lc10 jim and james culture final aug 20 2010.et€¢ describe how to lead through a crisis and use...

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The Changing Landscape of Health Care:Cultivating Leadership in Health‐System Pharmacy


Just Culture: Leading Through a Crisis and

Managing to Improvement James Hoffman, Pharm.D., M.S., BCPSMedication Outcomes and Safety OfficerSt. Jude Children's Research Hospital

Memphis, Tennessee

James A. Jorgenson, M.S., B.S.Pharm., FASHPVice President and Chief Pharmacy Officer

Clarian Health Partners, Inc.Indianapolis, Indiana

Learning Objectives

• Assess the attributes of “Just Culture.”

• Describe how to lead through a crisis and use the crisis for improvement includingthe crisis for improvement, including improving an organizations safety culture.

• List factors that must be in place to develop a “Just Culture” model in your department.

Start thinking…

• Have we made progress?

• How do we learn from errors?

• What does it take to establish a truly safe medication use system?

• How do we guard against complacency in our medication use systems?

Excerpt from Hospital’s Statement on Quaid Twins Heparin Errors

"As a result of a preventable error, the patients' IV catheters were flushed with heparin from vials containing a p gconcentration of 10,000 units per milliliter instead of from vials containing a concentration of 10 units per milliliter," said Langberg. "

November 20 08 http://www.people.com/people/article/0,,20161769,00.html.

Lethal Overdose Claims Third BabyINDIANAPOLIS, Sept. 20, 2006 (AP)

A third premature infant has died after being accidentally given an adult‐sized dose of a blood thinner medication at a hospital last week.

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General Approaches to Medical Errorto Medical Error

Copyright ©2000 BMJ Publishing Group Ltd.

Reason, J. BMJ 2000;320:768‐770.

A brief word on criminalization of medical error…

• Obviously, an important issue that is related to Just Culture

• Our focus today is at the organizational level

• NCCMERP statement against criminalization of medication errors coming soon

What is just culture?

• Various components and definitions

• Definition from ASHP Policy

– A just culture is one that has a clear and transparentprocess for evaluating errors andtransparentprocess for evaluating errors and separating events arising from flawed system design or inadvertent human error from thosecaused by reckless behavior, defined as a behavioral choice to consciously disregard what is known to be a substantial orunjustifiable risk.

ASHP Policy 1021 Just Culture and Reporting Medication Errors Available at: http://www.ashp.org/Import/PRACTICEANDPOLICY/PolicyPositionsGuidelinesBestPractices.aspx.

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Evolution of Cultural Perspectives in Patient Safety

• Punitive Culture (Person approach)– Points blame on person and ignores the system

– Reduces reporting

• Non‐punitive Culture (System approach)– Perceived as too laxPerceived as too lax

– Inconsistent or lack of consequences

– Often misunderstood

• Just Culture (Combined, balanced approach)– Includes a focus on behavioral choices

– Now the best practice

– Challenging to implement and maintain

Medical Conditions?

Were the actions as intended?

Were the consequences as

intended?

Unauthorized Substance?

Knowingly violatedsafe operatingprocedures?

Pass substitution test?

History of unsafe acts?

Were procedures available, workable,

intelligible and correct?

Deficiencies in training and selection, or

inexperienced? Blameless Error

yes yes yes yes nono

no no no yes

no

Sabotage, malevolent

damage, suicide, etc.

Substance Abuse without

mitigation

Substance Abuse with mitigation

Possible reckless violation

System induced violation

Possible Negligent Behavior

System Induced Error

Blameless Error, but corrective training or counseling indicated

yes yes yes yesno no no

BLAMELESSGRAY AREACULPABLE

From: James Reason“Managing the risks of organizational accidents”



Glossary

Glossary

• Human error– In general, all failures of a planned action to achieve intended outcome or use of a wrong plan

– A mistake, slip, or lapseA mistake, slip, or lapse

– No intent; cannot be attributed to chance

• Intentional Rule Violation– Knowingly violating a rule when performing a task

– Not necessarily a risky action

– Sometimes may be considered “at risk behavior”

Marx D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives Prepared by David Marx, JD, for Columbia University under a grant provided by the National Heart, Lung, and Blood Institute; Reason JT, Human Error Cambridge Press, 1990; AHRQ Patient Safety Network Glossary: http://www.psnet.ahrq.gov/glossary.aspx#E; AHRQ WebM&M: http://www.webmm.ahrq.gov/perspective.aspx?perspectiveID=49 .

