Creating a Culture of Patient Safety

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Creating a Culture of Patient Safety

• Wheat Plains Health Network
• Critical Access Hospitals

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Agenda

• Definition of Safety Culture
• Background
• Characteristics of a Safety Culture
• Making the case for a Patient Safety Culture
• Creating the culture/Using your toolbox
• Challenges
• AHRQ Survey
• Takeaways

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Goals and Objectives

• Understand the five key principles of
  reliability science
• Describe the characteristics of a patient safety
  culture
• Describe actions to create a culture of patient
  safety
• Identify implementation challenges unique to
  culture change

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What is culture?

• Are these the right clothes to wear to work?
• Should I bring my lunch to this staff meeting?
• Who do I tell about this event?
• Culture is
• the way we do things around here

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Definition of a safety culture

• Institute for Healthcare Improvement (IHI)
• A culture of safety is an atmosphere of mutual
  trust in which all staff members can talk freely
  about safety problems and how to solve them,
  without fear of blame or punishment essential
  to improving patient safety in any organization.

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Definition of a safety culture

• The National Patient Safety Agency (NPSA)
• A safety culture in health care is one where
  staff and organization have a constant and active
  awareness of the potential for things to go
  wrong.
• In a safety culture, both staff and leadership
  are able to acknowledge mistakes, learn from
  them, and take action to put things right.

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Patient Safety Culture

• A culture that puts safety first the number one
  priority, ahead of productivity and efficiency
• A safety culture must be in place for patient
  safety practices to be truly successful

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Background

• Patient Safety Culture has it roots in
  Reliability Science
• High risk industries
• Military Operations Cuban Missile Crisis
• NASA -Challenger
• Nuclear Power Plants Three Mile Island,
  Chernobyl
• FAA Air Traffic Controllers Study (1979)
• Health Care Organizations - To Err is Human (The
  IOM report, 1999)

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To Err Is Human Building a Safer Health System

• Released in 1999
• 44,000 to 98,000 people die due to preventable
  errors
• Eighth leading cause of death in the United
  States
• Regardless of the debate about the estimates,
  they remain the standard for describing the
  problem

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Fallout of To Err is Human

• Many organizations have endorsed use of
  patient-safety indicators
• The Joint Commission
• National Quality Forum
• Leap Frog Initiative
• Institute for Healthcare Improvement (IHI)
• National Patient Safety Foundation
• Agency for Healthcare Research and Quality (AHRQ)
• CMS National Patient Safety Initiative
• Legislation passed in 2003 and 2004 intended to
  increase the reporting of medical errors
• Numerous documentaries, professional and lay
  press publications, PBS Mini-series
• Increase in public awareness as to the hazards of
  healthcare

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Framework of Reliability Science

• Five Core Principles
• Sensitivity to Operations
• Reluctance to Simplify
• Preoccupation with Failure
• Deference to Expertise
• Resilience
• Implementation of these core principles leads to
  an overall state of mindfulness

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Sensitivity to Operations

• Constant awareness to the state of the system
• Situational awareness
• Operations are king small deviations in
  processes get full attention
• Note risks
• Prevention

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Reluctance to Simplify

• Simple processes are good
• Reluctance to accept simple explanations can be
  risky
• E.g. Lack of communication, training, staff
• Essential to know true reason why patients are
  placed at risk

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Preoccupation with Failure

• Near Misses Opportunity for system improvement
• Strengths
• Weaknesses
• Reduce potential for harm
• Devotion of resources for improvement

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Deference to Expertise

• Organizational leaders defer to person with most
  knowledge
• Situational decision making authority migrates
  based on the situation at hand
• Issue relevant
• De-emphasizes hierarchy

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Resilience

• Expect failure in unanticipated ways
• Develop capability to detect, contain and bounce
  back when errors do occur
• Function despite setbacks
• Prepare
• Assessment
• Contain
• Improvise

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Mindfulness

• Collectively , these core principles engage a
  constant state of mindfulness
• Consistently safe, high quality care
• Results in highly reliable systems

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Discussion Questions

• What principles of a high reliability
  organization were used in this scenario?
• What principles of a HRO were not used in this
  scenario?
• Rewrite the scenario using principles of a HRO

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Creating a Patient Safety Culture

• Characteristics of this culture
• Why embrace this culture
• When do we start
• Where do we start

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Characteristics of a Patient Safety Culture

• Just Culture
• Perception of fairness and blamelessness
• Flexible Culture
• The ability to adapt
• Reporting Culture
• The willingness to report mistakes
• Learning Culture
• Learning from mistakes
• Informed Culture
• Information flow

