Effective Approaches in Leading Patient Safety and

Prepared for the Foundation of the American College of Healthcare Executives
Effective Approaches in Leading
Patient Safety and Error Reduction
Presented By:
Gary R. Yates, MD
©Copyright American College of Healthcare Executives 2013
Effective Approaches in Leading
Patient Safety & Event Reduction
Gary R. Yates, MD
Tucson, Arizona
May 7, 2013
American College of Healthcare Executives
1
Sentara Healthcare

123-year not-for-profit mission

8 hospitals – 1,935 beds

3,400 medical staff members

10 long-term care/assisted living centers

Extended stay hospital

520-physician medical group

432,600-member health plan

Sentara College of Health Sciences

$3.3B total operating revenues

$3.9B total assets

19,225 employees

2 Sentara hospitals & 5 specialties ranked in
nation’s Top 50 by U.S. News & World Report

Sentara eCare® HIMSS Analytics Stage 7 and
HIMSS Davies Award
Virginia
North
Carolina
2
Page 1
Sentara Norfolk General
Sentara Leigh
Sentara CarePlex
543 beds
250 beds
200 beds
Sentara Heart Hospital
Sentara Williamsburg
Regional Medical Center
Sentara Virginia
Beach General
112 beds
(included in SNGH license)
Sentara Obici
150 beds
145 beds
282 beds
Sentara Potomac
Sentara Princess Anne
183 beds
160 beds
3
HPI – A Reliability Company
Methods based on science and facts
 Science of human error and event prevention
 Practical experience in high-reliability industries including
nuclear power and aviation
Experienced-based mentoring
 Entered healthcare in 2002
 Over 450 hospitals
 Consulting team with HRO experience and healthcare
experience (clinicians, non-clinicians, and physicians)
4
Page 2
Introductions