Glossary

• Negligence– Legal term; usually only used when harm has occurred

– In general the person should have been aware substantial and unjustifiable risk was being taken that substa t a a d u just ab e s as be g ta e t atcaused an undesirable outcome

• Reckless Behavior– Behavioral choice to consciously disregard what is known to be a substantial orunjustifiable risk

– Higher degree of culpability than negligence

Marx D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives Prepared by David Marx, JD, for Columbia University under a grant provided by the National Heart, Lung, and Blood Institute; Reason JT, Human Error Cambridge Press, 1990; AHRQ Patient Safety Network Glossary: http://www.psnet.ahrq.gov/glossary.aspx#E; AHRQ WebM&M: http://www.webmm.ahrq.gov/perspective.aspx?perspectiveID=49 .

Glossary

• Responsibility

– Focus on assigned task

• Accountability

ll– Focus on overall outcome

• Blameless

– No responsibility or accountability

• Punitive

– Punishment; discipline

Marx D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives Prepared by David Marx, JD, for Columbia University under a grant provided by the National Heart, Lung, and Blood Institute.

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Glossary

• Root Cause Analysis– “Process for identifying the basic or contributing causal factors that underlie variations in performance associated with adverse events or l ll ”close calls”

• Disclosure – “Patients and, when appropriate, their families are informed about the outcomes of care, treatment and services that have been provided, including unanticipated outcomes.”

VA National Center for Patient Safety: http://www.patientsafety.gov/glossary.html#iuaJoint Commission Comprehensive Accreditation Manual for Hospitals, January 2006. Standard RI.2.90.

Glossary

• High Reliability Organization

– Reason: “organizations which have less than their fair share of accidents…”

– Weick and Sutcliffe: “ potential for error andWeick and Sutcliffe: …potential for error and disaster is overwhelming… These diverse organizations share a single demand: they have no choice but to function reliably.”

Reason JT. Education and debate Human error: models and management BMJ 2000;320:768‐770 Weick KE and Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty 2nd Edition. John Wiley and Sons, Inc 2007.

How would you describe your department’s current safety culture?

• Punitive Culture GREEN

N iti RED• Non‐punitive RED

• Just Culture RED/GREEN

Safety Culture is intertwined with:

• Event reporting

– Frequency

– Quality

• Disclosure practices

• Many other aspects of patient safety

Disclosure: Defining the players…

• Transparency: Voluntary information for the community at large

• Disclosure is advising a specific individual of an unanticipated outcome

A l i h l d i ki d h i i i h• Apology is what we learned in kindergarten ‐ that it is right, good and okay to tell someone you are sorry.

Disclosure

• Transparency is a healthcare buzz word (2002)

• Disclosure is a regulatory requirement whenDisclosure is a regulatory requirement when an adverse outcome occurs (since July, 2001 )

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Disclosure Decision Tree

Patientoutcome

Within the range of expected results

Unanticipated outcome, but

within the

Unanticipated outcome, but

standard of careof expected results within the standard of care

standard of carebreached

Disclose, apologizeand defend

Disclose, apologize and offer

compensation*

Continue to communicate

regarding progress

Learn from mistakesand experience

Careful analysis/Decision tree

• Disclosure is a careful, deliberate process.

• Disclosures should be timely, but not rushed.

• Disclosures can take place

over days or weeks.

How would you describe your organization’s current safety culture?

• Punitive Culture GREEN

N iti RED• Non‐punitive RED

• Just Culture RED/GREEN

Culture Eats Strategy/Process

Corporate Culture

• The specific collection of values and norms that are shared by people and groups in an organization and that control the way they interact with each other and with stakeholdersinteract with each other and with stakeholders outside the organization.

• “How we do things around here.”

How Old is Your Culture?

• IUSM 1903

• Methodist Hospital 1908

• Riley Hospital 1924

• IU Hospital 1970

• Clarian Health Partners 1997

• Clarian West 2004

• Clarian North 2005

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Purpose Built Culture

• A purpose built hospital culture gives you a significant head start in safety culture.

– Sense of shared mission

Commitment ritual– Commitment ritual

– Pruning of poor fits

Even when purpose‐built culture is not specifically built for patient safety it

helps focus and refine peoplehelps focus and refine people.



