CULTURE OF SAFETY

DR. MOHAMED MOSAAD HASANMD, MPH, CPHQ, CPPS, GBSS

Consider a Case

• You are a medical leader and receive a call.

• A 25-year-old was transported to your emergency department (ED) following a road traffic accident.

• Your team identified multiple orthopedic injuries and intra-abdominal bleeding, requiring multiple transfusions.

Consider a Case• While cleaning up, a team member

identified that the patient received 2 incompatible units of PRBC.

• Patient developed multisystem failure and died.

• Uncertain if the transfusion error contributed.

• The nurse who administered the incompatible units is experienced.

Consider a CaseThe ED was busy.

• Policy directs personnel to confirm two identifiers before administering blood products.

• After a “near miss” a year earlier, all ED and operating room (OR) personnel were retrained.

Consider a Case• Quality and risk teams will review

records and schedule interviews.• Policy directs a root cause analysis

(RCA) to be attended by involved personnel.

• Other thoughts:

“I wonder what has been shared with the family.”

You also think about your team—nurses, physicians, or others—who are involved

Safety Culture DefinitionThe safety culture of an organization is

the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management.

related JCI Standards• Standard GLD.13

Hospital leadership creates and supports a culture of safety program throughout the hospital.

• Standard GLD.13.1

Hospital leadership implements, monitors, and takes action to improve the program for a culture of safety throughout the hospital.

Elements that promote success1. Clear leadership commitment

2. Articulated goals

3. Changes in work patterns to create teams that communicate and participate in decision making

4. Elimination of unnecessary variation

5. Measures for tracking progress and providing feedback

6. Stepwise, graduated interventions for personnel exhibiting non-teamwork-promoting (disruptive) behavior

Foundational elements

Four foundational elements:

• Shared values and goals

• Effective leadership

• Teamwork

• Safety culture

All affirm and mutually reinforce to

make health care safer

Shared values and goals for team members

Credo

• I make those I serve my highest priority.

• I communicate effectively.

• I conduct myself professionally.

• I respect privacy and confidentiality.

• I have a sense of ownership.

• I am committed to my colleagues.

Effective Leadership

• Authority derives from their organization role, policy directives, and hospital and medical staff bylaws.

• Leaders understand mission and credo.• Leaders establish (and follow) processes that

are transparent and data driven.• Leaders understand their own accountability.• Leaders will not “blink.”

Features of patient safety culture program

• acknowledgment of the high-risk nature of a hospital’s activities.

• an environment in which individuals are able to report errors or near misses without fear of reprimand or punishment;

Features of patient safety culture program (Continued)

• encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems;

• organizational commitment of resources, such as staff time, education, a safe method for reporting issues

Just culture

• Balancing safety and accountability.• The single greatest impediment to error

prevention in the medical industry “that we punish people for the medical mistakes”.

Just culture

• 3 basics:

1. It doesn’t reduce the personal accountability and discipline. It emphasizes the learning from the errors and near misses to reduce errors in the future.

2. The greatest error not to report a mistake. Thereby prevent learning.

3. All in the organization to serve as safety advocates. Both providers and consumers will feel safe and supported when they report medical errors, near misses and voice concerns about patient safety.

It has zero tolerance for reckless behavior.

Behaviors • Human error – inadvertent action: doing other than what

should have been done.

Manage through change in processes, procedures and training.

• At risk behavior: behavioral choice that increase risk where risk is not recognized or is believed to be justified.

Manage through increase awareness, and providing incentives for healthy behaviors and disincentives for risky behaviors.

• Reckless behavior: consciously disregard substantial and unjustifiable risk.

Manage through Remedial and punitive action.

Reckless behaviors

• failure to follow hand-hygiene guidelines, • Not performing the time-out before

surgery, • or not marking the surgical

Zero Tolerance to Reckless Behavior

Red rules

• cannot be broken • few in number• easy to remember • associated only with processes that can cause

serious harm to employees, customers, or the product line.

• must be followed exactly as specified except in rare or urgent situations.

• Every worker, regardless of rank or experience in the company, is expected to stop the work or production line if the red rule is violated.

REASON’s “Unsafe Acts” Algorithm

• Did the team member intend to cause harm?

• Did the team member come to work impaired?

• Did the team member knowingly and unreasonably increase risk?

• Would another team member in the same situation act in a similar manner?

