Shifting from Blame-&-Shame to a Just-and-Safe Culture
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1 Shifting from Blame-&-Shame to a Just-and-Safe Culture Barb Sproll Medication Safety Pharmacist Winnipeg Regional Health Authority 29 May 2018 Conflict of Interest I have no conflicts to disclose. Objectives: Identify characteristics that differentiate a Blame & Shame Culture from a Just & Safe Culture. Identify some tips to improve the safety culture of your organization or team. 1
2 The Blame & Shame Punitive Culture Individual workers held fully accountable for patients outcomes. Perfect performance is achievable through education, professionalism, vigilance and care. Threat of disciplinary action for errors thought necessary to maintain proper safety vigilance. Error follow-up focused on individual weaknesses. Focused on weeding out of bad apples! Impact of Punitive Culture Decreased incident reporting re: self and colleagues. Decreased reporting of near-misses and hazards. Creation of work-arounds introduces new risks. False sense of security. Missed opportunities to learn about risks and implement changes. Blame-Free Culture Institute of Medicine s TO ERR IS HUMAN: BUILDING A SAFER HEALTH SYSTEM first identified the failure of the Punitive Culture: One of the report s main conclusions is that the majority of medical errors do not result from individual recklessness or the actions of a particular group--this is not a bad apple problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. For example, stocking patient-care units in hospitals with certain full-strength drugs, even though they are toxic unless diluted, has resulted in deadly mistakes. 2
3 Blame-Free Culture Acknowledges human fallibility. Recognizes systems issues that may contribute to error. Understands there is little benefit to punishing workers for unintentional acts. Down Side of a Blame Free Culture But fails to confront individuals who: willfully make unsafe behavioral choices. knowingly disregard risk. What is this CULTURE thing??? A pattern of basic attitudes shared by a team/organization: Value - What is important to us in our work day? Beliefs - What do we believe about the work we do? Behaviors - How do we go about our work? These are taught to staff in both explicit and implicit ways. 3
4 The belief and the practice of placing patient safety at the centre of everything we do in healthcare. An exact definition of a culture of safety is still emerging in healthcare Using themes from high-reliability organizations (HROs) like aviation, nuclear power production, etc. can get us there. Strategic emphasis on safety A palpable passion for safety, grounded in a healthy acknowledgment of the high-risk nature of healthcare. Preoccupation with failure/safety. Just culture Supports reporting and investigation of hazards and errors. Staff trust each other and their leaders and report hazards and errors without fear of retribution or embarrassment. Feedback loops Have established, meaningful, feedback systems that keep staff informed about safety, errors and causal trends. Leaders hold discussions with staff to learn about barriers to safe work, to build trust and to demonstrate that safety is a priority. 4
5 Learning organizations Enhance capacity through real-life experiences gained over time. Staff see learning as inseparable from everyday work and a necessary precursor to change. Desire to change Profound change comes from commitment, not management-driven compliance that directs to staff to just do it. Staff carry a great deal of power when it comes to either maintaining the status quo or changing. 2 fundamental assumptions underlying much of the safety culture research A positive safety culture is associated with improved safety performance. It is possible to improve the culture of a team/organization. 5
6 Maturity Level Pathological Reactive Calculative Proactive Generative Approach to Improving Safety Culture Why do we need to waste our time on safety? We take patient safety seriously and do something WHEN we have an incident. We have rules, policies and procedures in place to manage patient safety. We are always on the alert/thinking about safety issues that might emerge. Managing safety is an integral part of everything we do. Avoid organizational arrogance. Actively pursue what is unknown. Make information & data available. Use available technology. Empower staff to recognize and respond to system abnormalities. Design redundancy make it easy to do the right thing. Set an environment that supports teamwork and communication. Use of Structured Communication Techniques: Briefings/ Time-outs/Huddles SBAR/ DARP Common Language Debriefings 6
7 Set the tone for teamwork & situational awareness. Shared understanding of: What s going on? What s likely to happen next? What to do if what is supposed to happen doesn t? Situational Awareness Strategies Use concise, specific and timely communication. Ensure every team member knows the game plan. Acknowledge and demonstrate common understanding (e.g. repeat-back). Talk to one another as events unfold so the team can monitor and verify perspectives. Anticipate the next steps and discuss contingencies. Constructively assert opinions and perspectives. Verbalize any red flags. Bottom Line: Good communication talk to each other & your patients Talk about safety issues and learn from the experiences of others (good and bad). 7
8 In the hospital setting we ve had good success with the use of safety huddles. Teams, patient care areas, etc. start their day with a 10-minute huddle and discuss the day ahead; error prone situations, anticipated stressors, etc. Time is always on short supply huddles are manageable chunks of time! Trust & Support Staff are empowered and freely participate in all safety discussions without judgement. Support and follow-up after an incident has occurred. Our regional safety committee is at a point where sharing of vulnerabilities is a teaching moment for all solutions are found together! Does not happen immediately! Trust has to be earned. References 1. Institute of Medicine To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press. 2. ISMP Medication Safety Alert, Acute Care. 31 July Safety requires a state of mindfulness (Part 1). (19)15: College of Pharmacists of Manitoba Newsletter. Spring What s Your Safety IQ?. 1, National Patient Safety Agency and School of Psychological Sciences, University of Manchester Manchester Patient Safety Framework (MaPSaF). 8
9 References 5. ISMP Medication Safety Alert, Acute Care. 14 July High-reliability organizations (HROs): What they know that we don t (Part I). (10)14: ISMP Medication Safety Alert, Acute Care. 28 July High-reliability organizations (HROs): What they know that we don t (Part II). (10)15: Fleming, M and N Wentzell Patient Safety Culture Improvement Tool: Development and Guidelines for Use. Healthcare Quarterly. (11): Barb Sproll bsproll@wrha.mb.ca
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