Case 1Heparin: Leading

Through a Crisis and gManaging to Improvement

Clarian Health, 2006

• Methodist Medical Center

• Indiana University Medical Center

• Riley Hospital for Children

Points of Discussion

• How the error occurred: pharmacy process

• Action plan in response to the error

• Management of staff following the error

• Lessons learned

• Impact on Culture of Safety

The Heparin Event

• September 16, 2006: Two infants in the NICU, who received an overdose of heparin, died.

• September 19, 2006: A third infant who received an overdose of heparin who hadreceived an overdose of heparin, who had been moved to Riley Hospital, died.

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Pyxis Restocking ProcessSeptember 15

• CardinalASSIST ® ‐ direct download from Pyxis® to Cardinal Distribution in Aurora, Illinois (62% of non‐narcotic meds), Cardinal delivers to the warehouse packaged and barcoded

• Manual Picks‐ Pyxis® report interfaces with Lawson; pick ticket is printed per nursing unit, technician picks meds using pick document

• CII Safe‐ narcotic restocking process

Heparin Error

• Manual pick ticket was printed at 11pm, (Friday, September 15)

• Picking document for NICU indicated to pick 25 heparin 10 unit/ml vials frompick 25 heparin 10 unit/ml vials from location 1A (shelf location)

• Technician mistakenly picked 25 heparin 10,000 unit/ml vials from 1D and placed in tote to deliver with other NICU stock

Heparin Error (continued)

• Technician combined CardinalASSIST® meds with manual picked meds and narcotics for delivery to NICU

• At 1:17 am on September 16 technician signedAt 1:17 am on September 16, technician signed into Pyxis®, indicated she was refilling heparin 10 unit/ml stock and placed the 10,000 unit/ml product in cabinet

• Subsequent to the errant fill; the heparin 10,000 unit product was removed and administered

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Saturday, Sept. 16, 2006

• Director of Pharmacy received notification from MH pharmacy that a severe med variance had occurred

• Later received phone call from hospital• Later, received phone call from hospital administrators to ensure awareness

• Call at 7 pm to get into the hospital ASAP

• Reaction on the unit

• Reaction in the pharmacy

Sunday, September 17, 2006

• Press conference at 5pm

• Called pharmacy management staff

• Preparation for root cause analysis the f ll i i 0800following morning at 0800

Monday, September 18

• 0700, call from CEO

• 0800, Root Cause Analysis

– Warehouse space

l i l h i d– Multiple heparin products

– Product location

– Pyxis® replenishment/check process

– Lack of bar code options

Culture of Safety

• Not addressed in RCA

• All of the elements noted in RCA had been previously identified but were not implemented due to budgetary concernsimplemented due to budgetary concerns

• Pyxis® restock errors had been made multiple times ‐ just not with heparin that reached a patient

Response to the ErrorPharmacy Department

PerspectivePerspective

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Pharmacy Immediate Steps

• Double check system for cabinet replenishment

• Removed heparin 10,000 unit vials, l d ith 5 000 it ireplaced with a 5,000 unit syringe

• Standardized/reduced heparin formulary selection available

• Engaged ISMP for consultation

Hospital Immediate Steps

• Transparent communication from leadership

• Clarian broadcast emails sent daily updating staff on current status

• Senior leaders began receiving daily reports ofSenior leaders began receiving daily reports of medication variances that had occurred in the previous 24 hours

• Education provided to staff on how to deal with questions from patients

• RNs asked to sign a re‐commitment to the 5 rights

Subsequent Pharmacy Steps

• Increased number of products on CardinalASSIST®

• Bar‐coded replenishment process(Cardinal to Cabinet) with PARx

• Expanded warehouse for better storage and i l i f PAR ®implementation of PARx ®

• Planned BCMA at bedside for Q4 of 2007

• Replaced heparin 10 unit vial with a 10 unit syringe

• Urged medical staff to review heparin vs. saline

• Developed plan to notify staff of product changes

Subsequent Steps: Hospital

• ISMP visit completed in November

• Response to ISMP

– Subgroup formed

– Short term and long term reports

– Ongoing process changes

• Standardization of flush procedures

• Continued heightened awareness on medication variances by administration

• Employee Assistance Program (EAP) offered to all employees

Regulatory Agencies

• Indiana State Department of Health

• Prosecutor’s Office/Investigator

• JCAHO

• ISMP – Institute for Safe Medication Practices

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Just Culture

• Five nurses and the pharmacy tech came back to work in the same jobs

– Time off from work and restrictions upon returning, if any were needed, were determined by employee and independentdetermined by employee and independent counselor