REASON’s “Unsafe Acts” Algorithm

Problem Level Of Intervention

Single Unprofessional Incidents

Informal “Cup Of Coffee” Intervention

Apparent Pattern Awareness Intervention

Pattern Persists Guided Intervention By The Authority

Still Disciplinary Intervention

Patient Complaints

• “Dr. ___ is either too busy or scatterbrained to read my files or is dangerously neglectful.... I fear for my safety and for her other patients....”

• “Dr. __ inserted a drain and walked out of the room. After a while another MD removed the drain and explained it wasn’t even in the cyst.”

Back to the case

The RCA revealed:• The incompatible units were intended for a

second victim.• During the frenzy of activity, a nurse was

dispatched for trauma blood.• By chance, he pulled two units intended

for another patient (E-admitting system did not “talk” to lab system).

Back to the case

• As the nurse approached patient’s bedside, he came under a barrage of expletives from Surgeon X about getting the #@*&%! blood in.

• Nurse asserted, “I tried once to state I was following procedure but felt pressured to do as ordered.”

• Another team member—an RN—recognized the high-risk situation but reflected, “I just didn’t speak up.”

But What about The Human Accountability

You Meet with Nurse 2

System needs:

The observer:• Recognized a problem (colleague under

verbal assault) but did not speak up or get help.

• No evidence of intended harm…no history of unsafe acts.... You believe others might have behaved similarly.

You Meet with Nurse 2

• However, by not speaking up, Nurse 2 increased the probability of risk.

• You follow up this isolated incident with an informal cup of coffee conversation.

Principles for Informal Conversation

Your role:• To report an event• To let the colleague know that the

behavior/action was noticed (surveillance)• To avoid embarrassment/humiliation.• Know message and “stay on message.”• Allow the individual to be a professional.

You Meet with Nurse 1

• Came under verbal assault by Surgeon X.• Reason’s Unsafe Acts Algorithm: Did not

intend...no prior history.... The nurse acknowledges violating a policy.

• You believe a Level 1 “Awareness” feedback would be appropriate to allow the nurse, as a professional, to reflect on what happened.

• Goal is to provide feedback in a way designed to protect other patients and to protect the well-being of your team.

Awareness Guiding Principle

How to have the conversation:• Review whatever “data” or story you have.• Seek colleague's view (anticipate potential responses).• Invite colleague to take time to identify potential ways to

address issue(s).• Express appreciation if possible; acknowledge

contributions to organization; however…• Explain that you will follow up….• Document the conversation.

You Meet with Nurse 1

• You affirm that Nurse 1 is a valued team member.• You review the results of the RCA.• Ask Nurse 1 to reflect on the issues….• Nurse 1 asks for assertiveness coaching as is concerned

that he allowed another team member to intimidate him.

Definition of Disruptive Behavior

• Disruptive behavior includes, but is not limited to, words or actions that:

• Prevent or interfere w/an individual’s or group’s work, or ability to achieve intended outcomes (e.g., intentionally ignoring questions or not returning phone calls or pages related to matters involving patient care, or publicly criticizing other members of the team or the institution).

Definition of Disruptive Behavior

• Create, or have the potential to create, an intimidating, hostile, offensive, or potentially unsafe work environment (e.g., verbal abuse, sexual or other harassment, threatening or intimidating words, or words reasonably interpreted as threatening or intimidating).

• Threaten personal or group safety, aggressive or violent physical action

Consequences of Disruptive Behavior

Failure to Address Disruptive Behavior

• Team members may adopt disruptive person’s negative mood/anger (Dimberg & Ohman, 1996)

• Lessened trust among team members can lead to lessened task performance (always monitoring disruptive person)... affects quality and patient safety (Lewicki & Bunker, 1995; Wageman, 2000)

• Withdrawal (Schroeder et al, 2003; Pearson & Porath, 2005)

Prior to Meeting with the Surgeon

• Review results of RCA• Review other performance/behavior data: mal claims An apparent pattern on non-teamwork promoting

(disruptive) behavior directed toward patient and staff

• You previously spoke with Surgeon X about complaints from coworkers and patients.

• You find it concerning that Surgeon X failed to self-correct after previous (awareness) feedback.