Who you are
Where you work
What you do
Why you signed up for this course – what
you hope to take away
5
Learning Objectives
1. Identify effective approaches to improve patient
safety and reduce human errors
2. Describe approaches from HROs to drive safety
improvements
3. Describe the critical role of senior leadership in
creating a high reliability culture.
6
Page 3
Course Agenda
• Putting a Face on Safety
• Behaviors for Error Prevention
• The Call for Safety Leadership
• High Leverage Leadership Tactics
• Lessons from HROs
• Engaging Physicians
• The Science of Safety
• Just Culture
• Safety as a Core Value
• Summary
7
Putting A Face On Safety
8
Page 4
9
“Make my hospital right;
Make it the best.”
Abigail Geisinger
1. Don’t harm me
2. Heal me
ALWAYS Keep Safe
+
Evidence-Based Care
3. Be nice to me
Promptly and with
courtesy and compassion
Quality
10
Page 5
Josie King – Medication Error
Darrie Eason – Misdiagnosis
Sebastian Ferrero – Medication Error
11
Second Victims
“The devastated Kimberly
Hiatt committed suicide after
she gave a baby a fatal
overdose of medication at
Seattle Children’s.
Hiatt was totally destroyed as
a nurse after she accidentally
overdosed baby Kaia Zautner
on 14 September 2010, with
ten times too much calcium
chloride.
Kim Hiatt RN
Her error led to the unravelling
of her life.”
Kaia Zautner
12
Page 6
Please
Raise
Your
Hand
If…
• YOU have suffered harm as a
patient at a hospital or other care
facility (an infection, fall, delayed
diagnosis causing delay in
treatment, other …)
• A FAMILY MEMBER has suffered
harm in a hospital or other care
facility
• A FRIEND or COLLEAGUE has
suffered harm in a hospital or
other care facility
13
The Call for Safety Leadership
14
Page 7
In the News...
Hospitals hurt 18 percent of patients, study says
• NEJM study of 2,341 patients at 10 hospitals
November 25, 2010
• 63.1 % of the injuries were preventable
• 2.4 % caused or contributed to a patient’s death
“Process changes, like a new computer system or the use of a checklist, may help a bit,” he
said, “but if they are not embedded in a system in which the providers are engaged in
safety efforts, educated about how to identify safety hazards and fix them, and have a
culture of strong communication and teamwork, progress may be painfully slow.”
Medical mistakes plague Medicare
patients
• 780 randomly selected Medicare patients
November 16, 2010
• 1 in 7 (13.5%) experienced serious harm
• Less serious harm in additional 13.5% of patients
“Although hospitals have broadly embraced safety initiatives, the still-high rate of adverse
events indicates that far more needs to be done. Hospitals must work faster to adopt
evidence-based practices that reduce medical errors.”
15
Success: Hospital-Associated Infections
In the United States:
between 2008 and 2011:
- 42% decrease in
CLABSI
- 17% decrease in
surgical site infections
- 7% decrease in CAUTI’s between 2008
and 2010
16
Page 8
HRET/ CMS HEN Progress on Elective Deliveries
355 hospitals have submitted data on Elective Deliveries at >= 37 Weeks and < 39 Weeks (JC PC-1).
•
There is a 42.40% reduction from baseline rate of 16.29% to a follow-up rate of 9.39% (October
to December 2012).
•
This translates to 5,196 EEDs prevented in 2012, and this represents an estimated cost savings
of $21,303,600 for 2012.
17
17
How Safe Is Healthcare?
Dangerous
(>1/1,000)
100,000
Ultra Safe
(<1/100K)
Health
Care
Driving
In US
Total lives lost per year
(1 of ~600)
10,000
Scheduled
Commercial
Airlines
1,000
100
Mountaineering
10
Bungee
Jumping
1
1
10
100
Chartered
Flights
European
Railroads
Chemical
Manufacturing
1,000
10,000
100K
Nuclear
Power
1M
10M
Number of encounters for each fatality
18
Page 9
Patient Exposure
35 million hospital
discharges annually
900 million clinic
visits annually
Outpatient visits occur 25 times more
frequently than hospital admissions
19
American College of Healthcare Executives Announces
Top Issues Confronting Hospitals: 2011
Issue
20111,2
20103
20093
Financial challenges
Healthcare reform implementation4
Patient safety and quality
62% in 2007
Governmental mandates
Care for the uninsured
Physician-hospital relations
Patient satisfaction
Technology
Personnel shortages
Creating an accountable care organization
2.5
77%
76%
4.5
53%
53%
4.6
31%
32%
4.6
32%
30%
5.2
28%
37%
5.3
30%
25%
5.6
16%
15%
7.2
10%
7%
7.4
11%
13%
8.4
---
---
1In
2011 the average rank given to each issue was used to place issues in order of concern to hospital CEOs, with the lowest numbers
indicating the highest concerns.
2
In 2011 the survey was confined to CEOs of community hospitals (nonfederal, short-term, nonspecialty hospitals).
3In
2010 and 2009, the percent of CEOs who named an issue among their top three concerns was used to place issues in order of concern
to hospital CEOs.
4In
2009 this issue was referred to as “implications of healthcare reform.”
20
Page 10
Sentara Serious Safety Event Rate
Sentara Hampton Roads Hospitals
0.75
80% Reduction Since 2003
Event Rate
0.50
0.00
J-03
M-03
M-03
J-03
S-03
N-03
J-04
M-04
M-04
J-04
S-04
N-04
J-05
M-05
M-05
J-05
S-05
N-05
J-06
M-06
M-06
J-06
S-06
N-06
J-07
M-07
M-07
J-07
S-07
N-07
J-08
M-08
M-08
J-08
S-08
N-08
J-09
M-09
M-09
J-09
S-09
N-09
J-10
M-10
M-10
J-10
S-10
N-10
J-11
M-11
M-11
J-11
S-11
0.25
Each monthly data point is a rolling 12-month average of serious events
of harm expressed per 10,000 adjusted patient days
21
A deviation from generally accepted
performance standards (GAPS) that…
Serious Safety Event
Serious
Safety
Events
• Reaches the patient
• Results in moderate to severe harm or death
Precursor
Safety
Events
Precursor Safety Event
• Reaches the patient
• Results in minimal harm or no detectable harm
Near Miss Safety Event
• Does not reach the patient
• Error is caught by a detection barrier
or by chance
Near Miss Safety Event
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
22
Page 11
Worker Safety Improvements
Workman's Compensation
Costs
$600,000
1. Represents over 250 employees
that have not been
$500,000
injured
$400,000
2. 80% Reduction in Lost Time
Claims
3. 88% Reduction in OSHA$300,000
IIR from 12.2 to 1.5
4. Over $900,00 saved year to date
$200,000
$100,000
$0
CY 07
CY 08
CY 09
CY 10
23
Lessons from HRO’s
24
Page 12
Reliability
Reliability: The probability that a system, structure,
component, process, person will successfully provide
the intended function(s).
Often a ratio such as 0.96 or 96%
Sometimes a frequency such 10-3 per year
25
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)
Risk is a function of probability and consequence.
By decreasing the probability of an accident,
HRO’s recast a high-risk enterprise as merely a
high-consequence enterprise.
HROs operate as to make systems ultra-safe.
26
Page 13
Naval Aviation Mishap Rate
776 aircraft
destroyed in
1954
Mishap rates per 100,000 flight hours
60
Angled decks
50
Aviation Safety Center
Naval Aviation Maintenance Program (NAMP), 1959
40
15 aircraft
destroyed in
2008
RAG concept initiated
NATOPS Program, 1961
30
Squadron Safety program
System Safety Designated Aircraft
20
ACT
ORM
10
USN/USMC, FY50-06
0
50
55
60
65
70
75
80
85
90
95
00
Source: www.safetycenter.navy/mil ORM Flight Mishap Rate
27
28
Page 14
Reliability
Journey to improving reliability – the next zero
10
-8
10
-7
10
-6
10
-5
10
-4
10
-3
10
-2
10
-1
Optimized
Outcomes
Human Factors
Integration
Intuitive design
Impossible to do the wrong thing
Obvious to do the right thing
Reliability Culture
Process Design
Core Values & Vertical Integration
Hire for Fit
Behavior Expectations for all
Fair, Just and 200% Accountability
Evidence-Based Best Practice
Focus & Simplify
Tactical Improvements (e.g. Bundles)
© 2010 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
29
Descriptive Theories of HRO
Karl Weick & Kathleen Sutcliffe
1.
2.
3.
4.
5.
Preoccupation with failure
Sensitivity to operations
Reluctance to simplify interpretations
Commitment to resilience
Deference to expertise
Rene Amalberti
1.
2.
3.
4.
5.
Accepting limits on discretionary action
Abandoning autonomy
Transition from craftsman to equivalent actor
Sharing risk vertically in the organization
Managing the visibility of risk
Admiral Hyman Rickover
1.
2.
3.
4.
5.
6.
7.
Rising standards over time (more than the minimum)
Highly capable people trained over a wide range
Leaders face bad news (mobilize effort, report up)
Healthy respect for dangers
Training is constant and rigorous
All functions fit together
Learning from the past
30
Page 15
Five Principles of HROs
Three Principles of Anticipation
Preoccupation with Failure
Regarding small, inconsequential errors as a symptom that
something’s wrong
Sensitivity to Operations
Paying attention to what’s happening on the front-line
Reluctance to Simplify
Encouraging diversity in experience, perspective, and opinion
Two Principles of Containment
Commitment to Resilience
Developing capabilities to detect, contain, and bounce-back from
events that do occur
Deference to Expertise
Pushing decision making down and around to the person with the most
related knowledge and expertise
31
USS George Washington
32
Page 16
Preoccupation with Failure
Operating with a chronic wariness of the possibility of unexpected events that may
