What is Patient Safety? “The names of the patients whose lives we save can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed and books read, and symphonies heard, and gardens tended that, without our work, would never have been.” Donald M. Berwick, MD, MPP President and CEO Institute for Healthcare Improvement Creating a Culture of Safety Kaiser Permanente Southern California 6th Nursing Quality & Innovation Conference – 10/1/10 1 Beyond Blame As you watch this video Please think about how this story Made you feel and Whether or not the Situations were handled Correctly Objectives Upon completion of this presentation, you will be able to: • Define a culture of safety • Define a Just Culture • Describe our current safety culture and the need for change • Describe what KP SCAL is doing to spread a Just Culture across all Medical Centers 2 Reporting Errors • How many of you think it is important to report errors? • Why is it important to report errors? • Do you report errors? • Why do you think some staff/physicians don’t report errors? What should be reported? •Errors that cause harm •Errors that do not cause harm Errors Reported Errors Actually Occurring •Near misses 3 Near Misses Sometimes the only thing separating an error that causes no injury from one that causes major harm is pure luck or the robust nature of human physiology. Death 1 Severe 10s Minor – Moderate 100s Prevented/No harm incidents 1,000s What is a Just Culture? • A key component of a safety culture • A culture of trust where people are encouraged and recognized for providing essential safetyrelated information • A culture which clearly defines where the line must be drawn between acceptable and unacceptable behavior Ref: James Reason 4 Working in a Just Culture • Errors and mistakes are inevitable • Learn from your mistakes • Encourage reporting Causes are looked for Things get fixed Reporters are valued, not harassed Management supports reporting and fixing LMP National Agreement 2005 Patient Safety Improving the quality of care delivered to members and patients requires significantly increasing the reporting of actual errors and “near misses.” It is recognized that the reporting of such errors can only improve if employees are assured that punitive discipline is not seen as the appropriate choice to handle most errors. We must jointly create a learning environment which views errors as an opportunity to continued, systematic improvement. This environment must encourage all employees to openly report errors or “near misses” and participate in analyzing the reason for the error and the determination to the resolution and corrective action needed to prevent reoccurrence. 5 Reporting System The Reporting System will include the following components: • Reporting of errors, with systematic, standardized analysis of errors and near misses; • Communication of learning to help make needed policy and procedure changes; • Confidentiality of involved employees unless prohibited by statute or law; • Involvement of staff in error analysis and/or resolution; • Positive reinforcement for reporting; • Training and education programs that enhance skills and competency to help prevent future errors; • Maintenance of the integrity of privileged information; and • Ability to collect and trend data across the organization. Authorizing Sponsors • Benjamin Chu, MD – President Southern California Region KP • Patty Harvey, RN – Vice President Regional Quality and Risk Management • John Brookey, MD – SCPMG Assistant Medical Director, Quality and Risk Management • Kathy J. Sackman, RN – President UNAC/UHCP • Arlene Peasnall – Vice President Human Resources, KP Southern California • Al Carver – Vice President Pharmacy Strategy and Operations 6 Steering Committee Members •Susan Al-Sabih, NP – SCPMG Nursing •Libra Baker, RN BSN – Director Home Care Patient Services Kaiser Riverside •Barbara Blake, RN – State Secretary UNAC/UHCP •Terry Bream, RN – Nursing Manager SCPMG Administration •Dottie Carmichael, RN – Director Adult Primary Care •Denise Duncan, RN – Staff Representative UNAC/UHCP •Linda Fahey, NP – Regional Manager, Quality & Patient Safety •Suzanne Graham, RN, PhD – Director Patient Safety California Regions •Kristine Hilary, RN – Regional Director Home Care Services •Janna Hoff, RN – Regional Manager, Clinical Practice Med/Surg •Helen Horn - Union Representative, UHW •Judy Husted, RN – Executive Director Patient Care Services •Carol Jones, RN – Staff Representative UNAC/UHCP •Cindy Klein, RN – Out Patient, Kaiser Riverside •Rich Levy – Pharmacy Quality KP/SCPMG •Janice MacDonald, RN – Patient Safety Officer, LAMC •Barbara Macon, RN – Staff Representative, UNAC/UHCP •Paul Martin – HR LAMC •Nancy Miner – OE Consultant •Therese Morley, RN, EdD – Practice Leader Patient Safety •Regina Okura – Pharmacy Technician •Richard Rosas – Labor Relations •Pamela Pressney, RN – In-Patient Kaiser San Diego •Jodi Santiago, RN – AMGA Kaiser Fontana •Peter Sidhu, RN – In-Patient, Kaiser Woodland Hills •Heddy Steinman – UFCW Representative, OutPatient Pharmacy Technician •Cathy Turner, RN – Patient Safety Officer Kaiser West LA •Pamela Wald, MD – Pediatrician Kaiser Downey •Kara Yoneshige – Management Consultant Steering Committee Desired Outcomes • Employees report errors that could or did cause harm to patients • Employees report systems and processes are improved based on errors and near misses reported • Employees are treated fairly when an error occurs and there is appropriate use of corrective action • Staff report leadership (labor and management) support and foster a just culture through organization • Employees feel comfortable