Guided Intervention

• Pattern, no improvement; or Singular significant event

• Plan developed: Authority figure and individual co-develop a plan; or Authority figure develops and specifies plan

• Clearly defined consequences if plan not followed or doesn’t work within defined time

Evaluation of Patient Safety Culture

• Hospital leadership evaluates the culture on a regular basis using a variety of methods, such as:

Leadership walk-Around: allows leaders to visit, observe, listen and ask questions that elicit information about events or near misses, concerns about safety

Evaluation of Patient Safety Culture

Team member reports: • Incidents events, near misses, unprofessional

behavior, observed or suspected violations of regulatory requirements (privacy, unethical or improper conduct), harassment or discrimination complaints, unsafe equipment and medications, equipment/product recalls.

Evaluation of Patient Safety Culture

• Safety culture surveys• Unsolicited patient/family complaints• Trigger tools (systematic review of patient

charts to find markers that can identify harm)

Patient Safety Leadership WalkRounds

Developed by IHI

Purpose

• Demonstrate commitment to safety. � �• Fuel culture for change pertaining to patient

safety. �• Provide opportunities for senior leaders to learn

about patient safety. • Identify opportunities for improving safety.• Establish lines of communication about patient

safety. �• Establish a plan for the rapid testing of safety-

based improvements.

Indicators

• Response rate to cultural survey of front-line workers and managers (process measure).

• Number of errors reported per month from voluntary reporting systems (outcome measure).

• Number of safety-based changes made by heads of departments per year

• Percent of changes in overall infection rate.

Ground Rules

• The time and place of the WalkRound would not be announced before its commencement.

• All information that is discussed during the WalkRounds is strictly confidential, and leaders shall reassure employees for that.

Who Should Conduct WalkRounds

• Hospital Director,• Medical Director, • Nursing Director, • CQI/ PS director/ head,• Assistant Hospital Director.

How often?

• Hospital Leaders shall commit to conduct Walkrounds at a minimum of once per week with no cancellation.

• Postponement can be done from previous scheduled date, but shall be conducted within the same week.

• Every member shall do the WalkRounds with other members or alone.

Where

• Patient care units �• Operating rooms �• Emergency Department �• Radiology Department �• Pharmacy • Laboratories�

What format

• Conversation with the member and three to five employees that can be structured in various ways, including:

Hallway conversations �Individual conversations in succession

Script for WalkRounds

• Opening statement:

“We’re interested in focusing on the system and not individuals (no names are necessary).”

• Questions to Ask “Can you think of any events in the past day or few

days that have resulted in prolonged hospitalization for a patient?”

Examples: Appointments made but missed Miscommunications Delayed or omitted medications

Script for WalkRounds

Have there been any near misses that almost caused patient harm but didn’t?”

• Examples: Selecting a drug dose from the medications cart or pharmacy to

administer to a patient and then realizing it’s incorrect. Incorrect orders by physicians or others caught by nurses or

other staff.

“Have there been any incidents lately that you can think of where a patient was harmed?

Examples: Infections. Surgical complications

Script for WalkRounds “What aspects of the environment are likely to lead to the next patient

harm?”• Examples: Consider all aspects of admission, hospital stay, and discharge Consider movement within the hospital Consider communication Consider informatics and computer issues.

“Is there anything we could do to prevent the next adverse event?” • Examples: What information would be helpful to you? Consider alterations in the

interaction between clinicians. Consider teamwork Consider environment and workflow

Script for WalkRounds “Can you think of a way in which the system or your environment

fails you on a consistent basis?”• Examples: Not enough information available. Requirements that don’t make sense

Requirements that are unnecessarily time-consuming “What specific intervention from leadership would make the work you do safer for patients?”

• Examples: Organize interdisciplinary groups to evaluate a specific problem. Assist in changing the attitude of a particular group. Facilitate

interaction between two specific groups.

Script for WalkRounds

“What would make the WalkRounds™ more effective?” • Examples: Informal conversations in the hallway instead of organized

conversations Individual conversations instead of group discussions Ensure free

time to discuss issues

“How are we actively promoting a blame-free culture and working on the development of a blame-free reporting policy?”

• Examples: We do not penalize individuals for inadvertent errors. The institution grants immunity to individuals who report adverse

events in a timely fashion.

Script for WalkRounds

• Closing Comment:

“We’re going to work on the information you’ve given us. In return, we would like you to tell two other people you work with about the concepts we’ve discussed in this conversation.”

CAN WE MEASURE THE CULTURE OF SAFETY?

Thank You