jeopardize safety by engaging in proactive and preemptive analysis and discussion
33
Counteracting the Risks
 FOD walkdown
 Situational awareness – monitoring for
anything that “does not fit” expectations
of the correct routine
 Landing Officer – listens to the pilot’s
voice to detect subtle cues of tension
 Every landing graded – used to
improve performance
 Near misses debriefed within the
hour
 Healthcare example: RRT to EWS
34
Page 17
Sensitivity to Operations
FOD Walk-Down
35
36
Page 18
“Patients don’t suddenly deteriorate.
Healthcare professionals suddenly notice.”
Anticipated Recovery
Clinical
status
Admission Assessment
Early
Warning
Score
Systematic
identification
& Mitigation
Medical
Emergency
Team
Effort needed to return to recovery
CPR
Source: Cincinnati Children’s Hospital Medical Center
Time
37
Identify
Family
concerns
High risk
therapies
Mitigate
Escalate
Bedside
Team
Unit
Team
Organization
Team
Intern
Watchstander
Senior Resident
Medical
Response
Team (MRT)
Bedside
nurse
Watchstander
Charge Nurse
Safety Team
(Nurse Manager
and Safety Officer)
Early Warning
Score ≥5
Watcher
Communication
concern
Attending
38
Tested on 4 nursing
units then spread
on 3/22/10
Source: Cincinnati Children’s Hospital Medical Center
Page 19
Situation
Awareness project
go-live
Robust plan and
prediction
39
Codes Outside the ICU
MRT Preventable Codes Outside Critical Care w/ BVMV or CC or Both per 1000 patient
days
U Chart
0.50
Events per 1000 Hospital Patient Days
0.45
0.40
0.35
0.30
0.25
0.20
0.15
0.10
0.05
19832
18217
17885
17593
19606
19771
19609
19773
21200
19869
20407
21854
21080
19745
20827
18560
20061
19052
18143
19275
20957
19545
19909
19860
21253
19983
20268
19828
21404
0.00
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
FY 2005
FY 2006
FY 2007
FY 2008
FY 2009
FY 2010
Q4
FY 2011
Patient Days, Quarter
Actual Rate
Mean: FY 2004 Q3- FY 2007 Q3
Last Updated 5/3/2011 by J. Barth, James M. Anderson Center for Health Systems Excellence
Goal
Control Limits
Source: Dr. Derek Wheeler, CCHMC Division of Critical Care Medicine/Census Database
40
Page 20
Reliability Culture - Genius of the AND
Safety Focus +
performed as intended
consistently over time
Evidence-Based
performed as intended
+
Process Bundles
consistently over time
Patient Centered +
performed as intended
consistently over time
= No Harm
= Clinical Excellence
= “Satisfaction”
RELIABILITY
CULTURE
“Failure Prevention”
Financial Focus +
performed as intended
consistently over time
= Margin
41
Challenges to Achieving High-Reliability
 Question whether things
could really be that much
better
 Not sure how to get there
 A piecemeal approach:
more tactics than strategy
 Few healthcare examples
42
Page 21
New Leadership Competencies
43
High Reliability Leadership
1. Create a robust culture of reliability and safety
- Be clear about the target and message on the mission
- Create commitment, not compliance
2. Learn about high reliability principles and the
science of safety
- Understand the value of non-technical skills
- Leaders as teachers and coaches
3. Implement structures and processes that support
high reliability
-
Daily operating systems for front-line staff and leaders
44
Page 22
The Science of Safety
45
Anatomy of a Safety Event
Multiple Barriers - technology,
processes, and people - designed to stop
active errors (our “defense in depth”)
EVENTS of
HARM
Active Errors
by individuals result
in initiating action(s)
Latent Weaknesses in barriers
PREVENT
DETECT & CORRECT
The Errors
The System Weaknesses
From James Reason, Managing the Risks of Organizational Accidents, 1997
46
Page 23
Unreliability and Patient Safety
Deviations
from bestpractice care
causing
Significant
Patient
Harm
=
Serious
Safety
Event
Serious Safety Events include errors that result in death, permanent
loss of function, or injury, such as:
 transfusion reaction
 medication event
 misdiagnosis
 hospital-acquired Infection
 treatment error
 delay in treatment
 wrong site/side surgery or procedure
 fall with serious injury
47
Common Cause Analysis Data
2010-2011
Top 10 Patient Safety Event Types
Comparison based on 1,613 events from72 hospitals in HPI CCA Database
HPICompare
23.6%
Delay in Diagnosis or Treatment (CM8)
21.3%
Medication Error (CM1)
15.2%
Other Care Management (CM10) - HAI
10.2%
Fall (EE3)
7.4%
Other Procedural (PR6)
4.2%
Retained Foreign Object (PR4)
2.2%
Wrong Site Surgery (PR1)
2.2%
Wrong Patient Surgery (PR2)
1.2%
Suicide or Attempt (PP3)
1.1%
Grade 3 or 4 Pressure Ulcer (CM7)
48
Page 24
"At the sharp end, there is almost always a discretionary
space into which no system improvement can completely
reach. Systems cannot substitute the responsibility borne by
individuals within that space."
Sidney Dekker
Just Culture: Balancing Safety & Accountability (2007)
49
Human Error – A Symptom, Not Cause
Human error is not the cause of failure,
but a symptom of failure
Human error – by any other name or by any other
human – should be the starting point of our
investigations, not the conclusion
Source: Fitts, P. M., & Jones, R. E. (1947). “Analysis of factors contributing to 460 'pilot error' experiences
in operating aircraft controls.” Memorandum Report TSEAA-694-12, Aero Medical Laboratory, Air Material
Command, Wright-Patterson Air Force Base, Dayton, Ohio.
50
Page 25
Human Error Classification
Based on the Skill/Rule/Knowledge classification of Jens Rasmussen and the Generic Error Modeling System of James Reason
Skill Based
Rule Based
Knowledge Based
Activity
Type
Familiar, routine acts that can
be carried out smoothly in an
automatic fashion
Problem solving in a known
situation according to set of
stored “rules,” or learned
principles
Problem solving in new,
unfamiliar situation for which
the individual knows no rules
– requires a plan of action to
be formulated
Error
Types
 Slips
 Lapses
 Fumbles
 Wrong rule
 Misapplication of a rule
 Non-compliance with rule
 Formulation of incorrect
response
 Self checking – stop and
think before acting
 Educate if wrong rule
 Think a second time if
misapplication
 Non-compliance – reduce
burden, increase risk
awareness, improve
coaching culture
 Stop and find an expert
Error
Prevention
Themes
Error
Probability
1:1000
1:100
3:10 to 6:10
© 2007 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
51
Common Cause Analysis Data
2010-2011
Human Error Types in the GEMS leading to Patient Harm
Comparison based on 4,874 acts from 168 hospitals in HPI CCA Database
HPICompare
14.3%
Skill-based
69.5%
Rule-based
16.1%
Knowledge-based
52
Page 26
Limitations of Attention
53
Common Cause Analysis Data
2010-2011
Professional Groups Experiencing
Acts in Healthcare Safety Events
Comparison based on 3,112 inappropriate acts from 72 hospitals in HPI CCA Database
HPICompare
39.0%
Nurse
30.6%
Medical Staff
8.3%
Care Team
7.7%
Technician/Technologist
3.4%
Pharmacist
2.6%
Nurse Extender
2.2%
Management
1.9%
Unit Clerk
1.6%
NP + CRNA
1.1%
Therapist
54
Page 27
3 Reasons for a Culture of Safety
in Support Organizations
1. Harm at their hand –
all professional groups in a hospital setting have
been the direct cause of harm.
2. Cross Monitoring –
if support organizations are not always part of the
problem, they can still always be part of the solution.
3. Hospital Readiness –
high-reliability support organizations unwind time
pressure, distractions (interruption type), and high continuous workload.
55
Common Cause Analysis Data
2010-2011
“How” Data
“Why” Data
People Causes
HPICompare
Knowledge & Skill
12.8%
Structure (job design)
10.5%
Attention on task
15.0%
Culture (people & people interaction)
57.3%
Process
19.3%
Information processing
8.7%
Systems Causes
HPICompare
Critical Thinking
36.0%
Policy & Protocol
8.2%
Non-Compliance
21.4%
Technology & Environment
4.7%
Normalized Deviance
6.0%
Acts coded for human error
1,820 of 2,845
(64%)
Acts coded for system cause
Culture Preventable =
2,444 of 3,102
(80%)
76.3%
Comparison based on 1,613 events / 3,112 acts from 72 hospitals in HPI CCA Database
56
Page 28
Influencing Behaviors at the Sharp End
Design of
Policy &
Protocol
Design of
Culture
Design of
Structure
Design of
Work
Processes Design of
Technology &
Environment
Behaviors
of Individuals & Groups
“You have to manage a system. The
system doesn't manage itself.”
"A bad system will DEFEAT
a good person every time.“
W. Edwards Deming
W. Edwards Deming
Outcomes
Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994)
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
57
What is Culture?
Culture
The shared values and beliefs
of individuals in a
group or organization
Culture =
Shared Values
& Beliefs
Shared Values
& Beliefs
Our Behaviors
Our Behaviors
Outcomes
58
Page 29
Job
Design
EOC
Culture
Process
Policy
Protocol
Technology
Culture makes
the other shaping
factors work as
intended.
High Reliability is
the right mix of
Blunt End behavior
shaping factors.
Culture is not just
one of the spaces
Culture is also the space
between the other spaces
Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994)
© 2012 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
59
Complementary Strategies
Codes Outside
the ICU
Surgical Site
Infections
Hand
Hygiene
Central Line
Infections
Culture
















