to change behavior

Calvert Memorial Hospital in Prince Frederick, MD, which is part of the VHA Central Atlantic, chose to use safety coaches to monitor hand hygiene compliance. The safety coach program was piloted on the med/surg unit with two coaches per floor, and the hospital monitored pre- and post-implementation MRSA rates and then decided to move forward with the coaching program.

Ginger Everton, RN, BSN, director, risk management, says coaches, who still work only as part of the MRSA reduction program, receive an eight-hour class on observing employee work behaviors. One of the tools they're taught is ARCC. "They're taught to speak up, ask a question, make a request, voice a concern, and if there's no success then use the chain of command," Everton says. Coaches also were educated on proper hand hygiene — not simply running your hands under water and drying them off.

Terri Bowersox, FACHE, director, performance improvement at VHA Central Atlantic, says first the coach approaches "a physician who's not wearing the gown when they need to. First you ask, 'Dr. Smith, would you mind putting on your gown?' And if they ignore you, then you go the next, where you request, 'Dr. Smith, I need you to put on this gown.' The theory is that most of the time, 90% of the time, if you just ask, people will comply. So it's kind of like an elevation that you use that you start with the most simple, basic, least intrusive approach. And then you elevate it if it's not working.

"I did hear an example from a CEO where he talked about how a physician was approached by a staff member about washing his hands and he got all upset about it, furious about it, went to his chief of staff and everything. And the chief of staff, which we just love him for this, said, 'So you're complaining to me because a nurse told you to wash your hands? You should be thanking that nurse. We've known for over a 100 years that we're supposed to wash our hands,'" Bowersox says

"So leadership support is so important because the staff member who is going to coach has to know that that physician cannot go to the chief of staff or the CEO and complain. They've got to know that those leaders are going to support this work," she says.

Everton says they've spent a lot of time getting safety coaches comfortable to approach people and how to do it. One thing they've done to make the communication less confrontational is establish a code word staff members can use to alert someone to wash their hands. This functions well, she says, especially in front of patients. Using the code word, the doctor is not embarrassed in front of the patient and the patient is not alarmed. The hospital also uses reminder cards.

In selecting coaches, Everton says the goal was to have two coaches per department and not just clinical ones but ancillary services as well. She looked for willing volunteers, team members in good standing and admired by their peers, as well as those with strong communication skills. They also should "demonstrate a personal commitment to outcomes and know the expectations, practice the expectations, and make them personal work habits."

"Right now, their responsibility is to identify when people are doing the right thing and promote that good behavior and then identifying when we're not doing the right thing and addressing that and giving them the tools and techniques in reminding them of the right thing to do. We haven't really used them to empower everyone else. The idea behind the safety coach and the whole culture change and the high reliability organization idea is that if you can eliminate that culture of being defensive and not being receptive to when people speak up, then I think we can slowly hopefully change that," she says.

Coaches are expected to do at least 10 observations a month — whether they find noncompliance or comment to an employee that he or she is doing the right thing. They also come together monthly to continue to share hurdles and create more incentives or ways to encourage staff.

To staff, she explains, the safety coaches are "looking out for you to make sure you're doing the right thing. They're not there to point out that you're doing the wrong thing. They're trying to help you and make sure you're doing the right things to keep people safe." Notes congratulating and thanking compliant staff are put on the hospital's intranet.