Culture of Culture of SafetySafety

Patient safety is simply defined as Patient safety is simply defined as

"the prevention of harm to patients.”"the prevention of harm to patients.”

Our systems are too complex to expect merely extraordinary people to perform perfectly 100 percent of the time. We as leaders have a responsibility to put

in place systems tosupport safe practice.”

-- James Conway, IHI Senior Fellow; former Executive Vice President and Chief Operating Officer, Dana-

Farber Cancer Institute

LeadershipLeadership

• THE critical element in a successful patient safety program and is non-delegable.

• Only senior leaders can productively direct efforts in their health care.

• Commitment required to address the underlying systems causes of medical errors and harm to patients.

Leadership Leadership continuedcontinued

• Although it is now widely accepted that serious medical errors occur in health care

organizations, many leaders hold the view that “it couldn’t happen here.”

• Increasingly, it appears that health care CEOs and other leaders want to make these changes happen, but they don’t have a tried-and-true method by which to bring about system-level, raise-the-bar change.

Leadership Leadership continuedcontinued

• If leaders are to bring about system-level performance improvement, they must channel attention to and take action regarding several, if not all, of these

leverage points that follow:

Seven Leverage PointsSeven Leverage Points

• Leverage Point One: Establish & Oversee System-Level Aims for Improvement at the Highest Board & Leadership Level.

• Leverage Point Two: Align System Measures, Strategy, & Projects in a Leadership Learning System

• Leverage Point Three: Channel Leadership Attention to System-Level Improvement

Seven Leverage Points Seven Leverage Points continuedcontinued

• Leverage Point Four: Get the Right Team on the Bus

• Leverage Point Five: Make the Chief Financial Officer a Quality Champion

• Leverage Point Six: Engage Physicians• Leverage Point Seven: Build

Improvement Capability

Adverse Health Care Adverse Health Care EventsEvents

• Patient safety remains at the forefront of every facility’s plan for effective and safe patient care.

• Adverse health care events are a leading cause of death and injury • Too many patients die or are disabled as a

result of adverse health care events • Adverse health care events occur in all

health care settings: hospitals, clinics, nursing homes, urgent care centers and surgery centers.

ProjectionsProjections

• The Institute of Medicine's report, To Err is Human, projected between 44,000 and 98,000 deaths annually secondary to preventable medical errors in our hospitals.

• The higher estimate of 98,000 deaths ranks medical errors as the fifth leading cause of death in the United States – higher than motor vehicle accidents (43,458), breast cancer (42,397), or AIDS (16,516).

Preventable Injury CostsPreventable Injury Costs

• Preventable injury resulting from medical errors cost the economy $17 billion to $29 billion annually.

• Half of which are health care costs.

• One in five Americans (22%) reported that they or a family member has experienced a medical error of some kind….………

Preventable Injury Costs Preventable Injury Costs continuedcontinued

• Nationally, this translates to an estimated 22.8 million people with at least one family member who experienced a mistake in a doctor's office or hospital.

• Of those experiencing a medical error, 10% reported that they or a family member had gotten sicker.

• 50% of those said the problem was serious.

• Nationally, this means that an estimated 8.1 million households reported a medical mistake that was very serious.

Ensuring Patient SafetyEnsuring Patient Safety

• Is complex and replete with obstacles.

• Health care organizations must make patient safety a declared & serious aim.

• Establishing a comprehensive patient safety programs with defined executive responsibility, operated by trained personnel and in a culture of safety.

Goals of Patient Safety Goals of Patient Safety ProgramsPrograms

• Provide strong, clear and visible attention to safety.

• Implement a just system for reporting & analyzing errors within their organizations.

• Incorporate well-understood safety principles (such as Best Practices).

• Establish interdisciplinary team training programs for providers that incorporate proven methods of team training such as simulation.

• Identify & analyze system failures such as medical errors & near misses.

Goals of Patient Safety Programs Goals of Patient Safety Programs contiuedcontiued

• Provide proactive evaluation & redesign of systems to improve care processes to prevent future errors.

• Involve participation of patients & their families & be responsive to their inquiries.

