DELEGATION OF SAFETY CULTURE PROGRAM

DELEGATION OF SAFETY CULTURE PROGRAM

ASPECTS OF SAFETY Fish Diagram

KEY FUNCTIONS AND ROLES

1. Chief Executive Officer and Hospital Executive Leadership

• Establishes and supports the hospital’s culture of safety program that promotes accountability and transparency.
• Develops and documents code of conduct and identifies and corrects behaviors that are unacceptable.
• Provides education and information (such as literature and advisories) relevant to the hospital’s culture of safety to all staff.
• Defines how issues related to a culture of safety within the hospital are identified and managed.
• Provides resources to promote and support the culture of safety within the hospital.
• Provides a simple, accesible and confidential system for reporting issues relevant to a culture of safety in the hospital.
• Ensures that all reports related to the hospital’s culture of safety are investigated in a timely manner.
• Identifies systems issues that lead healthcare providers to engage in unsafe behaviors.
• Uses measures to evaluate and monitor the safety culture within the hospital and implement improvements identified from measurement and evaluation.
• Implements a process to prevent retribution against individuals who report issues related to the culture of safety.

Quality Management Department

1. Supports the hospital’s culture of safety program that promotes accountability and transparency.
2. Coordinates with Safety team, Infection Control team, Pharmacy team, Nursing team and other concerned according to the requirement.
3. Receives, investigates and acts upon issues or incidents related to the hospital’s culture of safety.
4. Ensures that all reports related to the hospital’s culture of safety are investigated in a timely manner.
5. Provides education and information relevant to the hospital’s culture of safety to all staff.
6. Manages and provide summary reports to leaders on a quarterly basis.
7. Encourages staffs to report issues relevant to a culture of safety in the hospital.
8. Identifies systems issues that lead healthcare providers to engage in unsafe behaviors.
9. Uses measures to evaluate and monitor the safety culture within the hospital and implement improvements identified from measurement and evaluation.

Heads of Department/ Service:

As a commitment to the culture of safety program, each head of the department/ service is responsible for:

1. Implementing the hospital’s culture of safety program within the department.
2. Identifies, documents and corrects behaviors that are unacceptable within the department.
3. Provides education and information relevant to the department’s culture of safety in coordination with QM.
4. Encourages staffs to report issues relevant to a culture of safety in the hospital.
5. Helps evaluate and monitor the safety culture within the department or service and implement improvements identified from measurement and evaluation.

Departmental QI Officers

1. Assists in the implementation of departmental and hospital-wide culture of safety program
2. Collaborates with the Head of the Department/ Service and the Quality Management Department in monitoring, reporting and communicating issues relevant to a culture of safety in the department.

Hospital Staff Members

1. Holds a proactive and positive attitude towards reporting culture of safety occurrences.
2. Initiates and reports culture of safety related incidents using the hospital’s OVR system.