How to Create a Culture of Safety
How to Create a Culture of Safety Michael Leonard, M.D. – Expert Faculty for the Institute for Healthcare Improvement (IHI) and Adjunct Professor of Medicine, Duke University School of Medicine Creating a Culture of Safety Michael Leonard, MD, Pascal Metrics Adjunct Professor of Medicine, Duke University Confidential & Proprietary 2 Safety is a characteristic of a sociotechnical system System-level failures occur almost always because of unforeseen combinations of component failures ©2012-13 Developed cooperatively by Mayo Clinic and Pascal Metrics, Inc. 3 Evolution of A Culture of Safety GENERATIVE Organizational Culture “Genetically-wired” to produce safety PROACTIVE “We methodically anticipate”— prevent problems before they occur SYSTEMATIC Systems being put into place to manage most hazards REACTIVE “Safety is important. We do a lot every time we have an accident” UNMINDFUL “We show up, don’t we?” Chronically Complacent WHERE ARE YOU? Confidential & Proprietary Patient & Family Centered Care GENERATIVE Organizational Culture “Genetically-wired” to produce safety PROACTIVE “We methodically anticipate”— prevent problems before they occur SYSTEMATIC Systems being put into place to manage most hazards REACTIVE “Safety is important. We do a lot every time we have an accident” UNMINDFUL Chronically Complacent • Truly patient-centered care, it’s all about them, a true partnership • Structured process for patient & family at the table, input is valued, results visible • Care process visible to the patient, learning and feedback process is sporadic • Customer service is a focus, PFCC is not incorporated in a meaningful way • Care process built around the convenience of the providers, not patients and families Confidential & Proprietary 5 Putting Patients and Families First Anthony Digioia - Total Joint Program - UPMC Patient centered, reliable care process with teamwork and safety Seeing the process through the patient’s eyes Standardization and continual learning Workgroup involves all involved in the care of the patient – weekly, multidisciplinary meetings Teamwork and safety principles key components – huddle around every patient to plan individualized care HCAPS – 91 overall, 99% antibiotics admin, D/C within 24 hrs. Infection rate 0.3 % ( aver. 0.8-2.5% ) High functional status at D/C, 93% walking without handheld assistance; LOS 2.8 TKR, 2.7 THR, 91% D/C home Confidential & Proprietary 6 Senior Leadership GENERATIVE Organizational Culture “Genetically-wired” to produce safety PROACTIVE “We methodically anticipate”— prevent problems before they occur SYSTEMATIC Systems being put into place to manage most hazards REACTIVE “Safety is important. We do a lot every time we have an accident” UNMINDFUL Chronically Complacent • Systematic, structured, cyclic flow of information with feedback and learning • Methodical engagement with dialogue and learning • In the conversation with front • line In the conversation with staff front line staff • The suits are here – something bad must have happened • Where are they? Who are they? Confidential & Proprietary 7 CLINICAL UNITS WITHIN THE SAME HOSPITAL Confidential & Proprietary 8 Culture Matters 9 Confidential & Proprietary High Low Psychological Safety Characteristics of High Performing Cultures Comfort Zone Learning Zone Everyone works well together, but assumes good care is delivered, no need to waste time insuring safety and quality Optimal, safe care is a team effort, all mistakes are reported so they can be discussed & new ways are identified to avoid future problems Apathy Zone Anxiety Zone No one is interested or willing to coming up with more efficient & safe ways to work or learning from mistakesthat’s managements job Mistakes are a sign of personal weakness and will be punished so they are covered up and go unreported Low High Accountability ©2012 Developed cooperatively by Mayo Clinic and Pascal Metrics, Inc. Source: Edmonson, A.C. “The Competitive Imperative of Learning,” HBS Centennial Issue. Harvard Business Review 86, nos. 7/8 (2008) 10 360-degree View: Identify and Prioritize Highest Risk Units Geriat Target L&D Prioritize Safety Climate Score Admin ORs Lab PACU Med Unit Peds Cardiopulm Surg Unit Teamwork Climate Score Confidential & Proprietary CULTURE IS RELATED TO… Teamwork Climate Scores Across Facility 98 CCU REHAB OR EMERG 5 WEST 6 WEST PEDS GERI DIALYSIS PERIOP PHARM 3WEST ICU NICU SICU PEDS OB 100 73 75 80 80 62 62 55 52 51 60 45 45 49 49 41 36 40 28 33 20 0 HCAHPS 50 92 Medication Errors per Month 6.1 2.0 Days between C Diff Infections 40 121 Days between Stage 3 Pressure Ulcers 18 52 Illustrative Data: Extracted from Blinded Client Data Confidential & Proprietary Confidential & Proprietary AND UNFAVORABLE EMPLOYEE OUTCOMES Teamwork Climate Scores Across Facility 100 80 75 73 80 