introduction to a culture of safety -...

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Introduction to a Culture of Safety

14 November 2016

Oslo, Norway

Aidan Fowler

What is culture?

Hva er kultur?

• The way of life, especially the general customs and beliefs, of a particular group of people at a particular time.

• Den livsstilen, spesielt de generelle skikker og tro, av en bestemt gruppe mennesker på et bestemttidspunkt.

• Safety/sikkerhet

• The condition of being protected from or unlikely to cause danger, risk, or injury

• Tilstanden beskyttet mot eller usannsynlig å volde fare, risiko eller skade.

.

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Improving Safety Requires a Learning

System

• Safety is a characteristic

of a Socio-Technical

system

• System-level failures

occur almost always

because of unforeseen

combinations of

component failures

“We can’t change the human condition,

but we can change the conditions

under which humans work.”

James Reason

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Safety Cultures Evolve5

UNMINDFUL“We show up, don’t we?”

Chronically Complacent

REACTIVE“Safety is important. We do a lot every

time we have an accident”

SYSTEMATICSystems being put into place to manage

most hazards

PROACTIVE“We methodically anticipate”— prevent

problems before they occur

GENERATIVEOrganizational Culture “Genetically-

wired” to produce safety

Where is Yours?

Attribution: Prof. Patrick Hudson, Univ. Leiden

SocioTechnical Framework

• Patient & Family Centred Care

• Leadership – Senior and Clinical

• Effective Teamwork

• Psychological Safety

• Organisational Fairness / Just Culture

• Highly Reliable Processes of Care

• Learning System - Improvement

Unmindful • Reactive • Systematic • Proactive • Generative

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What is a High Reliability Organisation ( HRO)?

• Organisations operating in high risk

environments, that through a combination of

reliable systems / processes with effective

organisational culture effectively manage risk

and operate very safely.

• Reliability must be designed into the system – to

manage the expected - and “Managing the

unexpected” baked into the operators

The HRO Legacy

• In the 1980’s researchers realised there were certain organisations that managed risk and hazards exceeding well. They operated under high production pressures with hazardous conditions quite safely.

• The prevalent safety model prior to this the Natural Accident Theory, which accepted that accidents, failures and harm were inevitable outcomes of managing risk.

• What about healthcare?

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The Legacy of Harm in Healthcare

• Historically medicine was based on the individual

expert model – highly skilled practitioners trying hard

and paying attention would not make mistakes.

• Harm was considered an unfortunate but acceptable

price for all the positive therapeutic interventions –

“the price of progress”

• Patient safety and the High Reliability Organisations

(HRO) brought a different perspective – the goal

needs to be zero avoidable harm

Avoidable Patient Harm

• 30% of hospitalised patients

have something happen to

them you and I wouldn’t

want to happen to us

• 6% are harmed seriously

enough to stay in the

hospital longer and go home

with a disability

• >200,000 Medicare patients

die every year from medical

harm

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Lessons and behaviours from HROs

• Structured, predictable team behaviours are “the way we do it here.”

• Effective leadership – modelling and reinforcing behaviours

• High degrees of Psychological Safety

• Situational Awareness

• Knowledge about human performance in complex systems

• Continual learning and improvement

• Active error detection, management and mitigation

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• In HRO interpersonal skills are equally as

important as technical expertise

• Huddles are an opportunity for caregivers

other than physicians and nurses to theorise

about what is going on with their patients

• Professional heterogeneity is usually

advantageous for collective learning,

improving the range, depth and integration of

information considered.

Reliable Systems of Care

• Visible, measurable, predictable

• Standardise – minimise unnecessary variation

• Minimise cognitive workload

• Make it easy to do the right thing, hard to do the

wrong thing

• Clear indications when the system is not

producing the desired outcome, so operators

can intervene

14

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Senior Leadership

• Cyclic flow of information with feedback and organisational learning

• Systematic engagement with dialogue, support and learning

• Process for interaction between senior leaders and front line staff

• They’re here – something bad must have happened

• We don’t know or see them

GENERATIVEOrganisation wired for safety and

improvement

PROACTIVEPlaying offence - thinking ahead,

anticipating, solving problems

SYSTEMATICSystems in place to manage hazards

REACTIVEPlaying defense – reacting to events

UNMINDFULNo awareness of safety culture

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The Ideal Unit

What are the qualities of effective

leaders?

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What makes a good leader?

• Honesty

• Ability to communicate

• Positivity

• Resilience

• Dedication

• Humility

• Creativity

• Fairness

• Openness

• Assertiveness

• A sense of humour

• Magnanimity

Clinical Leadership

• Leaders create high degrees of psychological safety and accountability.

• Leaders model the desired behaviours to drive culture of safety

• Training and support exists for building clinical leadership

• Episodic, completely dependent on the individual clinician

• Absent for the most part


improvement






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When you walk in in the morning, how long does it

take for you decide – good day vs. bad day?

As leaders, what is your role in setting the tone?