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Figure 1. Based on Reason (1997) The Components
of Safety Culture Definitions of Informed,
Reporting, Just, Flexible and Learning Cultures
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Just Culture

• It is irrational to expect individual workers to
  perform
• flawlessly in defective organizations. No matter
• how good our staff members are, everyone makes
• mistakes. They suffer from a condition called
• being human. Systems are too complex to expect
• merely amazing people to perform perfectly 100
• percent of the time no matter how hard they try.
• Given that the vast majority of errors are due to
• failures of bad systems and not bad people,
  providing
• support to clinicians and other staff at the
• sharp end of medical care is simply the
  respectful
• and compassionate thing to do. (Conway, 2009)

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Defining the borders of bad behaviors (From P.
Stastny Sixth GAIN World Conference, Rome, 18-19
June, 2002)
Defining the borders of bad behaviors (From P.
Stastny Sixth GAIN World Conference, Rome, 18-19
June, 2002)
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Types of Behavior Involved in Error
Behavior Type Definition
Human Error Unintentional action
At-Risk Behavior Unsafe habits
Reckless Behavior Substantial and unjustifiable risk
Intentional Rule Violation Willful disregard for the rules
Source Marx, 2001
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From Reason (1997) A decision tree for
determining the culpability of unsafe acts.
p209From Reason (1997) A decision tree for
determining the culpability of unsafe acts. p209
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Characteristics of a Patient Safety Culture

• Patient Safety Cultures exist to the extent that
  there exists
• Open communication
• Feedback communication about error
• Frequency of events reported
• Effective handoffs transitions
• Management support for patient safety
• Blame free environment
• Supervisor/manager expectations actions promote
  patient safety
• Teamwork across units
• Teamwork within units
• Organizational learning
• Overall perception of patient safety
• Adequate staffing

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Open Communication

• The message of patients safety must be well
  conceived, repeated and consistent across the
  entire organization.
• The organization openly discusses patient safety
  at all levels and seek mechanisms to foster such
  communications.
• The organization strive to include patients as
  active participants in their care and promote
  patient and family questioning aspects of care.
• The organization discloses information about
  errors that reach a patient to the patient and
  family.
• The governing board in informed of errors,
  safety problems and efforts to improve.

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Feedback and Communication about Error

• Staff informed about errors
• Staff are given timely feedback
• Changes that are implemented are communicated to
  all levels
• The organization discusses ways to prevent errors

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Frequency of Events Reported

• Mistakes of the following types are reported
• Mistakes caught and corrected before affecting
  the patient
• Mistakes with no potential to harm patient
• Mistakes that could harm patient, but do not

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Effective Handoffs and Transitions

• Important patient care information is transferred
  
• Across hospital units
• During shift changes

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Management Support for Safety

• Hospital management provides a work climate that
• Promotes patient safety
• Makes patient safety a top priority

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Blame-Free Environment

• The organization seeks to develop human resource
  and medical staff policies that support that most
  errors are a result of flawed systems.
• Develops ways of rewarding rather than
  discouraging the reporting of errors.
• Celebrates success at improving the reporting and
  use of reports to improve care delivery.
• The organization seeks to engender an environment
  where reporting errors is the norm, without fear
  of retribution.
• Implements methods of feedback to learn from
  errors

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Supervisor/Manager Expectations Actions Promote
Patient Safety

• Consider staff suggestions for patient safety
  improvement
• Praise staff for following patient safety
  procedures
• Do not overlook patient safety problems

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Teamwork Across Units

• Cooperation outside the unit
• Coordination between units
• End goal is to provide the best patient care

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Teamwork Within Units

• Staff support one another
• Treat each other with respect
• Work together as one team

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Organizational Learning

• Continuous Improvement
• The organization recognizes the weaker aspects of
  performance and works to design error out and
  safety into workplace processes PROACTIVELY.
• Seeks to reduce variation on delivery of care
  (protocols, checklists and standardization).
• Evaluates the number of steps, hand-offs and
  persons are involved in carrying out specific
  processes (LEAN Methodology).
• Looks to research and outside their own
  organization to reduce the possibility of errors
• Methodically evaluates vulnerabilities of
  current care, new processes and new technology
  for threats to patient safety
• Promotes an environment where mistakes lead to
  positive changes
• Change is evaluated for effectiveness

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Overall Perceptions of Patient Safety

• Procedures and systems are good at preventing
  errors
• General lack of patient safety problems
• Incorporates accountability for patients safety
  into employee position descriptions and medical
  staff activities.
• The organization discuss the importance of
  patient safety, surveillance and expectations for
  reporting patient safety concerns and errors with
  all employees, beginning at orientation.
• Evaluates employees on contributions made towards
  patient safety.
• The organization institutes team training and
  simulation for physicians and employees. Members
  of the team look out for one another, noticing
  errors before they cause an accident.

