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HRET HIIN Virtual Event QI Fellowship
Developing a Culture of Safety
Frank Federico, Vice President, IHIJune 30, 2017 1PM CT
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Welcome and Introductions
2
Mallory Bender, Program Manager, HRET
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Agenda12:00-12:05 Welcome & Introduction Mallory Bender, HRET
Lauren Macy, IHIKathy Duncan, IHI
12:05-12:30 Creating a Culture of Safety• Describe what we mean by a ‘culture of safety’• Discuss the evolution of culture• Explain how the science of improvement can be used to change
culture in an organization
Frank Federico, IHI
12:30-12:55 Office Hours Discussion• Ask your questions and share your experiences in developing a just
and fair culture in your hospital• Submit your questions in advance here
Frank Federico, IHI
12:55-1:00 Bring It Home Mallory Bender, HRET
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How Did You Hear About Today’s Virtual Event?
A) HRET HIIN flyerB) HRET HIIN websiteC) HRET LISTSERV D) State hospital associationE) QIN-QIO F) Your organization/colleagueG) Other, please specify.
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Objectives
• Describe what we mean by a culture of safety• Discuss the evolution of culture• Explain how the science for improvement can
be used to change culture in an organization• List three frameworks to use in a fair and just
culture
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Questions We Heard from You1. On our recent Hospital Survey on Patient Safety Culture, we scored low on "Staff feel
free to question the decisions or actions of those with more authority." What are some suggestions or best practices that will help us in this area?
2. What are the first steps an organization should take to begin the transition into a culture a safety; after the Culture of Safety Survey assessment and dissemination of results?
3. In your opinion, is Reasons fair and just culture algorithm the best?4. How do you keep all staff updated and trained on a safety culture?5. Please discuss the cross over between PDSA and DMAIC.6. My CMO and I are contemplating how to create/energize around a culture of
improvement. I think we are a bit a victim of our great clinical outcomes, and we haven't had a burning platform harm event.
7. What do you think would be the #1 most important thing to assure hospitals focus on to achieve a culture of safety?
8. What are your ideas for the tests of change that you would do in a PDSA process for improving a culture of trust?
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Developing a Culture of Safety
• In a culture of safety, people are not merely encouraged to work toward change; they take action when it is needed.
• Leadership’s message about safety must be consistent and sustained, as it takes a long time for culture to change.
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The Science of Improvement
The Science of Improvement is: • An applied science that emphasizes
– innovation– rapid-cycle testing in the field– Spread in order to generate learning about what changes,
in which contexts, produce improvements
• Multidisciplinary • Combines subject matter experts with improvement
methods
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“There is no single design that is “safe” or “best” for all organizations and all times; rather, clinicians and managers must design and
redesign for their organizations at different organizational stages.”
AHRQ
“Steal shamelessly; implement wisely”IHI
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464869/
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Safety Cultures Evolve
Where Are You?
Attr: Patrick Hudson, Univ. of Leiden
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National Culture
Corporate Culture
Safety Culture
Culture
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Transparency
Leadership
Psychological Safety
Negotiation
Teamwork & Communication
Accountability
ReliabilityImprovement
&
Measurement
Continuous Learning
Engagement of Patients & Family
Learning System
Culture
© IHI and Allan Frankel
Framework For Safe and Reliable Health Care
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Joy in Work
Step No. 1: Ask staff, “What matters to you?”
Step No. 2: Identify the unique impediments to joy in work in the local context
Step No. 3: Commit to making joy in work a shared responsibility at all levels
Step No. 4: Use improvement science to test validated approaches in your organization
http://www.ihi.org/resources/Pages/Publications/Restoring-Joy-in-Work-Healthcare-Workforce.aspx
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Applying the Joy in Work Steps to Changing Culture
Step No. 1: Ask staff, “What matters to you?”