…and on,
and on,
and on…
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
60
Page 30
Safety as a Core Value
61
Vive La Différence!
Safety as a Priority
Safety as a Core Value
 An objective that is ranked
among a list of other
objectives
 Position on the list may
shift, based on relative
importance at the time
 A distinctive guiding principle
that shapes thinking and
decision making
 Does not change
 Uncompromisable
62
Page 31
Safety at Norfolk Southern
Six Tenets of Safety
1. All injuries can be prevented.
2. All exposures can be safe-guarded.
3. Prevention of injuries and accidents
is the responsibility of each employee.
4. Training is essential for good safety
performance.
5. Safety is a condition of employment.
6. Safety is good business.
63
“Attention is the currency of leadership.”
Ronald Heifetz
Director of the Leadership Education Project
John F. Kennedy School of Government
Harvard University
“I’m careful about the
questions I ask…”
Lee Carter
Chair, Board of Trustees
Cincinnati Children’s Hospital
64
Page 32
Safety as a Core Value at Riverside
 Senior leader
message
 Transparent
 Action-oriented
 Clear
expectations
 Call for
Commitment
“I urge you to take this initiative to heart – learn
more about it, live it, own it…”
65
Care, Comfort, and Heal
…Without Harm
Lead with safety…
by beginning every meeting with a “safety moment” to keep safety topof-mind in thinking and decision making
Call the question…
when making decisions by asking, “What impact would this have on
safety?”
Say “thank you”…
when anyone reports an error, mistake, or event. Then, say, “Let’s
understand how it happen,” to encourage reporting and to promote
transparency and learning from events.
66
Page 33
Actions for Leaders
Make Safety an Explicit Core Value
Leaders show the way by setting expectations and being good
examples. Leaders model, inspire, train and encourage staff to keep
themselves and others safe each day.






