Transcript Presentation Notes - Colorado Healthcare Associated

Colorado Healthcare Associated Risk Managers
Michael Leonard, MD
Safe & Reliable Healthcare
Adjunct Professor of Medicine, Duke University
How do you Mitigate Risk?
• High risk areas – surgery, OB, ED, ICU,
deteriorating patients
• High risk medications
• Spontaneous reporting with analysis and
feedback
• Risk surveillance
• Barriers and hot spots
The Quality of Healthcare in America
• 30 evidenced based
practices:
• ACE inhibitors for CHF
• Beta blockers / ASA for
post MI
• The chance of an
average patient
receiving appropriate
care was 55%
Avoidable Patient Harm
• 30% of hospitalized
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
7
Type vs. Severity of Hosp. Acquired
AE’s
Courtesy Dr. Donald Kennerly,
Baylor Healthcare
Hospital Acquired Adverse Event Type vs. Severity
Adverse Event Type
Infection
Medication AE
Thrombosis/Emboli
Fall with Injury
Pressure Ulcer
Sepsis
Stroke
Pneumothorax
Surgical/Procedural AE
Perinatal AE
Other AE
Fluid Overload/Pulm. Edema
Blood Transfusion Reaction
IV Infiltrate
Total
SE = Sentinel Event
NCC-MERP Injury Score (%)
E
6.7
18.8
0.7
0.3
1.0
0.5
0.0
0.0
31.3
3.4
3.0
1.0
0.5
2.2
69.4
Waste
(8,400)
F
4.2
3.7
1.5
0.2
0.2
0.7
0.3
0.5
12.6
0.5
0.5
0.7
0.0
0.0
25.5
G
0.0
0.0
0.0
0.2
0.0
0.0
0.2
0.0
0.2
0.0
0.2
0.0
0.0
0.0
0.7
H
0.2
1.2
0.0
0.0
0.0
0.0
0.0
0.0
1.7
0.2
0.2
0.2
0.0
0.0
3.5
+Harm
(3,000)
+SE
(80)
+Risk
(400)
I
0.0
0.3
0.0
0.0
0.0
0.3
0.0
0.0
0.3
0.0
0.0
0.0
0.0
0.0
1.0
Total
11.1
24.0
2.2
0.7
1.2
1.5
0.5
0.5
46.1
4.0
3.9
1.8
0.5
2.2
100.0
Total
+ SE
(120) (12,000)
Success going forward under the new
healthcare model
• Population management is the name of the game
• Coherence in moving from primary care to acute
care
• Effective med reconciliation in the ED – every time
• Organized in hospital care
• Begin planning the discharge upon admission
• Effective transition back to primary care – care
coordinators
Improving Safety Requires a Learning System
Safety is a characteristic of a SocioTechnical system
 System-level failures occur almost always because of
unforeseen combinations of component failures

Safety Cultures Evolve
GENERATIVE
Organizational Culture “Geneticallywired” to produce safety
PROACTIVE
“We methodically anticipate”—
prevent problems before they occur
SYSTEMATIC
Systems being put into place to manage
most hazards
REACTIVE
“Safety is important. We do a lot every
time we have an accident”
Where is Yours?
UNMINDFUL
“We show up, don’t we?”
Chronically Complacent
11
Attribution: Prof. Patrick Hudson, Univ. Leiden
SocioTechnical Framework
Unmindful • Reactive • Systematic • Proactive • Generative
• Patient & Family Centered Care
• Leadership – Senior and Clinical
• Effective Teamwork
• Psychological Safety
• Organizational Fairness
• Reliable Processes of Care
• Learning System - Improvement
The Ideal Unit
Building the Conditions for Success
• How leadership, culture and process come
together
• It is essential to connect the 3 levels of the
organization – senior leaders, the middle and
caregivers at the bedside
Approaching Common and Serious
Problems
• With protocols and guidelines, are they suggestions
or are they the way we do business?
• Work as imagined v. Work as done
• What makes the difference?
• How do you measure that?
• How do you drive sustainable improvement?
• We always have to deal with both process and
culture.
