Follow the rules: The path to better compliance

Safety techniques, peer coaches reduce errors

Safety devices that are never activated. Lift equipment gathering dust. Spills that aren’t cleaned promptly and lead to slips and falls. How many of your injuries are caused by the failure to follow basic safety rules and procedures?

More than you might think, says Craig Clapper, PE, CQM, MBA, chief operating officer of Performance Improvement International in San Clemente, CA. More than half of all human errors that lead to injuries are caused by noncompliance, he says, citing his own unpublished surveys. Another 10% are caused by failure to pay attention or to recognize hazards. Only about 10% of human errors that lead to injury are due to lack of knowledge about the rule.

"We design systems to withstand human error, but there’s no system that can withstand noncompliance," he explains.

Most employers focus on disciplinary action as a way to enforce compliance. But what happens when no one’s looking? "There is no system that can force someone to do something they don’t want to do because it’s so easy to work around," Clapper says. "It’s better to get to the fundamentals of solving the noncompliance problem."

Yes, difficult as it is, you can reduce noncompliance. But first you need to understand its basic causes. It can be summed up by a simple equation, he says. "Noncompliance is an effort to perform the task safely or take protective action, divided by your risk awareness plus your compliance culture."

In other words, the lower the burden of the safety rule or equipment, the more likely your employees will follow it. A lift available in the room will get more use than one in a cramped storage closet down the hall.

Raising awareness of the risks — for example, of the prevalence of HIV and the need for prophylaxis following a needlestick — will increase compliance. So will an overall safety culture in which following safety rules is valued and rewarded.

"There is no one factor," Clapper notes. "If you start managing one like it’s more important than the others, it won’t help you as much as if you manage all three."

Stop and think for prevention

At Memorial Health University Medical Center in Savannah, GA, safety coaches help raise the awareness and safety culture — key factors in boosting compliance. Jonathon Flanders, patient safety coach and program coordinator, has a cadre of peer-based safety coaches in every unit. Larger departments have as many as six safety coaches.

These specially trained frontline workers actually use a checklist to monitor safety behaviors — focusing on both patient and worker safety.

When the program first began, some employees were very receptive to the safety coaching, while others responded negatively. But Flanders notes, "One of the requirements for working here is that you commit to the safety program and live the organization values."

The hospital began with a four-hour training session for all "Team Members" or employees, "Team Leaders" or managers, and physicians. The course emphasized behavior-based expectations and techniques related to error prevention. As a constant reminder, those expectations are even printed on the back of employee badges:

• Communicate clearly. Technique: Two clarifying questions. Repeat backs and verify. Phonetic and numeric communication.

• Adhere to policies, procedures, and red rules. Be sensitive to high-risk situations. STOP when unsure.

• Attention to details. Stop. Think. Act. Review. (STAR)

For example, the hospital expects employees to emphasize communication during shift changes by asking questions and repeating back information. They must follow "red rules," or the most important safety rules that have been identified in that department.

"Red rules are a minimum set of standards associated with certain patient safety processes and must be met and will require verbatim compliance to optimize the safety of our patients," Flanders points out. "For example, the global red rule is to positively identify patients every time they are touched using two forms of identification, neither of which can be a room number." They follow a procedure called STAR to prevent errors.

These techniques have implications for both patient and worker safety. Memorial Health identified 12 common high-risk situations and 12 high-risk behaviors. For example, being distracted immediately before or during administration of a treatment or medication can lead to errors. "Part of being personally committed to safety is looking for those high-risk situations," Flanders adds. "You adjust your behavior."

The STAR approach is strongly emphasized. "Most of the errors we make in life or health care are not skill-based, they’re simple slips or lapses," he says. "They’re simple mistakes that we can avoid if we just pay attention to what the heck we’re doing."

The hospital’s safety coaches bolster this effort. They observe their co-workers, praising them when they do something well and correcting them when they fail to take a preventive measure. The coaches also fill out a form to note gaps in safety performance. (See sample form.) It isn’t used for disciplinary purposes, and employee names are not collected on the form. It’s just a tool to identify areas that need improvement or more safety coach emphasis, Flanders notes.

"Research shows the best way to do [improve performance] is with constant reinforcement and co-worker coaching," he adds. "The safety coach gives immediate feedback."