identifying and escalating patient safety risks and concerns 7 Hopes • Promote patient safety; front-line staff feel comfortable in reporting • Educate our DA’s – give it substance • Decrease variation – implement consistent practices • Becomes our way of doing business for everyone – Union, Physicians, etc. • Implement Just Culture in pharmacy setting • Stay enthusiastic after kickoff • We can take algorithm and make it practical in fact-finding • Address more than just medical errors • Clarify that it is a culture of accountability at Medical Center level • More than just nursing and pharmacy Concerns • Political climate not one of just culture; instead, there is a need to punish • Regulations and rules not easy to change • Making sure there is follow-up • Resources – not just another initiative • Medical Center leadership needs to be able to prioritize for their area 8 Policy Statement It is the policy of Kaiser Permanente, Southern California, that leadership and management are responsible for creating and sustaining an environment in which employees are encouraged to report errors and “near misses” without fear of retaliation. When an error or potential error is discovered, leaders and managers will use the Managing Error in a Just Culture Algorithm (adopted from the work of James Reason) when investigating the event and determining next steps for the resolution of the identified risk. Just Culture Pilot Site Downey Medical Center 9 Informed Patient Safety University May 20-21, 2010 Presenters included: Program Office and SCAL Doug Bonacum, Suzanne Graham, Jeff Convissar MD, Therese Morley Locally: Lisa Owyang, MD Chief of Ophthalmology Aaron Lim, MD Assistant Chief OB-GYN 170 attendees: 21 physician leaders, 91 managers, 46 Labor leads, 10 community affiliates, 2 members from Pt. Safety Council Informed Downey Pilot Briefing Topics Escalation – March 15, 2010 Just Culture – June 21, 2010 Responsible Reporting – May 10, 2010 Great Communication Stories – March 22, 2010 Patient Safety/Just Culture Reading/Video List – September 20, 2010 DMC Near Miss – March 22, 2010 Patient Identification – April 26, 2010 The Anatomy of Escalation – August 10, 2010 10 Informed Face-to Face Labor Leads: Rounding Coalition One-on-Ones ___ ___ ___ ___ Management Leads: _ ___ ___ ___ __ __ _ __ _ _ ___ DA Meeting Chiefs Meeting AMCA Meeting Med Exec Meeting MCAT Meeting One-on-Ones In Partnership Department Training Informed Training • Training model developed by Site Steering Committee using preliminary work done at Regional level. • Training designed to convey the Just Culture model without overwhelming line level staff. • Training method utilizes strength of Partnership by using Labor Partners and Managers of each unit to train their own units. • Training method requires Managers to take ownership of Just Culture in front of their staff and helped to give credibility to the process. 11 Reporting Just Culture Rollout Physicians Focus on awareness and acceptable behavior Department chiefs educated at Chiefs Meetings and Patient Safety University General physician staff memo distributed explaining the Just Culture initiative and rollout Direct presentation to physicians at departmental meetings and upcoming physician offsite with Dr. Karm, Dr. Magallanes Just & Flexible New Approach Looking at balance between individual accountability and system failure on case-bycase basis. New Approach for: • Human Resources • Labor • Management Our greatest hurdle is gaining the trust of Labor. 12 Just Culture Rollout Where are we now? As of September 22: Train the trainer is 99% complete-each department is responsible for training its own members-accountability and ownership. About 1500 employees and managers have been trained. 4 departments are fully implemented. Many DAs are using the algorithm and the substitution test, even before staff is trained. Learning Our Journey • Celebrating our success • Learning from our missteps Culture change is a journey NOT a light bulb! You can’t just flip the switch! 13 Adopted from James Reason “Managing the Roles of Organization Accidents” and work of David Marx Managing Error in a Just Culture STEP 1 STEP 2 no Were the actions as intended? yes Updated 4/26/10 Just Managing Error in a Just Culture Substance Use Or Abuse? yes no STEP 3 no STEP 4 Knowingly violated safe operating procedures? no STEP 5 yes Pass substitution test? History of unsafe acts? no yes no yes Were the consequences as intended? yes Medical Conditions? Were procedures available, workable, Intelligible and correct? yes no no Deficiencies in training and selection, or inexperienced? no yes yes System induced Behavior Substance Abuse Possible Reckless Behavior Pass substitution test yes Malevolent, Sabotage, Damage, fraud, etc. yes Outside scope of “Just Culture” Refer to: Human Resources, Compliance Policies, EAP, etc Reckless Behavior Corrective Action Does the series of errors reside within system System induced human error System Induced Error Manager Action: Coaching and /or Corrective Action Manager Action: Refer to Primary Care Provider yes System induced human error in need of investigation Human Error Manager Action Management Action Console At Risk Behavior Coach no Although not culpable for this error coach/ counseling action may be needed Human Error Console What is Patient Safety? “The names of the patients whose lives we save can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken, and work completed and books read, and symphonies heard, and gardens tended that, without our work, would never have been.” Donald M. Berwick, MD, MPP President and CEO Institute for Healthcare Improvement 14