Looking at Sepsis
• Up to 50% of patients are septic at the time of death
in American Hospitals
• Some hospitals treat sepsis very consistently with
good outcomes, many do not.
• Let’s look and see how you think you would do or
where the important processes are to become
“always events.”
Sepsis: Getting it Right or Wrong
Define Time Zero
Diagnosis / high Index
Suspicion
Sepsis Bundle < 3hours
Lactate > 4, unstable gets
CVP, MVO2 measurement,
pressors PRN
Who owns the patient? Warm
handoff. No delay
Sepsis – A Phased Approach
• Severe sepsis – 4 things every time within
3 hours
• Septic shock – hemodynamic monitoring,
pressure support, etc.
• Patients who declare themselves in the
hospital – surveillance and EWS
• Patients who return septic after discharge
Patient & Family Centered Care
GENERATIVE
• Truly patient-centered care, a
Organization wired for safety and
improvement
PROACTIVE
•
Playing offense - thinking ahead,
anticipating, solving problems
SYSTEMATIC
•
Systems in place to manage hazards
REACTIVE
•
Playing defense – reacting to events
UNMINDFUL
No awareness of safety culture
•
true partnership, all about
them
Structured process for
patients and family at the
table, visible results
Care process visible, learning
and feedback sporadic
Customer service is the
primary focus
Care process built around the
convenience of providers
Seeing Through the Patient’s Eyes
• How do you assess the patient experience?
• When does that happen?
• What is the real story?
• How do you meet their expectations?
• How do we fail them?
• What happens when we do?
Senior Leadership
GENERATIVE
• Cyclic flow of information
Organization wired for safety and
improvement
PROACTIVE
•
Playing offense - thinking ahead,
anticipating, solving problems
SYSTEMATIC
•
Systems in place to manage hazards
REACTIVE
Playing defense – reacting to events
•
UNMINDFUL
•
No awareness of safety culture
with feedback and
organizational 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
Leadership Characteristics
•
•
•
Non Negotiable Mutual
Respect, Every
Interaction, Every Day.
Paul O’Neill – “Once
you get used to taking
the high road, putting
values over
expedience, and
treating people like
people and not the
means, it gets easier
and easier.
Chris Argyris
• Why is it so hard?
• Single loop learning
• Double loop learning
• Not talking about the stuff we don’t talk
about
The Ideal Unit
Clinical Leadership
GENERATIVE
• Leaders create high degrees of
Organization wired for safety and
improvement
PROACTIVE
•
Playing offense - thinking ahead,
anticipating, solving problems
SYSTEMATIC
•
Systems in place to manage hazards
REACTIVE
•
Playing defense – reacting to events
UNMINDFUL
No awareness of safety culture
•
psych safety and
accountability.
Leaders model the desired
behaviors 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
Adaptive versus Technical Leadership
• Known v. unknown
problems
• Differences in style
• Knowing when to shift
your leadership style
Gary Klein – Expert Decision making
• Experts pattern match
• Quick and accurate as
long as one tests
• Mental simulation is
common and valuable –
high performing teams
simulate together
• What about the
newbies?
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
Local Leadership by Unit
Hospital X: Domain - Psychological Safety by Unit
Lab (24)
2 East (8)
Emergency Department (38)
Telemetry (23)
Imaging (19)
Materials (10)
4 East (10)
3 East (39)
Other (21)
Hospital-wide (484)
3 South (37)
Physical Therapy (36)
Percent Posi ve
Engineering (8)
Percent Neutral
Percent Nega ve
Nursing Administra on (8)
Pa ent Accounts (27)
Respiratory Care (10)
Opera ng Room (21)
2 North (12)
1 East (22)
Pharmacy (8)
HIT (27)
Hospitalists (62)
Administra on (8)
4 North (8)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Psychological Safety
GENERATIVE
• Primary responsibility of
Organization wired for safety and
improvement
PROACTIVE
•
Playing offense - thinking ahead,
anticipating, solving problems
SYSTEMATIC
•
Systems in place to manage hazards
REACTIVE
•
Playing defense – reacting to events
UNMINDFUL
No awareness of safety culture
•
leaders, continuously modeled
everywhere.
