Culture of Safety of Safety.pdfA culture of safety that fully supports high ... •Select rounding checklists and evidence-based guidelines ... The field guide to human error investigations

10/25/2016

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©2016 ECRI INSTITUTE

Culture of Safety:Achieving the Quadruple Aim

Lee Patrick, RN, BHA, MBA, CPHRM, HEM, CPASRM

October 27, 2016


• Power Point Slides viewed here• Today’s session is recorded• Today’s slides and recording will be

posted to the ECRI website.

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How to Ask Questions

Please submit your text questions and comments using the Questions Panel

Remember . . .

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How to Download Slides

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This activity has been approved for up to 1.0 California State Nursing contact hours by the provider, Debora Simmons, who is approved by the California Board of Registered Nursing, Provider Number CEP 13677. Credit will only be issued to individuals that are individually registered and attend the entire program.

All faculty members involved in this October 27, 2016, live webinar, Culture of Safety: Achieving the Quadruple Aim, have disclosed that there are no conflicts or financial affiliations.

To be eligible for credit:

Credit will only be issued to individuals that are individually registered and attend the entire program. Each individual participant must log on prior to the start of the program and remain on the line for the entirety of the program. This is how individual timed attendance is verified. In addition you must complete an attestation survey included in the postwebinar evaluation at the conclusion of the webinar. Once all that information is verified, qualified attendees will receive a certificate via e-mail within 60 days of today’s program.

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About ECRI Institute

• Independent, not-for-profit applied research institute focused on patient safety, healthcare quality, risk management

• Nearly 50 years of experience, 400+ person staff

• AHRQ Evidence-Based Practice Center (since 1997)

• Federally designated Patient Safety Organization (since 2005)

• Online resources about quality and safety

• Look for forthcoming information to access ECRI Institute’s website

• Search or browse for topics you need

• Sign up to receive notifications of monthly webinars

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Learning Objectives

1. Understand the concept of a “culture of safety”

2. Know the key elements to creating a culture of safety

3. Identify tools to assess patient safety culture

4. Recognize the differences between human errors, at-risk behavior, and reckless behavior

5. Explain the guiding principles of high-reliability organizations

6. Identify strategies utilized by executive leadership and physician leadership to attain a culture of safety

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An Organization’s Culture

Incorporates a pattern of shared basic assumptions

• Values• Beliefs• Behaviors

Teaches the workforce in explicit and implicit ways

(Senge et al.)

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Culture in Healthcare

Just culture

Punitive

culture

Blame-free

culture

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“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”

—Lucian Leape, MD

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What Is a “Just Culture”?

• A fair and just culture is one that learns and improves by openly identifying and examining its own weaknesses.

• A just culture is about fair, enlightened, and reasonable assessment of behavior and produces a work environment that supports high reliability.

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“The point of a human error investigation

is to understand why actions and assessments

that are now controversial

made sense to people at the time.”

—Sidney Dekker*

*Human factors and safety expert

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What Is a “Culture of Safety”?

• A safety culture is one that is focused on preventing, detecting, and minimizing hazards and error without attaching blame to individuals.

(Kohn et al.)

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Assessing Culture

• AHRQ hospital survey on patient safety culture http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html

• Manchester Patient Safety Framework http://www.nrls.npsa.nhs.uk/resources/?entryid45=59796

• Patient Safety Climate in Healthcare Organizations http://www.midss.org/content/patient-safety-climate-healthcare-organizations-pscho

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http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html

http://www.nrls.npsa.nhs.uk/resources/?entryid45=59796

http://www.midss.org/content/patient-safety-climate-healthcare-organizations-pscho

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Action Planning Steps

1. Understand your survey results.

2. Communicate and discuss the survey results.

3. Develop focused action plans.

4. Communicate action plans and deliverables.

5. Implement action plans.

6. Track progress and evaluate impact.

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Strategies to Address Safety Culture Results

• Assign multidisciplinary team to review findings and develop the action plan. Share what works.

