Unit Based Culture of Safety and Learning Owensboro Health March, 2017
Owensboro Health 477 Bed Regional Hospital 32 Bed ICU 30 Transitional Care Beds Level III Trauma Center Level III NICU Largest employer west of Louisville in the Commonwealth of Kentucky
Owensboro Health Lisa Burnett RN Tyler Green RN Terra Crabtree RN Bill J. Bryant MD
Objectives Understand the importance of safety culture and learning at the macrosystem and microsytem (unit) level for high reliability. Describe how a unit safety huddle linked with a learning board promotes a culture of safety that enables learning and improvement. Describe unit safety culture s impact on eliminating harm events such as CAUTI and CLABSI.
Safety Subcultures Leadership Mindful Informed Reporting Just Flexible Learning Teamwork Evidence Based Communication Source: What is Patient Safety Culture? A Review of the Literature Christine E. Sammer, RN, PhD et al
The practice of modern healthcare encompasses an exceedingly complex set of activities, one that is highly dependent on the actions of human beings and that combines a variety of sophisticated technologies that are capable of both healing and causing significant harm. This combination of complex processes, dependence on human performance, and powerful technologies makes healthcare a high-risk and error-prone enterprise fraught with the potential for multisystem failures NQF p69
High Reliability Organizations (HROs) operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents. Managing the Unexpected (Weick & Sutcliffe)
Weick & Sutcliffe s Managing the Unexpected HROs think and act differently Collective State of Mindfulness Learning Organization
High Reliability environments deal with risk and hazard on a daily basis, yet maintain impressive levels of safety though building a safety culture and continuous learning. Michael Leonard & Allan Frankel Source: Michael Leonard & Allan Frankel. How can leaders influence a safety culture?
One fundamental, but important, difference is that highly reliable environments relentlessly assure safety, while in medicine, we often assume safety. This assumption of safety is a very dangerous mindset and often leads to serious avoidable injury. 44,000 98,000 deaths each year Michael Leonard & Allan Frankel Source: Michael Leonard & Allan Frankel. How can leaders influence a safety culture?
44,000 98,000 deaths each year 210,000 to 440,000 patients, each year, suffer from preventable harm that contributes to their death. Journal of Patient Safety, September 2013, Volume 9, Issue 3
IOM firmly established that the safety culture of the US healthcare system is deeply flawed and is the root cause of substandard care delivery. NQF p87 44,000 98,000 deaths each year
Hospitals 251,000 deaths each year???
IMPROVE Hospitals Chassin, Loeb The Joint Commission Health Affairs 30:4
IMPROVE REPORT Hospitals Chassin, Loeb The Joint Commission Health Affairs 30:4
IMPROVE TRUST REPORT Hospitals Chassin, Loeb The Joint Commission Health Affairs 30:4
Trust Non-negotiable Allan Frankel Respect
Psychological Safety Is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes. Do they have a high degree of confidence that the organization will act on their concerns? Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, Vol. 44, No. 2 (Jun., 1999), pp. 350-383 Amy Edmondson
IMPROVE TRUST Hospitals REPORT Safety Safety Culture Culture & Teamwork Chassin, Loeb The JC Health Affairs 30:4
Weick & Sutcliffe s Managing the Unexpected HROs think and act differently Collective State of Mindfulness: The power in a culture of safety with teamwork is all the sets of eyes being used Kerry Butler HPI Consultant enhanced ability to discover and correct errors that could escalate into a crisis.
IMPROVE TRUST 60% Hospitals REPORT Safety Culture Chassin, Loeb The JC Health Affairs 30:4 80%
Robust Process Improvement (RPI) Leadership IMPROVE TRUST TRUST Hospitals REPORT Safety Culture Chassin, Loeb The JC Health Affairs 30:4
Organizations with a positive safety culture are characterized by communications founded on mutual trust (and) by shared perceptions of the importance of safety An organization s safety culture determines the degree of personal risk an individual provider will take to protect the safety of his or her patients, thereby maximizing the safety of the unit and hospital. Its contribution to medical errors and adverse outcomes becomes elevated in relation to other factors when the perceived risk of being blamed or punished for mistakes is high. NQF p87:
Leaders drive values, values drive behaviors, and the collective behaviors of the individuals in an organization define its culture. NQF p70
A Robust Safety Culture is the combination of attitudes and behaviors that best manages the inevitable dangers created when humans who are inherently fallible, work in extraordinarily complex environments. The combination, epitomized by healthcare, is a lethal brew. Great leaders know how to wield attitudinal and behavioral norms to best protect against these risks. Michael Leonard & Allan Frankel Source: Michael Leonard & Allan Frankel. How can leaders influence a safety culture?