Leaders model and expect the
behaviors 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
Psychological Safety Is Local
© 2012 Pascal Metrics
Psychological Safety
We are our own image consultants
and best
image protectors
To protect one’s image, if you don’t want to look
STUPID
Don’t ask questions
INCOMPETENT
Don’t ask for feedback
NEGATIVE
Don’t be doubtful or criticize
DISRUPTIVE
Don’t suggest anything innovative
PSYCHOLOGICAL SAFETY CHANGES THIS PARADIGM
Source: Amy Edmondson
A Culture of Safety
No one is ever hesitant to
voice a concern about a
patient
Action is taken, feedback
reliably provided,
changes are visible for
staff and patients
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
Why is Culture Important?
• Culture reflects the behaviors and beliefs within an
•
•
•
•
•
organization.
There are behaviors that create value individually, for the
patient and the organization.
There are behaviors that create unacceptable risk.
These attitudes and behaviors 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
CULTURE IS RELATED TO…
Teamwork Climate Scores Across Facility
98
CCU
REHAB
OR
EMERG
5 WEST
6 WEST
PEDS
GERI
DIALYSIS
PERIOP
PHARM
3WEST
ICU
NICU
SICU
PEDS
OB
100
73 75 80
80
62 62
55
52
51
60
45 45 49 49
41
36
40 28 33
20
0
HCAHPS
50
92
Medication Errors per Month
6.1
2.0
Days between C Diff Infections
40
121
Days between Stage 3 Pressure Ulcers
18
52
Illustrative Data:
Extracted from
Blinded Client Data
… AND UNFAVORABLE EMPLOYEE OUTCOMES
Teamwork Climate Scores Across Facility
98
<60% Score =
Danger Zone
CCU
REHAB
OR
EMERG
5 WEST
6 WEST
PEDS
GERI
DIALYSIS
PERIOP
PHARM
3WEST
ICU
NICU
SICU
PEDS
OB
100
80
75
73
80
62 62
55
52
51
60
45 45 49 49
41
36
40 28 33
20
0
Employee Satisfaction
55
91
Employee Injury per 1000 days
16
0.1
Employee Absenteeism per 1000 days
15
10
RN Vacancy Rate
9
1
Illustrative Data:
Extracted from
Blinded Client Data
© 2008 Pascal Metrics
Wrong Site Surgery or Retained Foreign
Body in 17 Operating Rooms
Operating Rooms
Culture – What is Your Approach?
• What instrument do you use?
• At what level do you measure – hospital v. work
setting?
• What response rate is the desired minimum?
• Does it accurately reflect the perceptions of
caregivers?
• What is the process of debriefing and addressing the
issues raised?
• How is the process used to build trust, improve culture
and drive visible learning?
• Follow with qualitative assessment and explicit actions
The Value of an Integrated Survey
• The SCORE survey measures important dimensions of
organizational culture. It evolved from 20 years of
experience with the Safety Attitudes Survey and a dozen
years of experience with the AHRQ survey.
• Survey questions need to be both diagnostic and actionable.
• The insights are critical for organizational improvement and
the ability to drive habitual excellence.
• Specific actions can be taken to leverage organizational
strengths and address areas of fundamental opportunity.
All Domains - Hospital-wide
Phoenix Children's Hospital: Percent Posi ve Respondents by Domain
Learning Environment (561)
100%
80%
60%
Work / Life Balance (561)
64%
50%
Local Leadership (561)
40%
38%
20%
0%
24%
33%
Safety Climate (561)
Resilience / Burnout (561)
45%
Teamwork (561)
(c) 2013
SCORE Survey Domains
• Learning Environment – The ability to learn from defects and drive
improvement.
• Perceptions of Local Leadership - management interactions that enable
learning, safe systems, and appropriate behavioral choices related to risk
and quality.
• Resilience/Burnout - the shared ability to cope, and the perceived
availability of resources related to health and well being.
• Teamwork - the quality of teamwork and collaboration within a given unit.
• Safety Climate - the perceived level of commitment to and focus on patient
safety within a given unit.
