Improving safety culture

Transcription

1 Improving safety culture Stephen Leyshon 1 SAFER, SMARTER, GREENER

2 Objective and content Objective: To provide an overview of how systems thinking can be applied to support the development of a positive organisational safety culture Content: Safety culture and its relationship to quality Systems thinking and risk management The components of leadership Creating and enacting a vision Managing change Improving working conditions through: Workflow analysis Job analysis Analysis of group norms The need for a continuous improvement 2

3 Housekeeping Today builds on our previous webinar: Assessing Safety Culture Measure What You Treasure from the 27 th of April 2016 It will follow a similar format: 50 minute webinar 10 minute Q&A 3 polls The slides, along with a recording of today s webinar, will be circulated to participants after the webinar 3

4 To follow-up For further information on our safety culture work, please contact: Dr Tita Alissa Listyowardojo: A copy of our Safety Culture Mixed Methods Assessment Position Paper is available to download for free from: 4

5 But first, I ll introduce myself Global Clinical Officer for DNV GL Over 25 years experience in healthcare, working from bed-side to boardroom Registered Nurse and Community Nurse Specialist Health services manager: Population-based community health services (125, ,000 people, inner- London some of the most deprived areas of Europe) Lecturer and Academic Research Fellow: King s College London and University College London Clinical Lead for Patient Safety in Primary Care and Ambulance Services at the UK s National Patient Safety Agency: Building collaboratives and leading national policy to improve the quality of care outside of hospitals 5

6 and DNV GL Purpose: To safeguard life, property and environment Vision: Global impact for a safe and sustainable future 6

7 What is safety culture? Outcomes Processes Structure Safety Culture 7

8 A real-life example of how a poor culture can negatively impact healthcare quality an application of the loss causation model (LCM) Finding the underlying reasons for actual or potential nonconformity Lack of control: Basic causes: Immediate causes: Incident: Loss: Inadequate / inappropriate: Priorities Systems Standards Compliance Skills, knowledge, attitudes, rules: Personal factors Task factors Communication factors Substandard acts Substandard conditions Event Threshold limits Unintended / unwanted harm, damage, negative consequences Teamwork 8

9 Chelmsford Private Hospital in Australia Private hospital in New South Wales, Australia Use of Deep Sleep Therapy in patients with mental health needs between 1963 and 1979 Patients given a cocktail of barbiturates and kept in a coma for up to 39 days Administered repeated ECT Concerns raised about patient deaths and harms Royal Commission

10 The loss causation model applied to Chelmsford Hospital Lack of control: Lack of oversight particularly when introducing new and unproven therapies Lack of data monitoring processes and outcomes to detect problems early Ineffective regulation and inspection Questionable relationship between provider and policy makers Basic causes: Charismatic clinical leader able to persuade others to support unproven / unevaluated therapy even after concerns raised Hierarchical structures with staff unable to challenge or raise concerns Failure to listen to patients most vulnerable group and most likely to be dismissed (Martha Mitchell effect) Immediate causes: Use of unproven Deep Sleep Therapy even after concerns raised Incident: Patients administered Deep Sleep Therapy Threshold limits Loss: Patients died Survivors traumatised patients 2 nd victims Dr. committed suicide 2 nd victims whistle-blower leaves Australia Loss of trust in psychiatry AUS$ 5.5 million in compensation payments AUS$ 15 million Royal Commission costs 10

11 Poll 1 My organization uses risk-based systems to identify threats to a positive safety culture and to establish effective controls: Yes No Not sure 11

12 Systems Thinking Systems thinking is a way of seeing relationships rather than things patterns rather than static snapshots (adapted from Senge 1993) Human Technical Policy, law and ethics Organisational Financial Environmental 12

13 The value of risk management to systems thinking Quantitative Semiquantitative Qualitative Hazard identification and assessment of risk likelihood & consequences Evaluation Continuous risk communication Planning Controls Implementation Prevention Mitigation 13

14 Using Systems Thinking to Improve Safety Culture In the case of safety culture (i.e. the values that drive behaviour), this particularly relates to how individuals work together to achieve a common vision: Leadership Creating and enacting a vision Managing change Improving working conditions through: Workflow analysis Job analysis Analysis of group norms Continuous improvement 14

15 Leadership a relationship through which one person influences the behaviour or actions of other people [it] is related to motivation, interpersonal behaviour and the process of communication Leadership is dynamic The leaderfollower relationship is reciprocal and effective leadership is a two-way process which influences both individual and organisational performance (Mullins 1996 p 246) Leadership is the moral and intellectual ability to visualise and work for what is best for the [organisation] and its employees (Sieff 1991 p 133) 15