Patient safety message at start of every meeting
Link decisions to safety – “what’s best for the patient?”
Encourage reporting of events and problems
Recognize those who ask the safety question
Communicate lessons from safety events
Measure preventable harm and make harm visible
“There is no priority higher than patient safety. If there is a conflict
between safe practice and speed, efficiency or volume, then
safety wins – hands down.”
James M. Anderson
President & CEO
Cincinnati Children’s
67
The HRO Difference
Harm is visible – Risk is visible
68
Page 34
Making Harm Visible in Healthcare
…and more importantly, our efforts to eliminate it!
69
Safety Culture
What safety culture
sound bites do you hear?
Write them down as you
watch the video.
70
Page 35
Safety Culture Sound Bites:










Safety for the right reasons – not just to meet regulatory requirements
Safety is the most important thing we do…if we can’t do it safely, we’re not
going to do it
Want to understand the hazards and potential hazards before we get to the
field
Stop Work Ability in the hands of each and every individual – responsibility
and moral obligation
Culture: consistent, predicable behavior that takes time to develop – have to
break old paradigms
Not a “check in the box” but something we really believe in
Quiz people’s knowledge and their understanding of what’s right and what’s
wrong
Goal: ZERO lost-time accidents
Tout our safety program when we go out to win new work
Easy to talk about safety but to actually do something about safety, that’s
where the rubber really meets the road
71
Culture Embedding Mechanisms
From Organizational Culture & Leadership, by Edgar Schein
Secondary Articulation &
Reinforcement Mechanisms
Primary Embedding Mechanisms
• What leaders pay attention to,
measure, and control on a regular
basis
• How leaders react to critical
incidents and organizational crises
• Observed criteria by which leaders
allocate scarce resources
• Deliberate role modeling, teaching,
and coaching
• Observed criteria by which leaders
allocate rewards and status
• Observed criteria by which leaders
recruit, select, promote, retire, and
excommunicate organizational
members
• Organizational design and structure
• Organizational systems and
procedures
• Organizational rites and rituals
• Design of physical space, facades,
and buildings
• Stories, legends, and myths about
people and events
• Formal statements of
organizational philosophy, values,
and creed
72
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Culture Change: It’s Different Work
From The Dilemma of Foundation Leadership, by Ronald Heifetz
73
Behaviors for Error Prevention
74
Page 37
Non-Technical Skills
“They are not new or
mysterious skills but are
essentially what the best
practitioners do in order to
achieve consistently high
performance and what the rest
of us do “on a good day”.”
 HRO’s focus on effective,
widespread use of NonTechnical Skills
Flin, O’Connor, and Crichton
Safety at the Sharp End
75
Non-Technical Skills
Non-technical skills describe how people interact with technology, environment,
and other people. These skills are similar across a wide range of job functions.
These skills include attention, information processing, and cognition.
Generic non-technical skills:
 Situational awareness
 Attention
 Communication
 repeat backs