• Communicate findings throughout the organization in a consistent manner.

• Provide education related to patient safety science.

Gateway and ToolkitGateway and Toolkit

• Objective• Transforming the organizational

culture is critical to improving patient safety. The trend of providers focusing on learning from past mistakes rather than pointing the finger when something goes wrong is positive.

Components of a Safe Components of a Safe CultureCulture

• Patient Safety Dialogues

• Blameless Reporting

• Engaged Leadership

• Project Team consists of physicians, nurses, pharmacists & other health professionals.

• Assists in providing a solid framework for provider improvement in patient safety

Just CultureJust Culture

• Method used to create a positive culture for patient safety.• Created by David Marx, a system safety engineer,

the intent was to develop a system to fairly define culpability for potential or actual harm due to medication errors.

• Support open communication & development of systems for accountability.

• One goal is to assign consequences for an unsafe act in a fair way.

• Many health care facilities are beginning to implement the Just Culture approach to reduce errors, reduce medical harm, and improve patient safety.

Four Key Categories of Just Four Key Categories of Just CultureCulture

• Fault Assignment1. Human error:

unintended mistake

2. Negligence Conduct: failure to exercise care

3. Reckless Conduct: conscious disregard for a known risk

4. Knowing Violations: conscious disregard for known rules.

Mistake Proofing Mistake Proofing ApproachesApproaches

• Mistake Prevention• Reducing complexity, ambiguity, vagueness, and

uncertainty in the workplace.• Implementation of “visual systems,” “know by

looking.”

• Mistake Detection • Identifies process errors found by inspecting the

process after actions have been taken.• Set of methods that uses statistical tools to

detect if the observed process is being adequately controlled.

Mistake Proofing Mistake Proofing ApproachesApproaches continuedcontinued

• Mistake Processing• Mistake prevention identifies process errors

found by inspecting the process before taking actions that would result in harm.

• Preventing the Influence of Mistakes.• Designing processes so that the impact of

errors is reduced or eliminated. • This can be accomplished by facilitating

correction in a non-threatening manner with personnel.

Mistake Proofing ApproachesMistake Proofing Approaches continuedcontinued

• Prevent User Error from Occurring• Primary Event• Many health care

providers are implementing

• Bar Coding• Computerized physician

order entry (CPOE)• Robotic Pharmacies

Mistake Proofing ApproachesMistake Proofing Approaches continuedcontinued

• Alert Users to Possible Dangers• A Culture of Depending on

People, Not on Systems• Processes that Depend on

People, Not on Systems• Reduce the Effect of Use Errors

• Mistake-proofing involves designing changes into the physical aspects of the design of processes.

Full Board Self-Full Board Self-EvaluationEvaluation

1. The board conducts a self-evaluation at least once every two years.

2. The self-evaluation process begins with board members completing a confidential written questionnaire.

3. The self-evaluation questionnaire evolves from one cycle to the next.

4. The aggregate results of the self-evaluation questionnaire are used to facilitate open, honest discussion among the full board about its performance. This discussion is held outside of a regular board meeting (e.g., at a retreat).

Full Board Self-Evaluation Full Board Self-Evaluation continuedcontinued

5. The self-evaluation process leads to the development of a governance improvement action plan.

6. The action plan is implemented and is monitored by the full board over the course of the following one to two years.

7. As part of the next self-evaluation, the board assesses the action plan and makes modifications as appropriate.

8. The self-evaluation process leads to better governance.

Lessons LearnedLessons Learned

• A senior leadership team that "gets it" will incorporate the leadership development needs of the organization into its strategic planning process.

• A senior leadership team that "gets it" is visibly engaged in leadership development, including teaching and actively participating in course work.

• A senior leadership team that "gets it" holds leaders accountable for implementing skills learned in the organization's leadership development journey.

CEO Patient Safety CEO Patient Safety Self-AssessmentSelf-Assessment

• Hospital CEOs were surveyed on their familiarity with, confidence levels in, and learning preferences regarding patient safety issues and initiatives.

• http://www.psnet.ahrq.gov/resource.aspx?resourceID=7306