• Work/Life Balance - is the consensus of people related to self care and
human limitations.
• Engagement – the demands and resources that influence strain and
cynicism
(c) 2013
Domain - Learning Environment
Hospital X: Domain - Learning Environment Hospital-wide
In this work se ng, the learning environment
is observable by the way we treat each other
with respect. (486)
100%
In this work se ng, the learning environment
is valued by the people that work here. (480)
80%
71%
79%
74%
60%
In this work se ng, the learning environment
u lizes input/sugges ons from the people
that work here. (487)
40%
20%
In this work se ng, the learning environment
is protected by our local management. (480)
72%
0%
66%
In this work se ng, the learning environment
allows us to pause and reflect on what we do
well. (485)
65%
In this work se ng, the learning environment
integrates lessons learned from other work
se ngs. (484)
69% In this work se ng, the learning environment
effec vely fixes defects to improve the quality
of what we do. (485)
73%
In this work se ng, the learning environment
allows us to gain important insights into what
we do well. (486)
(c) 2013
Learning Environment by Unit
Hospital X: Domain - Learning Environment by Unit
Hospital-wide (485)
1 East (22)
2 East (8)
2 North (12)
3 East (39)
3 South (38)
4 East (9)
4 North (8)
Administra on (8)
Emergency Department (39)
Engineering (8)
HIT (27)
Percent Posi ve
Hospitalists (62)
Percent Neutral
Percent Nega ve
Imaging (19)
Lab (24)
Materials (10)
Nursing Administra on (8)
Opera ng Room (21)
Other (21)
Pa ent Accounts (28)
Pharmacy (8)
Physical Therapy (36)
Respiratory Care (10)
Telemetry (23)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Local Leadership – SCORE Survey
(c) 2013
Burnout by Unit
Hospital X: Domain - Burnout by Unit
Imaging (19)
Lab (24)
Telemetry (23)
3 East (38)
Pa ent Accounts (29)
Emergency Department (39)
Materials (10)
3 South (38)
4 North (8)
Nursing Administra on (8)
2 East (8)
Hospital-wide (486)
Percent Posi ve
Opera ng Room (21)
Percent Neutral
Percent Nega ve
Other (21)
HIT (27)
1 East (22)
Administra on (8)
Pharmacy (8)
4 East (9)
Respiratory Care (10)
Physical Therapy (36)
Hospitalists (62)
2 North (12)
Engineering (8)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
(c) 2013
Burnout by Position
Hospital X: Domain - Burnout by Posi on
All Posi ons (486)
Admin Support (Clerk/Secretary/Recep onist) (64)
Administra on/Management (33)
Clinical Support (Medical Assistant, EMT, etc.) (18)
Die cian/Nutri onist (8)
Environmental Support (Housekeeper) (13)
Percent Posi ve
Nurse (112)
Percent Neutral
Nurses Aide (29)
Percent Nega ve
Other (92)
Other Manager (e.g., Clinic Manager, Supervisor)
(12)
Physician: A ending/Staff (25)
Technician (e.g., Surg., Lab, EKG, Rad.) (19)
Technologist (e.g., Surg., Lab, Rad.) (32)
Therapist (RT, PT, OT, Speech) (32)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Debriefing – Linking teamwork and
Improvement
• What did we do well
?
• What did we learn so
we can do it better
the next time ?
• What got in the way
that needs to be
fixed ?
THE IMPACT OF ACTING ON SAFETY CULTURE
DATA IN RHODE ISLAND ICUS
ICUs that DEBRIEFED
ICUs that did not DEBRIEF
Change in survey scores
Reflected on culture scores and took action
1. >15% culture score increase in 5/7
domains
2. >10% BSI reduction
3. >15% VAP reduction
*
*
Did not reflect on SAQ scores nor take
action
1. 5% culture score drop in 5/7 domains
2. No reduction in BSIs
3. 5% increase in VAPs
*
Attribution:
et Metrics,
al. Improving
©2012 Developed
cooperativelyM.
by Vigorito-Cornell
Mayo Clinic and Pascal
Inc.