16 Leadership Personality High energy level and stress tolerance Self-confidence Internal locus of control Emotional maturity Personal integrity Socialized power motivation Achievement orientation Low needs for affiliation Competencies - Technical competence - Conceptual skills - Interpersonal skills 16

17 Poll 2 My organization has a clear vision for safety culture that is understood and shared by all: Yes No Not sure 17

18 Creating a common vision Questions to ask: Why are we trying to develop a positive safety culture? What will a positive safety culture look like for: Our service users? Our staff? Our partner organisations? Our executive board? Our investors/commissioners? How will we know that we ve achieved a positive safety culture? Soft data Hard data 18

19 A vision that addresses multiple demands the balanced scorecard End user impact Objectives: Activities: To achieve our vision, how should we appear to, and what impact should we have for, our patients and their communities? Target measures: Example areas for consideration when developing objectives, activities and target measures: Our vision is: Improvement in physical health status Improvement in quality of life Patient and family experience Improved patient safety outcomes Improved public health outcomes Achievement of sustainability goals Financial stewardship Objectives: Activities: To achieve our vision, how should we make best use of our financial resources and how should we appear to our commissioners/payers or Target measures: shareholders? Example areas for consideration when developing objectives, activities and target measures: Revenue Growth plan Balanced budgets that deliver efficiency and effectiveness Transparent reporting Cost reduction Reduced wastage Structure and processes Objectives: Activities: To achieve our vision, how should we be organised and how should we deliver our services? Target measures: Example areas for consideration when developing objectives, activities and target measures: Physical environment Access and waiting times Integrated, seamless care within and between organisations Leveraging of technology Adoption of evidence-based care Risk and safety management assurance, including infection control Culture, people and learning Objectives: Activities: To achieve our vision, how will we sustain our ability to change and improve? Target measures: Example areas for consideration when developing objectives, activities and target measures: Recruitment Retention Valuing diversity Continuous learning and development competence pipeline Just, generative culture Clear roles and lines of accountability 19

20 Creating and enacting a vision: IDEAL I Identify the problem what do we want to achieve and why, what is stopping us? D Define and represent the problem define the root causes of what is stopping us from achieving our vision E Explore possible solutions A Act on the solutions L Look back and evaluate the effect of the solutions 20

21 Understanding the causes of what is stopping us from achieving our vision Fishbone/Ishikawa Diagram Problem Here 21

22 Questions to reflect on our vision making process: GROW Goal Do we have: An inspiring vision? A clear statement of what you want to achieve to support that vision? Measurement criteria both progress and outcome (how will we know that the change is an improvement)? Does this all fit with the directorate and hospital vision (organisational coherence)? Reality Have we identified: Root-causes obstacles preventing the goal from being achieved? State of existing prevention and mitigation controls Steps that have already been taken (including learning from what didn t work and why but moving on)? Options Have we set out steps to reaching the goal: What to start doing? What to stop doing? What resources are needed (inner/personal, human, organisational, physical, technological, financial, information)? Way forward Have we set out actions from now: What? Who? By when? Key people to influence/get onside (stakeholders and powerbrokers)? What problems you foresee and how you will overcome them? How you will keep motivated? 22

23 Creating change Dissatisfaction and/or Desire x Vision x First Steps > Resistance & risks to improvement Human Technological Organisational Physical Environmental Financial Law and ethics 23

24 Overcoming groupthink as resistance to change Bring together groups that are diverse in: Age Length of service Education Disciplines More likely to be: Receptive to change Able to seek, accept and integrate new information Creative and innovative in decision making Willing to pursue and enact new strategies 24

25 Poll 3 My organization does regular workflow and job analysis to ensure that the right people do the right things at the right time: Yes No Not sure 25

26 Workflow analysis through risk-based process mapping (work as done, not as imagined) Pre-condition 1n What: Why (evidence, rationale, value): Who: When: Resources: Connectedness to pre and post stages: Measure: Key stage 1n What: Why (evidence, rationale, value): Who: When: Resources: Connectedness to pre and post stages: Measure: Goal/Impact What: For whom: Why (evidence, rationale, value): Measure: All possibilities? Threat 1n What could go wrong: How: Likelihood (L): Consequence (C): Risk priority number (L x C): Leading indicator(s): Lagging indicator(s): All necessary? Prevention control 1n What: Who: When: Resources: Strength: Integrity: Indicator(s) Mitigation control 1n What: Who: When: Resources: Strength: Integrity: Indicator(s) All necessary? 26