62 62 55 52 51 60 45 45 49 49 41 36 40 28 33 20 0 98 <60% Score = Danger Zone CCU REHAB OR EMERG 5 WEST 6 WEST PEDS GERI DIALYSIS PERIOP PHARM 3WEST ICU NICU SICU PEDS OB … Employee Satisfaction 55 91 Employee Injury per 1000 days 16 0.1 Employee Absenteeism per 1000 days 15 10 RN Vacancy Rate 9 1 Illustrative Data: Extracted from Blinded Client Data Confidential & Proprietary Using Cultural Data and Teamwork to Drive Improvement 2009 Percent Favorable 2010 Percent Favorable 2010 Hospital Partner Confidential & Proprietary Areas of Clear Focus and Action Effective Clinical Leadership Psychological Safety Comfort Learning from Errors Teamwork Behaviors Continual Learning and Improvement Confidential & Proprietary Socio-Technical Framework: Clinical Leadership GENERATIVE Organizational Culture “Genetically-wired” to produce safety PROACTIVE “We methodically anticipate”— prevent problems before they occur SYSTEMATIC Systems being put into place to manage most hazards Team leaders create high degrees of psych safety and accountability Leaders consistently model and teach effective behaviors Leadership training available, taught and a priority REACTIVE “Safety is important. We do a lot every time we have an accident” UNMINDFUL “We show up, don’t we?” Chronically Complacent Sporadic, based on individuals Noticeably absent Confidential & Proprietary Surg Tech Support Staff Surgeon OR Nurse Anesth MD Anesth Tech < 5 Respond Confidential & Proprietary Leaders The associated behaviors: GENERATE TRUST Open; Honest; Approachable PROMOTE RESPECT Non-negotiable; Non-hierarchical PSYCHOLOGICAL SAFETY Responsive to team members speaking up about concerns and ideas JUST CULTURE Clear policy and practice of fair treatment and accountability Confidential & Proprietary Socio-Technical Framework: Psychological Safety GENERATIVE Organizational Culture “Genetically-wired” to produce safety PROACTIVE “We methodically anticipate”— prevent problems before they occur SYSTEMATIC Systems being put into place to manage most hazards REACTIVE “Safety is important. We do a lot every time we have an accident” UNMINDFUL “We show up, don’t we?” Chronically Complacent Primary function of leaders – continuously modeled throughout the organization Leaders model and expect behaviors promoting psychological safety Awareness that speaking up, voicing concerns is important Personality dependent – depends who I’m working with Fear based – keep your head down – Don’t speak up Confidential & Proprietary In virtually every episode of serious avoidable harm or death, someone knew there was a problem and was unable to get the team to respond appropriately in a timely manner. Confidential & Proprietary slid e21 Psychological Safety Is Local © 2012 Pascal Metrics Confidential & Proprietary Psychological Safety Psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes. A shared sense of psychological safety is a critical input to an effective learning system. Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, Vol. 44, No. 2 (Jun., 1999), pp. 350-383 Amy Edmondson Confidential & Proprietary Psychological Safety We are our own image consultants and best image protectors To protect one’s image, if you don’t want to look STUPID Don’t ask questions INCOMPETENT Don’t ask for feedback NEGATIVE Don’t be doubtful or criticize DISRUPTIVE Don’t suggest anything innovative PSYCHOLOGICAL SAFETY CHANGES THIS PARADIGM Source: Amy Edmondson Confidential & Proprietary Psychological Safety We are our own image consultants and best image protectors To protect one’s image, if you don’t want to look STUPID Don’t Ask questions ask questions INCOMPETENT PSYCHOLOGICAL NEGATIVE SAFETY Don’t Ask for ask feedback for feedback DISRUPTIVE Don’t Be innovative suggest anything innovative Don’t Be doubtful be doubtful or criticize Source: Amy Edmondson Confidential & Proprietary Socio-Technical Framework: Organizational Fairness / Just Culture GENERATIVE Organizational Culture “Genetically-wired” to produce safety PROACTIVE “We methodically anticipate”— prevent problems before they occur SYSTEMATIC Systems being put into place to manage most hazards REACTIVE “Safety is important. We do a lot every time we have an accident” UNMINDFUL “We show up, don’t we?” Chronically Complacent Leaders share events, model a culture of accountability, learning is the priority Safe to discuss error, individual v. system error clear Algorithm present and used, learning more important than blame Depends on who I’m working with, errors usually lead to blame and punishment Nothing good will come from talking about mistakes, somebody’s in trouble Confidential & Proprietary SURGICAL SERVICE LINES WITHIN THE SAME ORGANIZATION Confidential & Proprietary 27 Perspectives on Human Error – Sidney Dekker Old View New View • Human error is a cause of trouble • Human error is a symptom