Step No. 2: Identify the unique impediments to providing safe care in work in the local context
Step No. 3: Commit to making providing safe care a shared responsibility at all levels
Step No. 4: Use improvement science to test validated approaches in your organization
http://www.ihi.org/resources/Pages/Publications/Restoring-Joy-in-Work-Healthcare-Workforce.aspx
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Transparency
Leadership
Psychological Safety
Negotiation
Teamwork & Communication
Accountability
ReliabilityImprovement
&
Measurement
Continuous Learning
Engagement of Patients & Family
Framework for Safe and Reliable Health Care
© IHI and Allan Frankel
Being held to act in a safe and
respectful manner given
the training and support to do so.
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Reflection
Have you developed a fair and just culture?
What are the challenges that you face(d)?
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Understand that Skilled Humans Will Make Mistakes
• Do you know what the rules are if you make a mistake?• Do you always feel safe reporting an error?• How do we differentiate individual problems for good
people working in unsafe systems?
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PERFORMANCE
ACCIDENT
Systemic Migration to BoundariesVE
RY U
NSA
FE S
PAC
E
Legal
Expected safe space of action as defined by professional standards
Market Demand
Life Pressures
INDIVIDUAL BENEFITS
Usual Space of Action
‘Illegal-Normal’
Always/Sometimes
‘Illegal-Illegal’ Space
Never/Sometimes Technology
Never/ Never
Policy, Protocols, Regulation
‘Real Life’
Amalberti
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Implementing a Fair and Just Culture
Focus on:• The leadership culture that sets the tone and
judges the behavior of others, and • The culture at the point of care, or team cultureRaise Awareness:• Survey staff• Educate about the just culture concept• Ensure that the highest level of leadership shows
support• Educate the staff
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Implementing a Fair and Just Culture• Examine practices and policies that conflict
with Fair and Just Culture Model• Incorporate the Fair and Just Culture practices
into every day work• Leaders must establish processes to know
when someone is engaging in reckless behavior and be willing to punish those who engage in it.
• Fair and Just Culture applies to everyone in the organization
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Prescribed?
Were the actions as intended?
Were the consequences as
intended?
SubstanceUse?
Knowingly violatedsafe operatingprocedures?
Pass substitution test?
Recent history of unsafe acts or
unintentional rule breaking?
Were procedures available, workable,
intelligible and correct?
Deficiencies in training and selection, or inexperienced?
Intentional rule breaking.
Investigate; Initiate
disciplinary action if indicated.
Substance Abuse without mitigation. Follow HR Policy
Substance Abuse with mitigation.
Engage EmployeeHealth
Possible reckless violation. Initiate
disciplinary process if indicated.
System induced violation. Employee assists in process
improvement.
Possible Negligent Behavior. Investigation possible
counseling, suspension, termination.
System Induced Error. Employee assists in process
improvement.
Blameless Error. Employee assists in process
improvement.
Human error. Develop remedial and/or
corrective action plan. Document verbal
counseling and assign a preceptor/mentor to
work with the employee.
yes
yes
yes yes yes
yes yes yesno no no
nono
no no no yes
no
From: James Reason“Managing the risks of
organizational accidents”Modified by Allan Frankel
and Lynda Hooper 2007
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Our Accountability for Our Behaviors
22
ResponseSupport
ResponseCoach
ResponsePunish
Independent from outcome
Marx D. Patient Safety and the "Just Culture". In: Community TJC, ed: Outcome Engineering; 2007.
Human Error
Inadvertent action: Slip, Lapse, Mistake
Manage through
•Processes•Procedures•Training•System design
At-Risk Behavior
A choice : risk not recognized or
believed justified
Manage through:
• Removing incentives for At-Risk Behavoirs
• Creating incentives for healthy behaviors
• Increasing situational awareness
Reckless Behavior
Conscious disregard of unreasonable risk
Manage through:
• Role modeling• Remedial action• Punitive action
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Culture of Safety Resources - IHI
• A Framework for Safe, Reliable, and Effective Care
• Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition)
• Creating a Culture of Safety (Interview with Lucian Leape)
• Conduct Patient Safety Leadership WalkRounds™
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Culture of Safety Resources - HRET
• HRET HIIN Culture of Safety Change Package
• HRET HIIN Culture of Safety Resource Library
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Bring It Home
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Mallory Bender, Program Manager, HRET
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THANK YOU!
28