• Include frontline staff in developing the action plan.

• Focus priorities on poor-performing areas of the safety culture survey.

• Ensure that organization priorities have a safety culture focus.

• Cultivate open communication about errors to learn from failures.

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Strategies to Address Safety Culture Results (cont.)

• Consider findings in context of the organization’s other patient safety and performance data.

• Tailor strategies to specific needs; avoid a one-size-fits-all approach.

• Give feedback about results to staff.

• Plan to resurvey to evaluate the impact of changes.

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Human Error At-Risk Behavior Reckless Behavior

A product of our current system design and our behavioral choices

A choice in which the risk is believed to be insignificant or justified

A conscious disregard for a substantial and unjustified risk

Manage through changes in: • Choices• Processes• Procedures• Training• Environment• Design

Manage through:

• Removing incentives for the behavior

• Creating incentives for better choices

• Increasing situational awareness

Manage through:

• Remedial action• Punitive action

Console Coach Punish

(Reproduced from Abujudeh and Bruno)

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James Reason’s “Unsafe Acts” Algorithm

1. Did the employee intend to cause harm?

2. Did the employee come to work drunk or equally impaired?

3. Did the employee knowingly and unreasonably increase risk?

4. Would another similarly trained and skilled employee in the same situation act in a similar manner?

(Reason)

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Decision Tree for Determining Culpability

(Adapted from Reason)

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Repetitive Errors

How do you handle staff who make repeated errors on the job?

• Is the job or task prone to error?• Redesign the system

• Is the source of the errors with the individual?• Remove the task• Change his or her job function/position• Add measures to supplement the task• Provide retraining

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What Is a “High-Reliability Organization”?

A high-reliability organization (HRO) is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity.

Imp

rove

d

read

ine

ss

Bet

ter

care

Bet

ter

he

alth

Low

er

cost

Patient safety

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©2016 ECRI INSTITUTE 23

High-Reliability Organization

“The hallmark of an HRO is not that it is error-free but that errors don’t disable it.”

(Weick and Sutcliffe)


HRO Guiding Principles and the Quadruple Aim

• Constancy of purpose / first, do no harm

• Sensitivity to operations

• Deference to expertise

• Reluctance to simplify

• Commitment to resilience

• Respect for people

• Collective mindfulness

• Preoccupation with failure

• Fostering a culture of safety

(Military Health System “Improving Care”)

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HRO: Where to Start1. Leadership commitment to the ultimate goal of zero patient harm

2. Incorporation of all the principles and practices of a safety culture throughout the organization

3. Widespread adoption and deployment of the most effective process improvement tools and methods

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A culture of safety that fully supports high reliability has three central attributes:

• Trust

• Report• Improve

(Reason and Hobbs)

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Learning is meaningless without action that brings about change

(Military Health System. “Leadership Engagement Toolkit”)

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Executive Leadership Strategies

• Board engagement in patient safety

• Safety culture debriefing

• Safety leadership rounds (walkrounds)

• Teamwork training and skill building

• Daily safety briefing

• Comprehensive unit-based safety program (CUSP)

• Evidence-based practices of execution

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Physician Leadership Strategies

• Medical leaders build patient safety structures

• Improved physician and patient communication at the bedside

• Unit-based huddles

• Physician champion at patient safety meetings

• Select rounding checklists and evidence-based guidelines

• Multidisciplinary teamwork training and skill building

• Physician leadership of post–adverse event debriefs

• Managing resistance

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SBAR

• Situation

• Background

• Assessment

• Recommendations

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TEAM UP

• Team together

• Educate yourself

• Ask questions

• Manage your medications

• Understand changes in the game plan

• Provide your perspective


Physician Leadership Strategies

• Medical leaders build patient safety structures

• Improved physician and patient communication at the bedside

• Unit-based huddles

• Physician champion at patient safety meetings

• Select rounding checklists and evidence-based guidelines

• Multidisciplinary teamwork training and skill building

• Physician leadership of post–adverse event debriefs

• Managing resistance

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Changing Staff Expectations: Where to Start

• Quick notification and response to wet floors

• Eliminate items used to prop open fire doors

• Lock all unattended med carts and prescription pads

• Consistent use of two patient identifiers

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At the end of the day, it is all about the patients

A spill, a slip, a hospital trip.