27 Job analysis core job dimensions and their connection to creating a positive culture (after Hackman and Oldham 1980) Core job dimensions Skill variety Task identity Task significance Autonomy Continuing competence development Critical psychological states Experienced meaningfulness of work Experienced responsibility for outcomes of work Awareness of own limitations Personal and work outcomes High quality of work performance High satisfaction with work Feedback Confident able to meet the needs of service users Knowledge of results of work and whether having an impact Low absenteeism and low turnover 27

28 Continuous approach Routine assessment and audits: Formal, direct (e.g. SAQ or AHRQ plus qualitative assessment mixed methods) Informal, direct (walk-around, informal discussion with staff, service users and other stakeholders) Other sources of intelligence (e.g. friends and family test, HCAHPs survey, general staff surveys) Cyclical approach Back to risk-management cycle Addresses hyper-complexity of healthcare (next slides) Supports use of accreditation standards (next slides) 28

29 Hypercomplex healthcare Scale of people involved in even a single patient episode Sr RN 14 Sr RN 13 Admin 1 Admin 8 Allied health 3 Admin 12 Sr nurse 22 Ward asst 1 Admin 7 Crosses boundaries within and between organisations Under-managed, under-resourced Highly technical but highly dependent on end users with differentiated needs and abilities need to personalise and protect Jr dr 26 Admin 3 Jr dr 30 Sr nurse 1 Admin 4 Jr dr 28 Allied health 4 Allied health 2 Sr dr 3 Sr nurse 13 Admin 9 Admin 11 Sr nurse 11 Admin 5 Jr dr 27 Sr nurse 9 Jr dr 2 Sr RN 8 EN 6 Admin 10 Sr nurse 21 Jr dr 25 Sr dr 4 Sr nurse 2 Sr dr 6 Jr dr 9 Sr nurse 12 Sr nurse 17 Jr dr 20 Jr dr 6 Sr dr 2 Jr RN 4 Admin 2 Ward asst 2 Sr nurse 3 Sr nurse 4 Admin 6 Jr dr 10 Sr dr 1 Sr nurse 10 Sr RN 4 Jr dr 29 Jr dr 8 Sr nurse 6 Sr dr 7 EN 1 Sr RN 1 Sr RN 7 Sr RN 6 Jr dr 3 Sr RN 11 Jr RN 11 Allied health 1 Sr RN 9 EN 2 Sr nurse 5 Jr dr 19 Jr dr 24 Jr RN 10 Sr nurse 8 Sr nurse 20 Sr dr 5 Jr RN 2 Jr dr 11 Sr nurse 14 Jr dr 12 Jr RN 3 Sr RN 2 Jr RN 6 Jr dr 17 Jr dr 21 Jr RN 8 EN 5 Sr nurse 7 Jr dr 22 Jr dr 1 Sr RN 10 Jr dr 23 Jr dr 16 Jr dr 15 Jr RN 1 EN 4 Sr RN 5 Sr nurse 19 Jr dr 18 Sr nurse 15 Sr nurse 18 Jr dr 7 EN 3 Jr RN 9 Sr nurse 16 Jr dr 4 Jr dr 13 Jr RN 5 Sr RN 3 Jr RN 12 Jr dr 5 Jr RN 7 Jr dr 14 Sr RN 12 Medication advice-seeking networks in an ED (Braithwaite 2015) 29

30 The value of accreditation beyond legal requirements Organisation Positive impact Management practice Evidence Organisations that have either ISO or accreditation are safer and better than those which have neither (Shaw et al 2010 p 449) Professional practice Compliance with QI mechanisms and achievement of other quality indicators Perception amongst health professionals (Greenfield and Braithwaite 2008, HAS 2010, Greenfield et al 2012) accreditation programs improve the process of care provided by healthcare services Accreditation programs should be supported as a tool to improve the quality of healthcare services (Alkhenizan and Shaw 2011 pp ) 30

31 Conclusion Today s webinar has provided an overview of how systems thinking can be applied to support the development of a positive organisational safety culture In particular, it has addressed: Safety culture and its relationship to quality Systems thinking and risk management The components of leadership Creating and enacting a vision Managing change Improving working conditions through: Workflow analysis Job analysis Analysis of group norms The need for a continuous improvement 31

32 Thank you Q & A 32

33 To learn more about our work in Strategic Research and Innovation To download for free or read online, please visit us at: 33

34 Stephen Leyshon SAFER, SMARTER, GREENER 34