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Adequate Staffing

• Enough staff to handle workload
• Work hours are appropriate to provide the best
  care for patients

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Characteristics of an Organization With a
Commitment to Safety

• Management must manage for patient safety just
  as they manage for efficiency and profit
  maximization. And safety must become part of
  what a hospital or health care organization
  prides itself on.
• Lucian L. Leape, M.D.
• Harvard School of Public Health

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• Mary Merchant, a RN who has been working
  with infectious disease patients for 15 years, is
  recognized as competent, careful and caring. She
  has supervisory and planning duties as well as
  her regular caseload, currently, five patients.
  Like most of her colleagues, Mary has a busy life
  outside her work. Today, she has an appointment
  with her sons teacher to discuss his behavioral
  problems, so she hopes she wont be asked to do a
  double shift.
• Donnie Smith in Room 202b was admitted
  for treatment of pneumonia and is receiving IV
  antibiotics. As the last dose finishes, Mary goes
  to the medication room off the nurses station to
  get some heparin flush to clear the IV. Several
  days ago, one of the meds rooms overhead
  fluorescent lights went out and maintenance
  hasnt gotten to it yet to fix it.
• Mary reaches into the drawer where the
  heparin flush is kept and pulls out a vial. Its
  hard to see it in this light, but she does this
  so many times a day its become a mechanical
  process. Marys thoughts drift to her meeting
  this afternoon at school whats going on with
  her son and whats shes going to do. She finds
  herself in the medication room wondering why she
  came in there in the first place. She suddenly
  remembers. The heparin for Mr. Smith.
• As she picks up the vial, Dr. Grendle
  taps on the medication room window and asks her
  to join him for lunch. She says sure while
  wiping the top of the vial with an alcohol swab.
  She turns the vial upside down and draws out the
  liquid into the syringe. She puts the vial onto
  the counter and heads towards Mr. Smiths room.
• As Mary is disconnecting the empty
  antibiotic container from the IV and flushing the
  line, Mr. Smith complains that the flush stings
  much more than the antibiotic did. Mary says it
  will stop in a few seconds. A minute later Mr.
  Smith slumps over in the bed in cardiac arrest.
• After her patient has been attended to,
  Mary rechecks the vial it is not heparin flush,
  but concentrated potassium chloride in a vial
  similar in size and shape to the heparin. Looking
  from the top, one cant tell the difference
  between the two.

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Discussion Questions

• Use Reasons decision tree to determine if Mary
  is culpable in this incident.
• What dimensions of a patient safety culture were
  present in this scenario?
• What dimensions of a patient safety culture were
  not present in this scenario?

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• LETS EAT!

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WHY a Safety Culture?

• Improved outcomes
• IOM report more people die from preventable
  medical mistakes than from AIDS, breast cancer or
  car accidents
• Health care is more dangerous than nuclear power,
  airlines, driving,
• Health care is as dangerous as bungee jumping
• Decrease never events for which care will no
  longer be reimbursed

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Why

• Making the case
• Jury awards 4.7 million for failure to
  administer calcium after thyroidectomy

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Why Building the Business Case

• Cincinnati Childrens Hospital
• Matched-case design
• Increased patient satisfaction
• Increased revenues by 17 annually
• Preventing complications and HAIs
• Reduced ALOS
• Freed beds for sicker patients with higher
  reimbursement rates
• Increased local and non-local demand for services

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Iceberg of IgnoranceThe of organizational
problems known to
Top Management - 4
Middle Managers - 9
Problems hidden from management
Supervisors - 74
Front-Line Employees - 100
Adapted from Sydney Yoshida, Japanese quality
expert
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HOW Create Momentum

• Seek support for creating a culture of safety in
  the organization
• Use your internal medical error and malpractice
  data
• Demonstrate how communication and teamwork can
  prevent many of these errors
• Share successful stories from other facilities

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HOW

• Educate yourself
• Understand the link between reliability science
  and patient safety culture
• Become the go-to person for patient safety
  culture

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HOW - Education

• Provide safety science education
• Frontline staff
• Management/executives
• Physicians
• Provide teamwork training
• ER teams
• OR Teams
• Provide education on communication techniques
• All staff and physicians