Practical Approaches to Establishing a Culture of Safety*

Transcription

1 Practical Approaches to Establishing a Culture of Safety* Leading the Transformation to High-Reliability Care IHI National Forum 8 December 2014 Gregg S. Meyer, MD, MSc Chief Clinical Officer, Partners Healthcare, Boston, MA * work in progress DISCLOSURES Dr. Meyer is a member of the Boards of Partners Community Healthcare Inc., The Joint Commission, CRICO/Risk Management Foundation, and the National Patient Safety Foundation. Dr. Meyer is a consultant to Winstron-Strawn, LLC. as an expert in quality. 1

2 Here is what I have Be Just Be Respectful Set Expectations Explicitly Create Accountability Be Transparent Be Demanding Be patient (enough) Take Care Of Yourself Your to do List But First, Some Fallacies Span of Control is important (If I only had authority I could do more) Working on change at the micro-system or macro-system (even on federal health policy) and everything in between brings similar challenges Data always drives the right decisions (If only I had data I would not have to sweat my decision) Its about data and anecdotes (and setting priorities which is the real tough part) No important decision is made with sufficient information Individuals drive improvement (If only I was I would be able to get the job done) We ask for help late and infrequently at our own peril Degree programs and letters after your name are the keys to effectiveness (If only I had gotten my degree I would get the next great posting) Being a cultural change agent will help you get the next job 2

3 Iron Laws of Cultural Improvement B Teams with A Systems always beat A Teams with B Systems It s the systems (studies of VA care) We need an A team, not A individuals and we need to provide that team with A systems It s not the seed, it s the soil Culture trumps all Innovation must be balanced with Spread The political is much more challenging than the technical Data + Anecdote = Action You need both 5 Be Just: How do we interpret events? 3

4 When SOP is NDG Bo s Law The fastest way to get yourself killed on a manned space flight is to not follow standard operating procedure The second quickest way to get yourself killed is to always follow standard operating procedure Karol Joseph "Bo" Bobko 4

5 The Just Culture Model The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes. Dr. Lucian Leape Professor, Harvard School of Public Health Testimony before Congress on Health Care Quality Improvement The Behaviors We Can Expect Human error - inadvertent action; inadvertently doing other than what should have been done; slip, lapse, mistake. At-risk behavior behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified. Reckless behavior - behavioral choice to consciously disregard a substantial and unjustifiable risk. 5

6 To Err is Human - Console To Drift is Human - Coach 6

7 Human Error and Drift Interaction At risk behaviors we choose make us more prone to human error e.g. driving in a residential neighborhood Performance shaping factors also make us more prone to human error e.g. fatigue Reckless is Reckless - Consequences 7

8 Be Respectful If we could change ourselves, the tendencies in the world would also change. As a man changes his own nature, so does the attitude of the world change towards him.... We need not wait to see what others do. 15 Be Respectful 16 8

9 Set Expectations Explicitly: MGH Credo As a member of the MGH community and in service of our mission, I believe that: The first priority at MGH is the well-being of our patients, and all our work, including research, teaching and improving the health of the community, should contribute to that goal. Our primary focus is to give the highest quality of care to each patient delivered in a culturally sensitive, compassionate and respectful manner. My colleagues and I are MGH s greatest assets. Teamwork and clear communication are essential to providing exceptional care. As a member of the MGH community and in service of our mission, I will: Listen and respond to patients, patients families, my colleagues and community members. Ensure that the MGH is safe, accessible, clean and welcoming to everyone. Share my successes and errors with my colleagues so we can all learn from one another. Waste no one s time. Make wise use of the hospital s human, financial and environmental resources. Be accountable for my actions. Uphold professional and ethical standards. MGH Boundaries As a member of the MGH community and in service of our mission, I will never: Recklessly ignore MGH policies and procedures. Criticize or take action against any member of the MGH community for raising or reporting a safety concern. Speak or act disrespectfully toward anyone. Engage in or tolerate abusive behaviors. Look up or discuss private information about patients or staff for any purpose outside of my specified job responsibilities. Work while impaired by any substance or condition that compromises my ability to function safely and competently. Journey versus Desination 9

10 Create Accountability 9% of MDs Accounted for 50% of Recorded Concerns (and 5% for 33% over 6 year study period) % of Concerns % of Physicians Note: 35-50% are associated with NO concerns Hickson et al, JAMA 2002;287: Incurred $s By Risk Category PredRisk Category # (%) Phys Mean $ Paid* % of Tot. $ Score (range) 1 (low) 318 (49) 1 4% (23) 6 13% (12) 4 4% (8) 42 29% (hi) 51 (8) 73 50% >50 Total 644 (100) 1 100% * In multiples of lowest risk group 20 Moore, Pichert, Hickson, Federspiel, Blackford. Vanderbilt Law Review,

11 Disruptive Behavior Pyramid Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007 No Level 3 "Disciplinary" Intervention Pattern persists Level 2 "Authority" Intervention Apparent pattern Single unprofessional" incidents (merit?) Vast majority of professionals-no issues Level 1 "Awareness" Intervention "Informal" Cup of Coffee Intervention Mandated Issues Be Transparent Plus ca change, plus ce la meme chose We are just stewards 11

12 Transparency As A Cultural Lever Be Demanding 35% 30% Percent of Time 25% 20% 15% 10% 5% Q&S Finance Linear (Q&S) Linear (Finance) 0% Meeting Year Restructuring Within an Academic Health Center to Support Quality and Safety: The Development of the Center for Quality and Safety at the Massachusetts General Hospital. Richard M.J. Bohmer, MBBCh, MPH, Jonathan D. Bloom, MD, Elizabeth A. Mort, MD, MPH, Akinluwa A. Demehin, MPH, and Gregg S. Meyer, MD, MSc Acad Med. 2009; 84:

13 Be Patient (enough) Class A Mishaps/100,000 Flight Hours 776 aircraft destroyed in FY Angled Carrier Decks Naval Aviation Safety Center NAMP est RAG concept initiated aircraft destroyed in NATOPS initiated Squadron Safety program System Safety 20 Designated Aircraft 10 ACT 2.39 HFC s Fiscal Year How Much Is Enough? Choose your battles wisely Sun Tzu and The Art of War Explicitly choosing between blitzkrieg and sitzkrieg Time and I against any other two Baltasar de Gracian ( ) Spanish Jesuit I may be delayed, but not defeated MLK, Jr. KEEP THE PROMISE! 26 13

14 Take Care Of Yourself: Change Hurts If your goal is to make everybody happy you are in big trouble If you are taking flak you are over a high value target But don t linger over the target 27 Get Support 28 14

15 To Do List Be Just Include questions about systems and behavioral choices explicitly in event reviews (start with a non-clinical example) The CNO question Be Respectful Review articles in Journal Club with staff Set Expectations Explicitly Create your own credo and boundaries Create Accountability Adopt a system to deal with disruptive behavior Be Transparent Find a lemons to lemonade example and don t waste the crisis tell your story Be Demanding Ask your Board to spend more time on quality and safety than finance (and kick off every meeting with it) Be Patient (enough) Explicitly decide which of your interventions are blitzkriegs and when you need to wait it out Take Care of Yourself Create your own support group Some personal advice It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change. - Charles Darwin