call outs
phonetic & numeric clarification
clarifying questions
inquiry, advocacy, assertion
 Critical thinking
 Protocol use
 Decision-making
Flin, O’Connor, and Crichton
Safety at the Sharp End
76
Page 38
More Rules or More Tools?
Coverage on broad range of harm events
Synergy with people, process, and technology
Focused on several known harm events
Synergy with policy & protocol
77
Vertically Aligned & Explicit
For example:
Vision
Safest Hospital
Mission &
Goals
Zero events of harm
Policy & Programs
Infection Prevention
Behavior Expectations
“Wash Hands Before & After”
• Soap & warm water
• 15-second scrub (“Happy Birthday”)
• Paper towel to turn off faucet
Specific Tools & Techniques
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
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Page 39
Sentara Error Prevention Toolbox
1. Pay Attention to Detail

STAR (Stop/Think/Act/Review)
2. Communicate Clearly




Repeat Backs & Read Backs
Clarifying Questions
Phonetic & Numeric Clarifications
SBAR
3. Have a Questioning Attitude

Validate & Verification
4. Handoff Effectively

5P’s (Patient/Project, Plan,
Purpose, Problems, Precautions)
5. Never Leave Your Wingman


Peer Checking
Peer Coaching
79
Self-Checking Using STAR
Stop
Pause for 1 to 2 seconds to focus your attention
on the task at hand
Think
Consider the action you’re about to take
Act
Concentrate and carry out the task
Review
Check to make sure that the task was done right
and that you got the right result
The most effective way to avoid slips and lapses.
It takes only seconds and reduces the probability of making an
error by a factor of 10 or MORE!
80
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3-Way Repeat Back
When information is transferred...
Sender initiates communication using
Receiver’s Name. Sender provides an order,
1
request or information to Receiver in a clear
and concise format.
2
3
Receiver acknowledges receipt by a repeatback of the order, request or information.
Sender acknowledges the accuracy of the
repeat-back by saying, That’s correct! If not
correct, Sender repeats the communication.
A Safety Phrase
“Let me repeat that back…”
81
Peer Checking
Take advantage of working together:
 Check the accuracy of each other’s work
 Identify skill-based slips and lapses
 Point out unusual situations or hazards
 Impromptu consultation
Key to Successful Checking
Be willing to check others AND
be willing to have others check us
82
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Peer Coaching
Encourage and praise others
when they use safe and productive behaviors
Discourage and give advice to others
when they use unsafe and unproductive behaviors
Coaching Tips
 Look for opportunities to point out the good things –
ratio of 5 positives to 1 negative
 Provide feedback based on observations and facts
 Use the “lightest touch” possible
A Safety Phrase
“Thanks for saying something…”
83
Speak Up for Safety using ARCC
A responsibility we each have to protect in a manner of mutual respect –
an assertion and escalation technique
Use the lightest touch possible…
Ask a question
Make a Request
Voice a Concern
If no success…
Use Chain of Command
A Safety Phrase
“I have a concern…”
84
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People Bundle
Process Bundle
4 for VAP Prevention
1. Elevation of the head of the bed to
between 30 and 45 degrees
2. Daily “sedation vacation” and daily
assessment of readiness to
extubate
3. Peptic ulcer disease (PUD)
prophylaxis
4. Deep venous thrombosis (DVT)
prophylaxis (unless
contraindicated)
Read More:
Community Health Network Reduces Deadly Infections
Through Culture of Reliability, American Society for Quality
(June 2008)
85
Near Misses in Cardiac Surgery
Myles Edwin Lee, MD
“Mahatma Gandhi propounded the seven deadly sins…
I would add an eighth: medicine without teamwork.”
“A crucial interdependence exists among the various members
of the heart team, making it imperative that they be able to
recognize and articulate observations of real or imagined
problems that may or may not actually be within the realm of
their expertise…It is this system of mutual checks and
balances that constitutes the essence of team work.”
86
Page 43
Tenerife Disaster
27 March 1977
Copilot: Wait a minute – We don’t have takeoff clearance
Captain: No, I know that – Go ahead!
Moments later –
Copilot: Is he not clear then? Is he not clear, that Pan American?
Captain: Yes! (emphatic and angry)
87
It Always Starts with the Culture
Common Themes from Watershed Aviation Accidents

Captains treated crewmembers as
underlings, creating an environment of
“speak only when spoken to”

Intimidating atmosphere led to accidents
when critical information not
communicated among crew
88
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Power Distance
Large Distance
Small Distance
• Relations are autocratic and
paternalistic
• Power acknowledged based on
formal, hierarchical positions
• Relations are consultative and
democratic
• Relate as equals regardless of
formal positions
The perceived distance – not
necessarily the real difference –
as seen by the subordinate
Reference: Hofestede, Geert. Culture’s Consequences, 2001 (2nd edition).
89
Impact on Individual & Team Behavior
*Survey of 2,095 healthcare providers
(1,565 nurses & 354 pharmacists)
Types of Intimidation:
Affects on Safe Practice:
(regardless of source)

88% condescending language or tone

87% impatience with questions

79% reluctance or refusal to answer
questions or phone calls

48% strong verbal abuse

43% threatening body language

40% who had questions about an order
assumed it was correct or asked another
professional to interact with the provider

75% asked colleagues to help interpret
an order so that they did not have to
interact with an intimidating prescriber