of deeper system trouble • You need to find people’s mistakes, bad judgments and inaccurate assessments • Instead, understand how their assessments and actions made sense at the time — context • Complex systems are basically safe • Complex systems are basically unsafe • Unreliable, erratic humans undermine system safety • Complex systems are tradeoffs between competing goals — safety v. efficiency • Make systems safer by restricting the human contribution • People must create safety through practice at all levels Confidential & Proprietary VERY UNSAFE SPACE 100% Agreement Non acceptable Usual Space Of Action Expected safe space of action as defined by professional standards Real Life standards 60-90% Safety Reg’s & good practices, accreditation standards ACCIDENT LOW 100% ‘Illegal normal’ Individual Benefits HIGH Systemic Migration of Boundaries: Deviation is Normal HIGH Production Performance LOW Rene Amalberti, MD, PhD Confidential & Proprietary Little Things Can Cause Big Problems Room 20 Look out the window A simple knee scope He’s OK – he’s not too sedated - you go home What it says on the box is not what’s in the box Confidential & Proprietary 30 Drawing the Bright Line Repeat Events Malicious Substance Use Remediate / replace Conscious unsafe act Substitution Test could 2-3 others make the same mistake in similar circumstances? Reason, James Safe Harbor – Systems Approach Confidential & Proprietary Socio-Technical Framework: Effective Teamwork GENERATIVE Organizational Culture “Genetically-wired” to produce safety PROACTIVE “We methodically anticipate”— prevent problems before they occur SYSTEMATIC Systems being put into place to manage most hazards REACTIVE “Safety is important. We do a lot every time we have an accident” UNMINDFUL “We show up, don’t we?” Chronically Complacent Highly functional teams with systematic, continuous learning Methodical implementation and reinforcement of team behaviors Teamwork tools and training available, partial adoption Awareness and teamwork training after adverse events is the norm Individual expert model – “Just do your job and everything will be fine” Confidential & Proprietary TEM Teams The associated behaviors: PLAN FORWARD Brief (rounding, huddle, pause, timeout, check-in) REFLECT BACK Debrief COMMUNICATE CLEARLY Structured Communication SBAR and Repeat-Back MANAGE CONFLICT Structured Critical Language Confidential & Proprietary Repeat Back Ensuring transmission and reception of information is clear and accurate • All drug names • All numbers (patient ID, dosages, etc.) • Clinical histories • Handoff information Confidential & Proprietary slid e34 Critical Language A PHRASE THAT STOPS THE WORK “I need a little clarity.” “I am concerned or unclear. This is unsafe.” Confidential & Proprietary Debriefing Ask three questions: What did we do well? What did we learn? What do we want to do differently tomorrow or next time? Confidential & Proprietary THE IMPACT OF ACTING ON SAFETY CULTURE DATA IN RHODE ISLAND ICUS ICUs that DEBRIEFED ICUs that did not DEBRIEF Change in survey scores Reflected on culture scores and took action 1. >15% culture score increase in 5/7 domains 2. >10% BSI reduction 3. >15% VAP reduction * * Did not reflect on SAQ scores nor take action 1. 5% culture score drop in 5/7 domains 2. No reduction in BSIs 3. 5% increase in VAPs * * Vigorito-Cornell et al. ©2012 DevelopedAttribution: cooperatively byM. Mayo Clinic and Pascal Metrics, Inc.Improving * safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans. Jt Comm J Qual Patient Saf. 2011 Nov;37(11):50937 Socio-Technical Framework: Process Improvement GENERATIVE Organizational Culture “Genetically-wired” to produce safety PROACTIVE “We methodically anticipate”— prevent problems before they occur SYSTEMATIC Systems being put into place to manage most hazards REACTIVE “Safety is important. We do a lot every time we have an accident” UNMINDFUL “We show up, don’t we?” Chronically Complacent Unit level continuous learning, improvement, org. alignment Robust unit level learning and improvement the norm, linking opportunities to action Knowledge of process improvement, testing, collaborative work We try harder when faced with performance gaps or adverse events Simple things don’t get fixed, lots of first order problem solving Confidential & Proprietary Learning is Visible in Healthy Work Areas Confidential & Proprietary Acute Medicines Unit, Ninewells Hospital, Dundee, Scotland - Arun Chaudhuri, Medical Director Hand Hygiene DVT Prescribing Compliance Bld Culture Contamination Compliance with Med. Reconciliation Early Warning Scores Bundle O2 Prescribing Pressure Ulcer Prevention Bundle ? Confidential & Proprietary The Learning Board © 2012; Mercy Medical Center, Cincinnati, OH slide-41Confidential & Proprietary
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