*
*
safety culture results in Rhode Island ICUs: lessons
learned from the development of action-oriented plans. Jt Comm J Qual Patient Saf. 2011 Nov;37(11):509-1453
Effective Teamwork
GENERATIVE
• Teamwork and continuous
Organization wired for safety and
improvement
PROACTIVE
•
Playing offense - thinking ahead,
anticipating, solving problems
SYSTEMATIC
•
Systems in place to manage hazards
REACTIVE
•
Playing defense – reacting to events
UNMINDFUL
No awareness of safety culture
•
learning deeply embedded and
central to our culture
Teamwork methodically taught
and modeled across the
organization
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
Teams
• WHAT TEAMS DO:
The associated behaviors:
Plan Forward
Brief (huddle, pause, timeout, check-in)
Reflect Back
Debrief
Communicate Clearly
Structured Communication SBAR
and Repeat-Back
Manage Conflict
Critical Language
55
(c) 2013
Domain: Teamwork
Hospital X: Domain - Teamwork Hospital-wide
Disagreements in this work se ng are
appropriately resolved (i.e., not who is right
but what is best for the pa ent). (478)
100%
80%
61%
60%
40%
Dealing with difficult colleagues is consistently
a challenging part of my job. (reversed) (476)
39%
62%
20%
In this work se ng, it is difficult to speak up if
I perceive a problem with pa ent care.
(reversed) (467)
0%
The people here from different disciplines/ 72%
backgrounds work together as a wellcoordinated team. (487)
79%
It is easy for personnel here to ask ques ons
when there is something that they do not
understand. (490)
Teamwork by Unit
(c) 2013
Hospital X: Domain - Teamwork by Unit
Hospital-wide (480)
1 East (22)
2 East (8)
2 North (12)
3 East (39)
3 South (38)
4 East (10)
4 North (8)
Administra on (8)
Emergency Department (39)
Engineering (8)
HIT (26)
Percent Posi ve
Hospitalists (62)
Percent Neutral
Percent Nega ve
Imaging (19)
Lab (24)
Materials (10)
Nursing Administra on (8)
Opera ng Room (21)
Other (21)
Pa ent Accounts (26)
Pharmacy (8)
Physical Therapy (36)
Respiratory Care (10)
Telemetry (23)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
(c) 2013
Teamwork by Position
Hospital X: Domain - Teamwork by Posi on
All Posi ons (480)
Admin Support (Clerk/Secretary/Recep onist) (61)
Administra on/Management (32)
Clinical Support (Medical Assistant, EMT, etc.) (18)
Die cian/Nutri onist (8)
Environmental Support (Housekeeper) (13)
Percent Posi ve
Nurse (111)
Percent Neutral
Nurses Aide (29)
Percent Nega ve
Other (92)
Other Manager (e.g., Clinic Manager, Supervisor)
(11)
Physician: A ending/Staff (25)
Technician (e.g., Surg., Lab, EKG, Rad.) (19)
Technologist (e.g., Surg., Lab, Rad.) (32)
Therapist (RT, PT, OT, Speech) (32)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Courtesy Linda Hummel
Debriefing – Linking teamwork and
Improvement
• What did we do well ?
• What did we learn so
we can do it better the
next time ?
• What got in the way
that needs to be fixed ?
(c) 2013
Domain: Safety Climate
Hospital X: Domain - Safety Climate Hospital-wide
My sugges ons about quality would be acted
upon if I expressed them to management.
