culture eats strategy - south carolina hospital association · pdf fileis there thoughtful...

Culture Eats Strategy…Why Transforming Culture is the Key

To Improving Patient Safety

Robert M. Wachter, MDProfessor and Associate Chairman, Department of Medicine

University of California, San Francisco

Chief of the Medical Service, UCSF Medical Center

Safety Culture:

The Usual Questions

Are errors reported?

Is there a “systems focus”?

Is there “no blame”?

Safety Culture: My Questions

Is the hospital more like the IHOP or SFO?

Are the physicians more like Chuck Yeager

or John Glenn?

Are stories of errors turned into action?

Is there a “culture of low expectations?”

How steep are the hierarchies?

Is there thoughtful balancing of “no blame”

and “accountability”?

Production

Pressures

The Right Stuff

“In fact, considerable attention had been

given to a plan to anesthetize or tranquilize

the astronauts, not to keep them from

panicking but just to make sure they would

lie there peacefully with their sensors on

and not do something that would ruin the

flight.”

Tom Wolfe, The Right Stuff




or John Glenn?





Reporting Systems:

Why We Had It Wrong

Flawed notion that reporting has any intrinsic value

– Create stories

– Generate action

– A feedback loop (extra credit!)

Huge opportunity to waste time, money, and promote wrong paradigm

– Early experience in PA, UK, many hospital systems

Some successes

WebMM.ahrq.gov

UCSF’s Root Cause Analysis

Process

Prompted by state reporting requirement

Weekly 2 hour meeting

– First hour: detailed RCA of error from prior wk

– Second hour: series of 15 minute progress reports

Senior leadership/experts on committee

Participants not only present their case, they

learn about RCAs, systems thinking,

organization‟s commitment to improvement




or John Glenn?





The “Culture of Low Expectations”

“We suspect that these physicians and nurses had

become accustomed to poor communication and

teamwork. A „culture of low expectations‟ developed

in which participants came to expect a norm of faulty

and incomplete exchange of information [which led

them to conclude] that these red flags signified not

unusual, worrisome harbingers but rather mundane

repetitions of the poor communication to which they

had become inured.”

Drs. Mark Chassin and Elise Becher

Annals of Internal Medicine, 2002

“It must be right…”




or John Glenn?





A Hypothetical Scenario

Lowest person on the totem pole

Something seems glitchy

Head of CT or Neurosurgery

He drives a Hummer

He has a temper

He‟s been known to throw things

He‟s got good aim

The Extra Credit Scenario, cont.

She stops the presses, and it delays

the first case in the OR…

and it turns out that everything

was OK.

Here’s the Question:

What Happens to Her?

A)People whisper about her at the

watercooler for the next few days

B) The hospital CEO, CNO, or CMO

(and the surgeon!) come by later that day

to pat her on the back




or John Glenn?




Safety Culture is Unit-Based

Safety Climate Across

100 Hospitals

Safety Climate Across

49 Units in One Hospital

Pronovost/Sexton, QSHC 2005

culture eats strategy - south carolina hospital association · pdf fileis there thoughtful...

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