34% reported that they found the
prescriber's stellar reputation intimidating
and had not questioned an order for
which they had concerns
Source: Institute for Safe Medication Practices. 2003 Survey on Workplace Intimidation,
Medication Safety Alert, 11 March 2004
90
Page 45
Collegial Interactive Teams (CIT) =
Tone + Tools
Setting the tone…
 “You had me from Hello”
- Greetings – include first names
- Cordiality, openness
- Eye contact and body language
 Team goals
- Use “we” and “us” vs. “I” and “you”
- What’s best for the patient…
 Invite a Questioning Attitude
- Leaders set the tone for the flow of information
- “If any member of the team sees anything that is unsafe, I expect
you to speak up...”
91
Three Sources of Accountability
Optimal
Accountability
Leaders
Vertical
Accountability
Individual
Peers
Intrinsic
Accountability
Horizontal
Accountability
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
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Safety Culture Accountability Systems
Self-driven
 Hire for it – integrate into job
descriptions and hiring practices
accountability
Convert safety
behaviors to individual
and team work habits
 Make them your habits first!
 Connect the dots – here’s how the
behavior expectations apply to the work
in our department
 Cues and reminders integrated into work
processes
 Observe and coach using 5:1 feedback
 Aligning goals and incentives
 Integrate into performance appraisals
Leader-driven
accountability
 Safety Success Story Program
 Safety Coach Program
 Peers “check each other” and “coach
each other”
Peer-driven
accountability
93
Share Safety Success Stories
Environmental Services Associate Speaks Up For Safety
While going about her daily duties of cleaning a patient room, Janice, an Environmental
Services Associate observed a physician and nurse enter the room and prepare to
perform a minor procedure. She knew the hospital’s rule about site verification before a
procedure, yet noticed that the team was about to proceed without the verification. Janice
politely questioned the physician and nurse, “Shouldn’t we verify the site before the
procedure?” The physician and nurse thanked the Associate and verified the site. By
being aware of what was going on around her and being willing to speak up, Janice
helped ensure that the procedure was performed on the correct site.
What Makes a Great Story Great???




Everyday excellence – not just the great saves
Language we can all understand
More Clever: Use the number of
Name names to recognize
published safety success stories as
Link to a behavior expectation
a real-time metric.
94
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High Leverage Leadership
Tactics
95
High Reliability Leadership Method
Evidence Based Leadership =
Best-Practice Tools & Techniques
adopted and practiced as
Leadership Habit
resulting in
Predictable Leadership &
Reduced Variation in Operational Outcomes
96
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Leveraging Senior Leaders
lev·er·age the use of a small initial investment to gain a very high return in relation to one's
investment, to control a much larger investment, or to reduce one's own liability for any loss
High
• Core Value
• Daily Check-In
• Rounding to Influence (RTI)
• Top 10 Safety List
High Leverage
Tools & Techniques
for Senior Leaders
Impact
Visibility, Relevance
Degree of Influence
Low
Low
Investment
High
Time, Money,
Other Resources
© 2008 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
97
Daily Check-In
98
Page 49
Plan of the Day (POD) Meeting
in the Nuclear Power Industry
30-minute meeting of operational leadership to provide
situational awareness of plant operations and command and
control for issue prioritization, ownership, and resolution
Agenda
 Emergent safety issues
 Status of Top 10 Problem List
 Routine reports (operations priorities,
operations workarounds, alarms not working,
alarms locked-in, temporary modifications)
 Priorities for the day
 Critical questions
Palo Verde Nuclear Generating Station
Pressurized water reactor
99
The “Daily Safety Call” at
Community Hospital North
What It Is
A deliberate, intentional, purposed report
and conversation among leaders
about safety events and potential safety risks
so we can assign resources to follow-up appropriately
on what has occurred and assign resources to reduce
the risk of potential events of harm to patients,
families, caregivers and care supporters.
100
Page 50
“Talking about safety should not be an event.”
Barbara Summers, President
Community Hospital North






9:00-9:15 AM, Monday-Friday
Held via conference call
All departments directors
90% attendance expectation – “step out
of meeting to attend” or send a
representative if you can’t participate
Facilitated by senior leader
Prepare to participate…
101
How To Do It
 Include direct reports and others who know the status of
operations in your areas of responsibility.
 Establish a standing time. Schedule the time on your
calendar and stick to it.
 Keep it short – 10 to 15 minutes at the most – and hold it as
a “stand-up” meeting.
 Keep it focused. Follow a routine, 3-point agenda:
Daily Check-In Agenda
1. LOOK BACK – Significant safety or quality
issues from the last 24 hours/last shift
2. LOOK AHEAD – Anticipated safety or quality
issues in next 24 hours/next shift
3. Follow up on Start-the-Clock Safety Critical
Issues
102
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Look Back – Any Events of Harm?
Patient Safety
Events
Serious Safety Events &
Precursor Safety Events
Employee
Safety Events
Real-Time Harm Intelligence!!!







Injuries to patients
Assessment or treatment delays or deficiencies
Falls
Medication errors
Incidents of skin breakdown
Incidents of VAP
Etc., etc., etc.




Slips/trips/falls
Exposures to infectious disease
Assaults
Injuries to non-clinical staff
– Maintenance – equipment incidents
– Environmental Services – chemical incidents
– Food Services – burns, cuts
103
Look Ahead – Any Threats to Safety?












Procedures we have never done before
New piece of equipment
Very critical patient, especially one moving between departments
New high-risk medication
Issues that are causing staff to develop workarounds – POC testing
access, lack of equipment, staffing shortage, etc.
Equipment failures or concerns
Change in communication capabilities
Change in computer process or level of function
Facility/environmental issue that poses a safety hazard
Social safety issue – can involve patients, family members, employees
and others
Deficiencies in staffing, resources, or information
Anything new or different that increases the probability of error
104
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Start the Clock for Safety
Fault Exposure Time
Window of potential for harm
HRO Lesson: Leaders need structure.
105
Risk Awareness Curve
Risk Awareness
High
Complacency
How do you
increase risk
awareness without
having to have an
event?
Event
Low
Time
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
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Risk Awareness Leveling Strategies
“Talking about safety and risk should be a everyday occurrence.”
Barbara Summers, President
Community Hospital North
Risk Awareness
High
Leadership Methods for
Maintaining Organizational Risk Awareness
Complacency
Rounding-to-Influence
Daily Check-In
Pre-Job Briefs & After Action Reviews
Safety Success Stories
Events of Harm Stories
Event
Low
Time
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
107
Daily Check-In at
Cincinnati Children’s Hospital
108
Page 54
Daily Check-In at
Baptist Hospital
Ascension Saint Thomas Health
109
Rounding to Influence (RTI)
110
Page 55
Rapid Cycle Feedback
Do
Optimal
Feedback
PERFORMANCE