– Continued support from EAP and counselor

• Recommitment to 5 Rights

• Heparin double‐check policy for pediatrics

• Standard heparin flush procedures in place

Lessons Learned: Process

• Be vigilant with simple/basic processes‐especially related to dangerous drugs

• Don’t assume “it won’t happen here”

• Caution with immediate changes andCaution with immediate changes and subsequent risk associated with those changes

• Need for someone in charge of change for single voice during immediate process changes (e.g. COO, CMO)

Lessons Learned: People

• Communicate with managers/staff immediately

• Arrange for emotional support for staff i di t limmediately

• Don’t assume staff from others hospitals are unaffected

• Don’t lose sight of the accomplishments

Support for Staff

• Calls, emails and cards from other departments and hospitals

• Increased staffing support

• Debriefing sessions• Debriefing sessions

• EAP information with phone numbers

Lessons Learned: Hospital

• How to lead an organization through a high profile event

• Disclosure to families, staff, and media

• Importance of the 5 rights• Importance of the 5 rights

• Fear of administering a heparin product

• Full support of involved staff

• Support of the NICU and pharmacy staff

• Debriefing and Healing Sessions

Today ‐ Culture of Safety

• Recently proactively engaged ISMP for a system wide revisit

• Continual risk assessment and interaction with the Boardthe Board

• Full engagement of senior leadership in regular safety rounds at the staff level

• Challenge to not lose our focus as we move farther away from 2006

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Case 2Improving

Patient Safety Culturey

How can we assess and improve patient safety culture?

How do we get to just culture?

You recently became an Assistant Director at a mid‐size hospital with a variety of services. The hospital’s core services include several high‐risk areas, including a neonatal ICU and a b l i f i t Y l i thbusy oncology infusion center. Your role in the department includes leadership for medication safety.

Since your position was open for a nearly a year, you are working to rapidly prioritize and focus your work for the first year. You have already identified several important changes that must be in sterile product preparation forthat must be in sterile product preparation for safe preparation of chemotherapy and other high risk medications. Your hospital also just completed a major barcoding project and is in the midst of implementing CPOE.

You are still getting to know everyone in the department and at the hospital. Overall, staff are competent, have positive attitudes, and want to do the right thing. However, error review processes are inconsistent andreview processes are inconsistent, and occasionally, serious near misses occur that don’t get careful review.

Because of the dispensing deficiencies you have noted for high risk sterile products, there was recently a dispensing error that caused patient harm, and the pharmacist blamed the technician that prepared the i f i Y t f f linfusion. You are not aware of any formal work that has been done on safety culture to date. Given your current situation, what are your plans for working on safety culture?

Given your current situation, what are your plans for safety culture?

• GREEN

Informally monitor safety culture, but focus

• RED

Start to plan a formal assessment of patientsafety culture, but focus

on other priorities at this time (e.g. safe sterile product prep and CPOE).

assessment of patient safety culture as you work on other priorities.

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As the next few months pass, the need for a formal assessment of patient safety culture has become clear. This opinion has been formed by additional instances of conflict and blame between pharmacists and technicians when errors occur. You are also concerned about the frequency and qualityare also concerned about the frequency and quality of error reporting within the department. In fact, error reporting from the department declined dramatically over the last six months.

Despite the continuing need for improvement within your department, relationships with physicians, nurses, and others in your hospital remain largely positive. Individually, your focus on medication safety has been welcomed by the quality management and nursing departmentsquality management and nursing departments, and you are gaining credibility across the organization for your medication safety expertise and accomplishments.

You have had several informal discussions about patient safety culture that has given you some ideas for an action plan. However, you have learned about the Agency for Health Care Research and Quality (AHRQ) patient f t lt d ld lik tsafety culture survey, and you would like to

use the survey to further develop your plan. What is your safety culture assessment and planning approach?

What is your safety culture assessment and planning approach?