Accidents hurt—safety doesn’t.

Alert today. Alive tomorrow.

An accident can ruin your career.

Be alert—accidents hurt.Be alert, be aware, be alive.

A safer you is a safer me.

Safety is a full-time job.Safety . . . Did it, done it, doing it tomorrow.

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References• Abujudeh HH, Bruno MA. Quality and safety in radiology. New York (NY): Oxford University Press;

2012.

• Agnew J. 7 Keys for creating a safety culture. Bringing out the best [Aubrey Daniels’ blog]. 2013 Jan 23 [cited 2016 Oct 20]. http://aubreydaniels.com/blog/2013/01/23/7-keys-for-creating-a-safety-culture/

• AHRQ PSNet:Perspectives on safety. In conversation with . . . David Marx, JD. 2007 Oct [cited 2016 Oct 20]. https://psnet.ahrq.gov/perspectives/perspective/49/in-conversation-with-david-marx-jdSafety primer. Safety culture. 2016 Jul [cited 2016 Oct 20]. https://psnet.ahrq.gov/primers/primer/5

• Barnsteiner J. Teaching the culture of safety. Online J Issues Nurs 2011 Sep 30;16(3):5. http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-16-2011/No3-Sept-2011/Teaching-and-Safety.html PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22324571

• Chassin M, Loeb J. High-reliability health care: getting there from here. Milbank Q 2013 Sep;91(3):459-90. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3790522/ PubMed: https://www.ncbi.nlm.nih.gov/pubmed/24028696

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References (cont.)• Dekker S. The field guide to human error investigations. Aldershot (UK): Ashgate; 2001.

• Edmondson A. Strategies for learning from failure. Harv Bus Rev 2011 Apr;89(4):48-55,137. https://hbr.org/2011/04/strategies-for-learning-from-failure

• Edwards MT. An organizational learning framework for patient safety. Am J Med Qual 2016 Feb 25 [cited 2016 Oct 20; epub ahead of print]. http://ajm.sagepub.com/content/early/2016/02/24/1062860616632295.full

• Flemons WW, McRae G. Reporting, learning and the culture of safety. Healthc Q 2012;15 Spec No:12-7. PubMed: 22874441. http://www.ncbi.nlm.nih.gov/pubmed/22874441

• Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability. Health Serv Res 2006 Aug;41(4 Pt 2):1690-1709. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955339/PubMed: https://www.ncbi.nlm.nih.gov/pubmed/16898986

• Garvin D, Edmondson A, Gino F. Is yours a learning organization? Harv Bus Rev March 2008 Mar;86(3):109-16,134. https://hbr.org/2008/03/is-yours-a-learning-organization/PubMed: https://www.ncbi.nlm.nih.gov/pubmed/18411968

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http://aubreydaniels.com/blog/2013/01/23/7-keys-for-creating-a-safety-culture/

https://psnet.ahrq.gov/perspectives/perspective/49/in-conversation-with-david-marx-jd

https://psnet.ahrq.gov/primers/primer/5

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-16-2011/No3-Sept-2011/Teaching-and-Safety.html

https://www.ncbi.nlm.nih.gov/pubmed/22324571

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3790522/


https://hbr.org/2011/04/strategies-for-learning-from-failure

http://ajm.sagepub.com/content/early/2016/02/24/1062860616632295.full

http://www.ncbi.nlm.nih.gov/pubmed/22874441

http://www.ncbi.nlm.nih.gov/pubmed/22874441

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955339/


https://hbr.org/2008/03/is-yours-a-learning-organization/


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References (cont.)• Hornik S. Building a safety culture. Industrial Safety and Hygiene News. 2006 Aug 11

[cited 2016 Oct 20]. http://www.ishn.com/articles/86259-building-a-safety-culture

• Institute for Healthcare Improvement. Develop a culture of safety. 2016 [cited 2016 Oct 20]. http://www.ihi.org/resources/Pages/Changes/DevelopaCultureofSafety.aspx

• Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington (DC): National Academies Press; 2000.