Learning is doing with feedback
Decrease cycle time for feedback
Traditional
TIME
© 2008 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
111
Rounding to Influence (RTI)
a High Impact/Low Investment Leadership Method
A technique for reinforcing a vital behavior or
performance expectation linked to a core value
♥
Connect to a core value

Assess knowledge and reinforce the
specific behavior expectations

Identify problems impacting ability
to follow the behavior expectations

Ask about commitment actions
© 2009 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
112
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RTI – What’s the Difference?
Sensitivity to
Operations
Threshold
Genchi Genbutsu
“Go and see for yourself”
Walking Rounds
Rounding To Influence
Low - Moderate
Low - Moderate
Moderate
High
How do your shoes feel?
Shine your shoes
Take a few steps in their shoes
Walk a mile in their shoes
Adopt-a-Unit
Time
30 minutes
5 to10 minutes
> 30 minutes
Recurring visit boluses
Theme
General awareness
Specific focus
Blunt end to sharp end
translation of performance
expectations
Practical knowledge and
experience of unit work
Purpose
•Identify problems that
need to be fixed
•Build relationships
•Influence a specific
behavior expectation
•Identify problems
impacting a specific
performance
expectation
•Empathy for sharp end
realities
•Identify performance
deviations and conditions
impacting performance
that need remediation
•Sympathy for sharp end
realities
•Identify performance
deviations and conditions
impacting performance
that need remediation
Implementing
Detail
Global questions
Targeted questions
Observation of behaviors
and environment
Participation in work and
work life
Location
Work environment or
other
Work environment or
other
Work environment
Work environment
© 2009 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
113
RTI: Hand Washing for HAI Prevention
Greeting
Hello! Do you have a few minutes for a brief conversation about hand washing?
Core Value
Hand washing is very important to keeping our patients – and you –
safe. It’s one of the most important things we can do to prevent the
spread of MRSA and other hospital acquired infections.
Did you know that there are nearly 19,000 deaths each year (CDC)
from hospital acquired MRSA? In 2010, we had 10 cases of MRSA in
our own hospital…
Can Do’s
In addition to making hand washing your habit, I’d like to ask you to
help others build good hand washing habits, too. Give a thumbs up
when you see them doing it, and remind when you see them forget.
Concerns
Are there things that make this difficult in your department?
Commitment
Will you try it out today? Leave a message for me and let me know
how it goes.
114
Page 57
VCU Health System
Spectrum Health – Helen DeVos Children’s Hospital
115
Rounding To Influence Lectionary
 Provides uniform schedule
 Forces leaders to take on tough topics
– not just the easy messages
 Aids in sharing resources and insights
while preparing to influence
Cycle
Rounding-To-Influence (RTI) Topic
1
Speak Up for Safety Using ARCC
2
Reporting of Safety Events, Errors, & Unsafe Conditions
3
Safety Practice: Time outs
4
SBAR
5
Red Rule: Patient Identification
6
Communicating Clearly by Asking & Encouraging Clarify
Questions
7
Hand Hygiene for HAI Prevention
8
Staffing Shortages: Crisis or Chronic?
116
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Engaging Physicians
117
Blunt End Influencer
Sharp End Provider
© 2008 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
118
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Managing Your Strengths…
ASSETS
RELIABILITY
LIABILITIES
UNRELIABILITY
PERSONAL
ATTRIBUTES
Derived from Overcoming Your Strengths, by Lois P. Frankel, PhD
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
119
The Disruptive Path
Attributes
Liabilities
Unreliability
Intelligence
Elitest
Condescending
Independence
Team averse
Abrasive
Objectivity
Impersonal
Belligerent
Analytic Capability
Critical
Blaming
Sense of Urgency
Impatient
Insensitivity
Influence
Aggressive
Sabotage
Derived from Overcoming Your Strengths, by Lois P. Frankel, PhD
120
Page 60
The Success Path
Attributes
Strengths
Reliability
Intelligence
Competence
Independence
Confidence
Objectivity
Thinking Critically
Analytic Capability
Problem Solving
Sense of Urgency
Safety First
Influence
Team Building
 Preoccupation
with failure
 Sensitivity to
operations
 Reluctance to
simplify
 Commitment to
resilience
 Deference to
expertise
121
Aviators & Physicians – Some Observations
Aviators
o
o
o
o
o
o
o
o
o
o
o
Highly Skilled
Confident & Decisive
Self-sufficient
High need to achieve
Seeks responsibility
More concerned with modifying their
environment than changing their own
behavior
Low tolerance for imperfections
Crave excitement
Use humor to cope with stress
Have difficulty with ambiguous situations
Don't handle failures well
Physicians
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Highly Skilled
Confident & Decisive
Self-sufficient
High need to achieve
Seeks responsibility
More concerned with modifying their
environment than changing their own
behavior
Low tolerance for imperfections
Crave excitement
Use humor to cope with stress
Have difficulty with ambiguous situations
Don't handle failures well
Empathetic
Compassionate
Altruistic - sometimes
122
Page 61
What Aviators Had to Learn the Hard Way…
 We created Power-Distance Authority Gradient and
shunned speaking up for safety
 We poorly managed the Advancement of
Technology
 We developed additional individual roles but
simultaneously created the Absence of Teamwork
 We vehemently resisted Standardization
 Self-Imposed Stressors were only what you worried
about at home
 We failed to understand Aviators were more than
pilots; we didn’t accept Leadership by Default
123
Why It’s Important
 Better for you…and for your patient
 Contributors to harm in healthcare
- #2 professional group experiencing 31% of errors and
mistakes associated with safety events (HPICompare)
 Longer tenure – lower turnover
-
Boards – every 3 to 6 years
Hospital CEOs – 18% (in 2009; ACHE)
RNs – 21% (in 2000; AONE)
Physicians in Medical Groups – 7% (in 2006; AMGA)
 Impact on individual and team behavior…for better
or for worse!
124
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Just Culture
125
Just Culture creates an atmosphere of trust in
which people are encouraged to provide, and even
rewarded for providing, essential safety-related
information but in which they are clear about where
the line must be drawn between acceptable and
unacceptable behavior.
James Reason
Managing the Risks of Organizational Accidents (1997)
126
Page 63
Striking the Right Balance
Human Error
Rate
Blame-Free
(post-1990)
“Fair or Just
Culture”
Blame &
Punishment
(pre-1990)
127
Unintended Human Error
vs. Non-Compliance
 In a fair, or just, culture…
- No punishment for unintended error or mistakes driven
by system problems
- Fair consequence for intended decisions to act against
the rule
“If everything ‘goes,’ then in the end no problem may be seen anymore as
safety critical – and people will stop talking about them for that reason.”
Sidney Dekker, Just Culture: Balancing Safety & Accountability (2007)
 It’s the leader’s responsibility to differentiate, and
we can differentiate…
128
Page 64
The Drivers of Non-Compliance
Non-Compliance =
Perceived Burden
Coworker
Perceived
+
Coaching
Risk
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
129
Culpability Assessment Tools
James Reason
“Decision Tree for Determining the Culpability of Unsafe Acts”
from Managing the Risks of Organizational Accidents (1997)
United Kingdom’s National Health Service
“Incident Decision Tree,” adapted from James Reason’s
decision tree (2003)
P. Hudson
Refined Just Culture Model from the
Shell Hearts & Minds Project (2004)
David Marx
“Just Culture Algorithm” (2005)
130
Page 65
Performance Management Decision Guide
Adapted from James Reason’s Decision Tree for Determining the Culpability of Unsafe Acts and
the Incident Decision Tree of the National Patient Safety Agency (United Kingdom National Health Service)
Start
Deliberate Act Test
Incapacity Test
D1
Compliance Test
C1
I1
No
Did the individual
intend the act?
Is there evidence of ill health
or substance abuse?
Yes
No
Yes
Did the individual
depart from policies,
procedures, protocols, or
generally accepted
performance expectations?
Yes
Substitution Test
S1
No
Would individuals in
the same profession and with
comparable knowledge, skills,
and experience act the same
under similar circumstances?
No
Yes
C2
Were the policies,
procedures, protocols, or
performance expectations
available, understandable,
workable, and in routine use?
No
Yes
D2
Did the individual act
with malicious intent
(i.e. to cause individual harm
or other damage)?
C3
I2
No
Did the individual have a known
medical condition?
No
Is there evidence that
the individual chose to take an
unacceptable risk OR has a
trend in poor performance or
decision making?
Yes
Yes
S2
No
Were there deficiencies
in related training, experience,
or supervision?
Yes
No
Yes
C4
Were there significant mitigating
circumstances?
Yes
No
Malevolent or Willful
Misconduct
(Consult Human Resources)
 Disciplinary action
 Report to professional group
or regulatory body
 Law enforcement referral
Identify Contributing System Factors
Medical Condition and/or
Substance Abuse
(Consult Human Resources)
 Occupational health referral
 Adjustment of duties
 Leave of absence
If substance abuse:
 Substance abuse testing
 Disciplinary action
Identify Contributing System Factors
Possible Reckless or
Negligent Behavior
(Consult Human Resources)
 Disciplinary action
 Job-fit consideration
Identify Contributing System Factors
131
What
Senior Leaders
Can Do To Promote a
Just Culture
Possible Unintended
Human Error
(Consult Human Resources)
 Console
 Coaching
 Mentor assignment
 Increased supervision
 Performance improvement
plan
 Adjustment of duties
Possible System
Induced Error
Console and/or
Coach the
Individual AND
Find & Fix
Process
Problems
Identify Contributing System Factors
Revision 3, April 2009
© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.
Set the tone:
• When you hear about an event, count to 5 before responding…Stop & Think
before you speak!
• Say, “Thank you” when someone reports an event or error. Then say, “Let’s
understand how that happened…”
• Ask your direct reports to let you know when one of their employees reports
and event or error – go thank that person.
• Ask about events and errors during Daily Check-In.
• Round-To-Influence on the importance of reporting and learning from errors
and events.
• Observe and coach operational leaders in their response
What
Make it “safe” to report and demonstrate the value of reporting:
Operational Leaders • Share great catches – a.k.a. Safety Success Stories
Can Do To Promote a
Just Culture
• Reward reporting of Near Misses & Precursor Safety Events
• Diagnoses the cause of human error…and respond in a fair and just way:
 Fix system and management problems causing error
 Console and coach for unintended human error
 Apply fair consequence for non-compliance
• Communicate improvements made as a result of reporting
What
Personal commitment to safety:
Staff & Physicians
Can Do To Promote a
Just Culture
•
•
•
•
Report events, errors, and mistakes
Encourage others to report
Offer suggestions for improving the systems and processes
Be eager to learn and apply lessons from events and the experience of others
132
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References & Recommended Readings
Sidney Dekker, Just Culture: Balancing Safety & Accountability, Ashgate
(2007).
David Marx, JD, “Patient Safety and the ‘Just Culture’: A Primer for Health
Care Executives,” Columbia University (2001).
James Reason, Managing the Risks of Organizational Accidents, Ashgate
(1997).
Sandra Meadows, et. al., “The Incident Decision Tree: Guidelines for Action
Following Patient Safety Incidents,” National Patient Safety Agency,
United Kingdom (2003).
(http://www.npsa.nhs.uk/site/media/documents/760_IDT%20Information%20and%20Advice%20on%20Use.pdf)
Gary R. Yates, MD
gryates@sentara.com
133
Key Points
1. Safety is a science. Ultra-high levels of safety can be
achieved by employing High Reliability principles.
2. “Attention is the currency of leadership.” The role of
senior leaders is absolutely critical to HRO success.
3. Safety is a “dynamic, non-event.” Everyone has a role in
creating and maintaining a high reliability, safe culture.
4. The medical staff is critical to sustain safety as a core
value.
5. Everyone makes errors – serious patient harm events are
almost always a result of the “system” failing – not an
individual human error.
6. Staff, physicians and leaders must make proven error
prevention strategies practice habits.
134
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March 22, 1966
“The measure of
success is not
whether you have a
tough problem to
deal with, but
whether it is the
same problem you
had last year.”
John Foster Dulles
135
135
Thank you
Gary Yates, MD
gryates@sentara.com
136
Page 68
NOTES
NOTES
NOTES