• GREEN

Focus patient safety culture assessment and

• RED

Concentrate on developing anculture assessment and

improvement plans exclusively on your department at this time

developing an organizational patient safety culture effort; informally work on department safety culture as time allows

Use of a hospital wide safety culture assessment

• 2009 ASHP annual survey

– 62.9% of hospitals have completed an assessment such as the AHRQ survey

– Larger hospitals more likely to completeLarger hospitals more likely to complete

• 81.4% of hospitals with 400–599 beds

• 54.3% of hospitals with fewer than50 beds

Pederson CA et al. ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education—2009 Am J Health‐Syst Pharm. 2010; 67:542‐58

Did your organization complete a formal patient safety culture survey in the last three years?

• YES GREEN

NO RED• NO RED

• Being planned RED/GREEN

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Dimensions of the AHRQ Hospital Survey on Patient Safety Culture

Leadership– Manager/supervisor expectations and actions to promote patient safety– Hospital management support for patient safety

Error and event reporting– Frequency of events reported– Non‐punitive response to error

Teamwork and transitions– Teamwork within units– Teamwork across units– Hospital handoffs and transitions

Communication– Communication openness– Feedback and communication about error

Organizational learning and continuous improvementStaffingOverall perceptions of safety

AHRQ Hospital Survey on Patient Safety Culture. Available at: http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm.

The results from your hospitals AHRQ survey have been analyzed and distributed. Compared to the AHRQ benchmark, your hospital has opportunity to improve in several areas including organizational learning, non‐punitive response to error, and frequency of event reporting. The data were analyzed by position, which gave you some helpful perspectives on how to improve in your dept.

However, your attention has been drawn to the fact that individuals who classified themselves as “administration” or “management” consistently provided more positive scores then other respondents. This pattern exists across all dimensions of the survey, and it is particularly pronounced for the section focused on “management support for patient safety.” How do you approach the apparent disconnect between staff and administration’s perspective on patient safety?

GREEN

Focus on interacting with administrators and

RED

Concentrate on communicating with staff

How do you approach the apparent disconnect between staff and administration’s responses on

the safety culture survey?

with administrators and other formal leaders to explain the discrepancy in the results; educate them on how things “really are”

communicating with staff to understand why the patient safety culture survey scores are so low

Do you think there is a disconnect between formal leadership and staff perspectives of safety culture

at your hospital?

YES – 2 different views GREEN

NO tl li d REDNO ‐‐mostly aligned RED

Unsure/depends RED/GREEN

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How to Attack a Culture Problem

• Get past attacking the numbers

• Get your Board “on board”

• Go to your C‐Suite for help and support

• Take results back to the director/manager level and then front line staff

• Use a prominent symbol

• Bring new people up to speed

• Directly address staff concerns

• Produce results or at a minimum feedback

Measures of Success ‐‐ Qualitative

• Is pharmacy on the agenda for every significant quality and safety discussion at your organization?– CMO, CNO, Board of Trustees

• How much near miss data do you get? Are you using near miss data for improvement?

• Does your staff want to learn about errors and make improvements?

• Are you effectively using error data for improvement? Do you get it done?

Measures of Success ‐‐ Quantitative

• AHRQ Survey results

– Department

– Organization

E l i i d t• Employee opinion data

– Department

– Organization

• Frequency of event reporting

200

250

300

350

400

Number of Events Reported By Pharmacist Over a Recent 15 Month Period

‐37 pharmacists

‐ Range: 0 to 358 reports

0

50

100

150

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA BB CC DD EE FF GG HH II JJ KK

‐ 10 pharmacists represent 78.9% of reports

CEO‐Chief Executive Officer

COO Chi f O i Offi

THE CORE

CQOChief Quality Officer

CIOChief Information Officer

VP of Pharmacy (CPO)

C‐Suite Composition

COO‐Chief Operating Officer

CFO‐Chief Financial Officer

CMO‐Chief Medical Officer

CNO‐Chief Nursing Officer

OTHER STAKEHOLDERS

CPO CSO

Chief Purchasing Officer Chief Safety Officer

Data on File from CEO interviews conducted and PCAB Surveys.

• Pharmacy is the leader in medication safety

• Pharmacy is one of the only professions that fully understands both the clinical and financial aspect of the healthcare business.