• Leape LL. Testimony, United States Congress, House Committee on Veterans Affairs. 1997 Oct 12.

• Meadows S, Baker K, Butler J. The incident decision tree: guidelines for action following patient safety incidents. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in patient safety: from research to implementation, vol. 4. Rockville (MD): Agency for Healthcare Research and Quality; 2004:387-99. http://www.ahrq.gov/downloads/pub/advances/vol4/Meadows.pdf

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References (cont.)• Military Health System:

Improving care and driving performance excellence across the military health system through proactive reporting. 2016 Jan [cited 2016 Oct 20]. http://www.health.mil/News/Articles/2016/01/05/Feature-Improving-Care-and-Driving-Performance-Excellence-across-the-MHS-through-Proactive-ReportingLeadership engagement toolkit. 2016 Jul [cited 2016 Oct 20]. http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Quality-And-Safety-of-Healthcare/Patient-Safety/Patient-Safety-Products-And-Services/Toolkits/Leadership-Engagement-Toolkit

• Reason J, Hobbs A. Managing maintenance error: a practical guide. Boca Raton (FL): CRC Press; 2003.

• Reason JT. Managing the risks of organizational accidents. Aldershot (UK): Ashgate; 1997.

• Senge PM, Kleiner A, Roberts C, Ross R, Roth G, Smith B. The dance of change: the challenges to sustaining momentum in a learning organization (the fifth discipline). New York: Doubleday/Currency; 1999.

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http://www.ishn.com/articles/86259-building-a-safety-culture

http://www.ihi.org/resources/Pages/Changes/DevelopaCultureofSafety.aspx

http://www.ahrq.gov/downloads/pub/advances/vol4/Meadows.pdf

http://www.health.mil/News/Articles/2016/01/05/Feature-Improving-Care-and-Driving-Performance-Excellence-across-the-MHS-through-Proactive-Reporting

http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Quality-And-Safety-of-Healthcare/Patient-Safety/Patient-Safety-Products-And-Services/Toolkits/Leadership-Engagement-Toolkit

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References (cont.)• Sammer C, James B. Patient safety culture: the nursing unit leader’s role. Online J

Issues Nurs 2011 Sep;16(3):3. http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-16-2011/No3-Sept-2011/Patient-Safety-Culture-and-Nursing-Unit-Leader.html PubMed: https://www.ncbi.nlm.nih.gov/pubmed/22324569

• Sammons L. Create a learning organization to support a safety culture. Southern Ohio Medical Center leadership blog. 2012 Dec 2 [cited 2016 Oct 20]. http://www.somc.org/blog/create-a-learning-organization-to-support-a-safety-culture/

• Weick KE, Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty. 2nd ed. San Francisco (CA): Jossey-Bass; 2007.

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Upcoming Webinar Dates and Topics

Date* Topic

November 17, 2016 Managing 10,000 Medications:A Prescription for Safety

December 22, 2016 Implementing a Robust Quality Program

January 26, 2017 Data-Driven Quality Improvement

* All webinars (except the November program) are held the fourth Thursday of the month from 1–2 p.m. eastern.

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http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-16-2011/No3-Sept-2011/Patient-Safety-Culture-and-Nursing-Unit-Leader.html


http://www.somc.org/blog/create-a-learning-organization-to-support-a-safety-culture/

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Questions?

[email protected]

(610) 825-6000, x5800

Thank You

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Documents

Culture of Safety of Safety.pdfA culture of safety that fully supports high ... •Select rounding checklists and evidence-based guidelines ... The field guide to human error investigations