DELEGATION OF SAFETY CULTURE PROGRAM
ASPECTS OF SAFETY Fish Diagram
KEY FUNCTIONS AND ROLES
- 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
- Supports the hospital’s culture of safety program that promotes accountability and transparency.
- Coordinates with Safety team, Infection Control team, Pharmacy team, Nursing team and other concerned according to the requirement.
- Receives, investigates and acts upon issues or incidents related to the hospital’s culture of safety.
- Ensures that all reports related to the hospital’s culture of safety are investigated in a timely manner.
- Provides education and information relevant to the hospital’s culture of safety to all staff.
- Manages and provide summary reports to leaders on a quarterly basis.
- Encourages staffs to report issues relevant to a culture of safety in the hospital.
- 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.
Heads of Department/ Service:
As a commitment to the culture of safety program, each head of the department/ service is responsible for:
- Implementing the hospital’s culture of safety program within the department.
- Identifies, documents and corrects behaviors that are unacceptable within the department.
- Provides education and information relevant to the department’s culture of safety in coordination with QM.
- Encourages staffs to report issues relevant to a culture of safety in the hospital.
- Helps evaluate and monitor the safety culture within the department or service and implement improvements identified from measurement and evaluation.
Departmental QI Officers
- Assists in the implementation of departmental and hospital-wide culture of safety program
- 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
- Holds a proactive and positive attitude towards reporting culture of safety occurrences.
- Initiates and reports culture of safety related incidents using the hospital’s OVR system.