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Culture and Leadership

Effective Leadership

• Set a positive active tone

• Think out loud to share

the plan – common

mental model

• Continuously invite people

into the conversation for

their expertise and

concern

• Use their names

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A Culture of Safety

No one is ever hesitant to voice a

concern about a patient

Skilled caregivers playing by the rules feel safe to discuss and learn from errors

Concerns raised by front line

caregivers are taken seriously &

acted upon

Action is taken, feedback reliably

provided, changes are visible for staff

and patients

Why is Culture Important?

• Culture reflects the behaviours and beliefs within an organisation.

• There are behaviours that create value individually, for the patient and the organisation.

• There are behaviours that create unacceptable risk.

• These attitudes and behaviours are reflected in how people interact with each other both internally and externally with patients and their families

• Culture is the social glue

• Work as Imagined v. Work as Done

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28 33 36 41 45 45 49 49 51 52 55 62 6273 75 80

98

0

26

53

79

105

CCU EMERG PEDS PERIOP ICU PEDS

Teamwork Climate Scores Across Facility

HCAHPS 9250

Medication Errors per Month 2.06.1

Days between C Diff Infections 12140

Days between Stage 3 Pressure Ulcers 5218

Illustrative Data:

Extracted from

Blinded Client Data

Culture is Related to…

28 33 36 41 45 45 49 49 51 52 55 62 6273 75 80

98

0

26

53

79

105

CCU EMERG PEDS PERIOP ICU PEDS

Teamwork Climate Scores Across Facility

Employee Satisfaction 9155

Employee Injury per 1000 days 0.116

Employee Absenteeism per 1000 days 1015

RN Vacancy Rate 19

<60% Score =

Danger Zone

Illustrative Data:

Extracted from

Blinded Client Data

… and Unfavourable Employee Outcomes

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© 2008 Pascal Metrics

Measuring Culture

• Validated instrument

• High response rates

• Measure at a unit level - that’s where culture

lives

• Debriefing and feedback is key

• Culture data opens the door for the real

conversation – “ this is what you said. Please

help me understand what it means.”

• Take action that is visible and measurable

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Manchester Patient Safety Framework (MaPSaF)

Psychological Safety

• Primary responsibility of leaders, continuously modelled everywhere.

• Leaders model and expect the behaviours that promote psychological safety

• In some units it feels safe to speak up and voice a concern

• Personality dependent – it depends who I’m working with

• Fear based – keep your head down and stay out of trouble


improvement






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• What are the things that make it hard to speak

up here?

• What are the 1-2 things we can do to make it

better? Describe them in a way that they are

actionable, visible and measurable.

We are our own image consultants

and best

image protectors


Source: Amy Edmondson

To protect one’s image, if you don’t want to look

PSYCHOLOGICAL SAFETY CHANGES THIS PARADIGM

STUPID

INCOMPETENT

NEGATIVE

DISRUPTIVE

Don’t ask questions

Don’t ask for feedback

Don’t be doubtful or criticise

Don’t suggest anything innovative

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Effective Teamwork

• Teamwork and continuous learning deeply embedded and central to our culture

• Teamwork methodically taught and modelled across the organisation

• Training and tools available, partial implementation

• Focus on teamwork awareness / training in response to adverse events

• If people would just do their jobs we’d have no problems


improvement






Organisational Fairness / Just Culture

• Real events are shared by leaders, true culture of accountability and learning

• Clear ways to differentiate individual v. system error, safe to discuss mistakes

• Well understood algorithm, learning is the priority

• Depends who the boss is, blame and punishment are common

• Nothing good will come from talking about mistakes


improvement






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Process Improvement

• Unit level learning systems, continuous learning aligned with organisational goals

• Robust unit level learning and improvement is the norm

• Knowledge of testing, process improvement, collaborative work

• We try harder after process failures or adverse events

• Lots of first order problem solving, simple things don’t get fixed


improvement






Error Reduction Strategies

• Standardise

• Simplify

• Reduce cognitive and physical workload

• Protocols and checklists – predictability

• Forcing functions

• Good design and visual aids

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Design and information display

• Is it user centric or reflect the world view of the engineer?

• Does it make it hard to do the wrong thing, and easy to do the right thing?

• Can you think of examples in your practice or daily life of designs that work well, and ones that really don’t?

The needs of the patient come first

• Every patient and their family have the

basic right to be cared for safely,

respectfully and participate in their care.

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Transparency

Leadership

Psychological

Safety

Negotiation

Teamwork &

Communication

Accountability

ReliabilityImprovement

&

Measurement

Continuous

Learning

Engagement of

Patients & Family

Framework for Clinical Excellence

Facilitating and mentoring

teamwork, improvement,

respect and psychological

safety.

Creating an environment where

people feel comfortable and have

opportunities to raise concerns or

ask questions.

Being held to acct in a safe and

respectful manner given the

training and support to do so.

Developing a shared understanding,

anticipation of needs and problems,

agreed methods to manage these as

well as conflict situations

Gaining genuine agreement on

matters of importance to team

members, patients and families.

Regularly collecting and learning

from defects and successes.

Improving work processes and patient

outcomes using standard improvement tools

including measurements over time.

Applying best evidence and

minimizing non-patient specific

variation with the goal of failure

free operation over time.

Openly sharing data and other

information concerning safe, respectful

and reliable care with staff and partners

and families.

© IHI and Allan Frankel

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