(491)
100%
80%
60%
In this work se ng, it is difficult to discuss
errors. (reversed) (476)
54%
40%
62%
70%
20%
Errors are handled appropriately in this work
se ng. (485)
0%
64%
60%
The culture in this work se ng makes it easy
to learn from the errors of others. (483)
I receive appropriate feedback about my
performance. (485)
Safety Climate by Unit
(c) 2013
Hospital X: Domain - Safety Climate by Unit
Hospital-wide (487)
1 East (22)
2 East (8)
2 North (12)
3 East (39)
3 South (38)
4 East (10)
4 North (8)
Administra on (8)
Emergency Department (39)
Engineering (8)
HIT (27)
Percent Posi ve
Hospitalists (63)
Percent Neutral
Percent Nega ve
Imaging (19)
Lab (24)
Materials (10)
Nursing Administra on (8)
Opera ng Room (21)
Other (21)
Pa ent Accounts (28)
Pharmacy (8)
Physical Therapy (36)
Respiratory Care (10)
Telemetry (23)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
(c) 2013
Safety Climate by Position
Hospital X: Domain - Safety Climate by Posi on
Die cian/Nutri onist (8)
Nurse (112)
Technologist (e.g., Surg., Lab, Rad.) (32)
Therapist (RT, PT, OT, Speech) (32)
Admin Support (Clerk/Secretary/Recep onist) (64)
Technician (e.g., Surg., Lab, EKG, Rad.) (19)
Percent Posi ve
Environmental Support (Housekeeper) (13)
Percent Neutral
Other (94)
Percent Nega ve
All Posi ons (487)
Nurses Aide (29)
Other Manager (e.g., Clinic Manager, Supervisor)
(12)
Clinical Support (Medical Assistant, EMT, etc.) (18)
Administra on/Management (33)
Physician: A ending/Staff (25)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Organizational Fairness / Just Culture
GENERATIVE
• Real events are shared by
Organization wired for safety and
improvement
PROACTIVE
•
Playing offense - thinking ahead,
anticipating, solving problems
SYSTEMATIC
•
Systems in place to manage hazards
REACTIVE
•
Playing defense – reacting to events
UNMINDFUL
No awareness of safety culture
•
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
6
Inherent Human Limitations
• Limited memory capacity – 5-7 pieces of
information in short term memory
• Negative effects of stress – error rates
• Tunnel vision
• Negative influence of fatigue and other
physiological factors
• Limited ability to multitask – cell phones and
driving
VERY UNSAFE SPACE
Individual Benefits
HIGH
Drift = Risk
100%
Agreement
Nonacceptable
Usual Space
Of Action
‘Illegal normal’
Real Life standards
60-90%
LOW
ACCIDENT
HIGH
100%
Production Performance
Expected safe
space of action
as defined by
professional
standards
Safety Reg’s &
good practices,
accreditation
standards
LOW
Attribution: Dr. Rene Amalberti
Little Things Can Cause Big Problems
• Room 20
• Look out the window
• A simple knee scope
• He’s OK – he’s not too sedated - you go home
• What it says on the box is not what’s in the box
Perspectives on Human Error – Sidney Dekker
• Old View
• Human error is a cause
•
•
•
•
of trouble
You need to find people’s
mistakes, bad judgments and
inaccurate assessments
Complex systems are
basically safe
Unreliable, erratic humans
undermine system safety
Make systems safer by restricting
the human contribution
• New View
• Human error is a symptom
•
•
•
•
of deeper system trouble
Instead, understand how their
assessments and actions made
sense at the time — context
Complex systems are basically
unsafe
Complex systems are tradeoffs
between competing goals —
safety v. efficiency
People must create safety
through practice at all levels
Case One
• Box of heparin comes to the NICU, says 10 units/ ml on
the outside, contains 1000 U/ ml vials
• Pharmacy tech is great, been there 20 years, “wouldn’t
make a mistake”
• 9 people give 100 times too much heparin to very small
children
Organizational Fairness and Professionalism
Organizational Fairness and Professionalism Worksheet
Initial
Step 1
Step 2
Step 3
Step 4
Final Step
Reliably excellent patient centered care is dependent on healthcare departments that are effective learning systems; they routinely identify their defects
and then eliminate or ameliorate them. Individuals bring to light defects only when they trust others and feel safe about voicing their insights and
concerns. Professionalism and Just Culture create trust and psychological safety and are the essential foundation for all learning systems. The job of the
Safety and Reliability Committee is to safeguard Professionalism and Just Culture in order to protect and promote robust learning systems.