Culture Leadership Accountability Psychological Safety Teamwork Communication Adapted from Allan Frankel & Michael Leonard SAFE & RELIABLE Healthcare TeamSTEPPS Tools & Strategies Brief Huddle Debrief STEP Cross Monitoring Feedback Advocacy & Assertion Two-Challenge Rule CUS DESC Script Collaboration SBAR Call-Out Check-Back Handoff
Culture Learning Leadership Accountability Psychological Safety Teamwork Communication Adapted from Allan Frankel & Michael Leonard SAFE & RELIABLE Healthcare
A shared sense of psychological safety is a critical input into 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
At Toyota we get brilliant results from average people managing a brilliant process. Others get average results from brilliant people managing broken processes. Source: Toyota Motor Company
Workaround Culture Health care has a workaround culture that values expertise in overcoming obstacles to get the job done. Anita L. Tucker. Workarounds and Resiliency on the Front Lines of Health Care. AHRQ Patient Safety Network. August, 2009
Frontline health care providers are challenged by poorly performing work systems. (5 types of problems) Missing or incorrect information Missing or broken equipment Missing or incorrect supplies Waiting for a resource Human Equipment Simultaneous demands on their time Anita L. Tucker. Workarounds and Resiliency on the Front Lines of Health Care. AHRQ Patient Safety Network. August, 2009 Why Hospitals Don t Learn from Failures: Organizational and Psychological Dynamics that Inhibit System Change. Anita L. Tucker & Amy C. Edmonson. California Management Review. Vol. 45. No. 2. Winter 2003
Hospital nurses experience an average of one of these operational failures per hour. An average of 33 minutes per 7.5 hour shift For every 15 nurses working on a unit, the equivalent of one nurse has been removed from patient care Anita L. Tucker. Workarounds and Resiliency on the Front Lines of Health Care. AHRQ Patient Safety Network. August, 2009
the true magnitude of work system problems remains hidden because frontline health care professionals are so good at working around them. Anita L. Tucker. Workarounds and Resiliency on the Front Lines of Health Care. AHRQ Patient Safety Network. August, 2009
Negative consequences of workarounds: First-order problem solving: the job gets done Example: Out of linens: Bring back several linens Transfer the problem to another location Example: Secret horde of supplies or equipment Lack of communication hinders real improvement: Managers unaware of need for change Problems are not investigated to remove the underlying causes. Problem will recur No organizational learning When a workaround is superior to current standard practice, lack of discussion limits its diffusion Anita L. Tucker. Workarounds and Resiliency on the Front Lines of Health Care. AHRQ Patient Safety Network. August, 2009
Second-order problem solving is necessary for lasting improvement The way that real change is achieved. Health care organizations must solve this challenge if they are to deliver care as efficiently and safely as possible. Anita L. Tucker. Workarounds and Resiliency on the Front Lines of Health Care. AHRQ Patient Safety Network. August, 2009
Real time problem solving is examining a specific problem as close as possible to the location and time it occurred. Important information about underlying causes erodes over time. Anita L. Tucker. Workarounds and Resiliency on the Front Lines of Health Care. AHRQ Patient Safety Network. August, 2009
Successful organizations harness latent problem-solving power at the bottom of the organizational pyramid: Customers and frontline staff. These individuals have intimate knowledge of systems weak points, motivation to improve reliability, and feasible solution ideas. They vastly outnumber designated problem-solving staff typically tasked with systems improvement. Powerful to engage this army of creative minds and hands to improve work systems. Anita L. Tucker. Workarounds and Resiliency on the Front Lines of Health Care. AHRQ Patient Safety Network. August, 2009
Staff communication by itself is insufficient: Managers must resolve identified failures, provide feedback to staff about the actions taken, monitor that the fix worked, and resolved any unintended consequences. To learn from failures, people need to be able to talk about them without fear of ridicule or punishment. Anita L. Tucker. Workarounds and Resiliency on the Front Lines of Health Care. AHRQ Patient Safety Network. August, 2009
What can organizations do to move from a workaround culture to a culture that uses operational failures as opportunities for learning and systems improvement? Anita L. Tucker. Workarounds and Resiliency on the Front Lines of Health Care. AHRQ Patient Safety Network. August, 2009
Culture Learning Leadership Accountability Psychological Safety Teamwork Communication Transparency Continuous Learning Improvement & Measurement Reliable Processes Adapted from Allan Frankel & Michael Leonard SAFE & RELIABLE Healthcare
Fixing Holes in the Cheese Multiple Barriers designed to stop active errors EVENTS of HARM Active Errors by individuals result in initiating action(s) Latent Weaknesses in barriers Adapted from James Reason, Managing the Risks of Organizational Accidents (1997)
Improve Report Improve Report Trust Improve Report Trust Improve Report Trust Improve Trust Report Pathological: Chronically Complacent Improve Who cares as long as we are not caught Trust Report Reactive: Trust Safety is important. We do a lot every time we have an accident Calculative: We have systems in place to manage all hazards Proactive: Anticipating & preventing problems before they occur Generative: Constantly Vigilant Safety is how we do business here Slide Source: Adapted from Allan Frankel & Michael Leonard SAFE & RELIABLE Healthcare
Conclusions Safety culture and learning at the macrosystem and microsytem (unit) level are necessary for high reliability. A unit safety huddle linked with a learning board promotes a culture of safety with learning and improvement to achieve CAUTI/CLASI reduction and the aim of zero harm.