The Information Transfer

f p f

• Leverage expert stature/training

• Focus on system‐wide medication safety initiatives

• Valued and trusted member of institution

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ReliabilityReliabilityConsistency of message and standards

No lies, false feedback, ‘fess up

early

HonestyHonesty

Creating and Maintaining Trust

TrustFaithFaith

VulnerabilityVulnerability Openness

Greater good, perspective, no blame, take care

of others

CompetencyCompetencyKnowing what

needs to be done and doing it well

Trust

Conclusion

• Just Culture is – Teamwork – Organizational learning – Communication openness– Appropriate accountability– Appropriate accountability

• Culture is a journey – Start assessing and improving – Requires constant monitoring

• Positive safety culture requires intentional commitment and strong leadership



Appendix



High Reliability OrganizationsOrganizations

High Reliability Organizations (HROs)

• Definitions

– Reason: “organizations which have less than their fair share of accidents…”

– Weick and Sutcliffe: “ potential for error andWeick and Sutcliffe: …potential for error and disaster is overwhelming… These diverse organizations share a single demand: they have no choice but to function reliably.”

Reason JT. Education and debate Human error: models and management BMJ 2000;320:768‐770. Weick KE and Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty 2nd Edition. John Wiley and Sons, Inc 2007.

Five Concepts for High Reliability (and Ultimately Patient Safety)

Hines S, Luna K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. (Prepared by the Lewin Group under Contract No. 290‐04‐0011.) AHRQ Publication No. 08‐0022. Rockville, MD: Agency for Healthcare Research and Quality. February 2008.

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Five Concepts for High Reliability (and Ultimately Patient Safety)

1. Preoccupation with failure

2. Reluctance to simplify

3. Sensitivity to operations

4. Commitment to resilience

5. Deference to expertise

Hines S, Luna K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. (Prepared by the Lewin Group under Contract No. 290‐04‐0011.) AHRQ Publication No. 08‐0022. Rockville, MD: Agency for Healthcare Research and Quality. February 2008. Weick KE and Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty 2nd Edition. John Wiley and Sons, Inc 2007.

Five Concepts of HROs in further detail

• Preoccupation with failure

– PROACTIVE ‐‐ Focused on predicting and eliminating catastrophes rather than reacting

– “Near misses” are viewed as opportunities toNear misses are viewed as opportunities to improve and understand what went wrong

– “Near misses” are NOT just proof the system has enough checks


Five Concepts of HRO in further detail

• Reluctance to simplify– Given complex systems, simplistic solutions are not appropriate

– Range of possible failures ‐‐ so do not assume failures are due to a single simple cause

– However, does not mean that one should not work to make processes simple

Hines S, Luna K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. (Prepared by the Lewin Group under Contract No. 290‐04‐0011.) AHRQ Publication No. 08‐0022. Rockville, MD: Agency for Healthcare Research and Quality. February 2008. Weick KE and Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty 2nd Edition. John Wiley and Sons, Inc 2007


• Sensitivity to operations– Mindful of complexity – processes are not static

– Situational awareness to quickly identify errors

• Commitment to resilience• Commitment to resilience

– QUICKLY contain errors and improvise as needed when errors occur

– Aware work systems may fail in unexpected ways –be ready to respond quickly



• Deference to expertise

– Person with most knowledge of issue – not necessarily the “expert”

All levels of staff must be willing and comfortable– All levels of staff must be willing and comfortable to share information

– HROs de‐emphasize hierarchy


Highlights of Applications of HRO Concepts to Hospitals

• External environment

– Community collaboration (Local efforts can be better than national!)

• Don’t compete on safety

• Standardization across hospitals in community

– “Incremental muddle”

• Value of informal conversations


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• Internal environment– What leaders must do

• Culture is foundational• Transparency is key (really facing reality)p y y ( y g y)

• Safety overarching strategy• Leaders must set climate, generate clarity, and focus the work



• Internal environment– Staff behavior

• Align expectations with incentives for performance

• Owners for all actions

• Link safety/quality to operational issues

– Just culture • People can report without risk of reprisal (staff empowered)

• BUT individuals still held accountable (considering individual vs. flawed system


Planning and Implementing Projects using HRO Concepts

• Processes– Integrate safety/quality into other activities ongoing – Incremental progress – Simplify processes when possible

• Peoplef h i i i l id– Importance of physician involvement, provide resources

– Diverse teams (different disciplines, different shifts/areas/etc)– Reduce what you want staff to do to a limited set of clearly

defined behaviors

• Resources– Replacement staff for QI work– Short priority list since resources always limited




Just Culture: Leading Through a Crisis and

Managing to Improvement

Thank you!

lc10 jim and james culture final aug 20 2010.et€¢ describe how to lead through a crisis and use...

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