Event or Near Event
Identify Participants
Review Event or Near Event. Reassign participants if evidence of:
Malicious Behavior – HR, Legal,
Impaired Judgment - CMO, CNO, HR, EAP
Unprofessional Behavior – Perform Professional Behavior Evaluation
Complaint: Professional Behavior Evaluation and Intervention
Receive Report of Concerning Behavior.
Conduct confidential conversation with reporter regarding
focus person (FP) behaviors. Categorize types of behaviors as
well as frequency and severity. Conduct confidential interviews
with others.
Step 1: Assign level of intent:
Use best judgment to categorize each action as either Reckless, Risky or
Unintentional. The categorization determines the general level of culpability
and possible disciplinary actions, however these general categories require
further analysis as below prior to making a final decision.
Behavior categories include: Demeaning/angry, hypercritical,
uncollegial, shirking responsibilities, misconduct, sexual
harassment, patient communication concerns, boundary issues,
substance abuse, blaming, and otherwise act in a manner that
undermines trust and learning.
Allan Frankel
Michael Leonard
Jo Shapiro
RECKLESS ACTION
RISKY ACTION
UNINTENTIONAL
Step 1: Feedback Conversation Coaching If the concern is
The caregiver knowingly The caregiver made a
The caregiver made or
deemed an isolated incident, the FP has not had any other
violated a rule and/or
potentially unsafe choice. participated in an error issues, and the reporter feels safe to do so, provide coaching for
made a dangerous or
Their evaluation of
while working
the reporter on how to give the FP direct feedback regarding
unsafe choice. The
relative risk appears to
appropriately and in the behaviors. If the situation is more complex, proceed to Step 2.
decision appears to be
be erroneous.
patients' best interests
Step 2: Assessing Concerns To validate the concerns and assess
self serving and to have
their frequency and severity, multisource interviews are
been made with little or
conducted to provide comprehensive insight into and
no concern about risk.
corroboration of alleged behavior.
Step 2: Evaluate systems influences
Step 3: Involving Supervisor Share findings of assessment with
Perform a Substitution Test: Ask or consider whether 3 others with similar
department chair, division chief, or supervising physician.
skills or in a similar situation would behave or act similarly. Ask whether
Discuss a plan for feedback intervention (step 4) if deemed
systems factors were present that would affect all individuals similarly, such as necessary.
schedules leading inevitably to fatigue, unrealistic expectations regarding
Step 4: Feedback Intervention
memory, inability to effectively follow policies or procedures, an unsafe
Supervising MD and professionalism representative meet with
learning environment, or distractions or interruptions? If "Yes" system
FP to discuss/review
influence is likely and warrants evaluation. If "No", continue evaluation of the • specific disruptive behaviors
individual.
• FP's perspective on factors (including systems) that may be
Step 3: IF RECKLESS: The If RISKY: The caregiver is If UNINTENTIONAL:
contributing to the behavior
caregiver is accountable accountable and should Focus for improvement • resources for facilitating behavioral changes
and needs re-training.
receive coaching. If the should be on system
• plans for monitoring behavior
Discipline may be
Substitution Test is
issues. Coaching and
• unacceptability of retaliation
warranted. If the
positive (others would
reflection on human
• (if applicable) potential consequences for not adhering to
Substitution Test is
have performed
factors and personal
behavioral expectations
positive (others would
similarly) the system
improvement strategies A follow up email is sent to the FP summarizing the meeting.
have performed
supports risky action and may be appropriate,
Step 5: Monitoring and Support
similarly), then the
requires fixing. The
especially if the
• Inform those reporting concerns that an intervention has
system supports reckless caregiver is probably less Substitution Test is
occurred.
action and requires
accountable for the
positive (others would
• Inquire of them and others over time regarding subsequent
fixing. The caregiver is
action, and system
have performed
behaviors.
probably less
leaders share in the
similarly). System leaders • Have FP's supervisor address any systems issues discussed in
accountable for the
accountability.
are accountable and
Step 4.
action, and system
should apply error• Keep process discrete and respectful to FP.
leaders share in the
proofing improvements. Step 6: Intervention to Address Subsequent Lapses
accountability.
The institutional administration and legal counsel are involved.
Step 4: Promote learning and improvement
A plan of action is developed. Selected institutional
The caregiver should
The caregiver should
The caregiver should
administrators meet with FP to detail expected behavioral
participate in teaching
participate in teaching
participate in
changes and consequences, including termination.
others the lessons
others the lessons
investigating why the
learned.
learned.
error occurred and teach
others about the results
of the investigation.
Final Step: Evaluate the individual for a history of unsafe acts: Evaluate whether the individual has a history of unsafe or problematic acts. If
they do, this may influence decisions about the appropriate responsibilities for the individual i.e. they may be in the wrong job. Organizations
should have a reasonable and agreed upon statute of limitations for taking these actions into account.
Jo Shapiro MD and Allan Frankel MD, ©2015, Safe and Reliable Care Inc., www.safeandreliablecare.com
Algorithm available on our website
Review events for applicability
Event or Near Event
Identify Participants
Review Event or Near Event. Reassign participants if evidence
of:
Malicious Behavior – HR, Legal,
Impaired Judgment - CMO, CNO, HR, EAP
Unprofessional Behavior – Perform Professional Behavior
Evaluation
Step 1: Assign level of intent
Step 1: Assign level of intent:
Use best judgment to categorize each action as either Reckless, Risky or
Unintentional. The categorization determines the general level of culpability and
possible disciplinary actions, however these general categories require further
analysis as below prior to making a final decision.
RECKLESS ACTION
The caregiver knowingly
violated a rule and/or made
a dangerous or unsafe
choice. The decision
appears to be self serving
and to have been made
with little or no concern
about risk.
RISKY ACTION
The caregiver made a
potentially unsafe choice.
Their evaluation of relative
risk appears to be
erroneous.
UNINTENTIONAL
The caregiver made or
participated in an error
while working appropriately
and in the patients' best
interests
Step 2: Evaluate system influences
Perform a Substitution Test: Ask or consider whether
3 others with similar skills or in a similar situation
would behave or act similarly. Ask whether systems
factors were present that would affect all individuals
similarly, such as schedules leading inevitably to
fatigue, unrealistic expectations regarding memory,
inability to effectively follow policies or procedures,
an unsafe learning environment, or distractions or
interruptions? If "Yes" system influence is likely and
warrants evaluation. If "No", continue evaluation of
the individual.
Step 3: Assign Behaviors
Step 3: IF RECKLESS: The
caregiver is accountable
and needs re-training.
Discipline may be
warranted. If the
Substitution Test is
positive (others would
have performed
similarly), then the
system supports reckless
action and requires
fixing. The caregiver is
probably less
accountable for the
action, and system
leaders share in the
accountability.
IF RISKY: The caregiver is IF UNINTENTIONAL:
accountable and should Focus for improvement
receive coaching. If the should be on system
Substitution Test is
issues. Coaching and
positive (others would reflection on human
have performed
factors and personal
similarly) the system
improvement strategies
supports risky action and may be appropriate,
requires fixing. The
especially if the
caregiver is probably less Substitution Test is
accountable for the
positive (others would
action, and system
have performed
leaders share in the
similarly). System leaders
accountability.
are accountable and
should apply errorproofing improvements.
Step 4: Promote Learning & Improvement
The caregiver should
participate in
teaching others the
lessons learned.
The caregiver
The caregiver
should participate in should participate in
teaching others the investigating why
lessons learned.
the error occurred
and teach others
about the results of
the investigation.
Step 5: Evaluate history of unsafe acts
Step 5: Evaluate the individual for a history of unsafe acts
Evaluate whether the individual has a history of
unsafe or problematic acts. If they do, this may
influence decisions about the appropriate
responsibilities for the individual i.e. they may be in
the wrong job. Organizations should have a
reasonable and agreed upon statute of limitations for
taking these actions into account.
Case Two
• A 23 y/o woman is admitted for bowel surgery related to
•
•
•
•
•
IBD.
Admitted to the hospital bed by the door, her roommate
leaves, and she wants to move to the bed by the window.
Nurses say yes, but forget to change it in the computer.
They anticipate transfusing her during surgery, as she is
chronically anemic.
Someone comes at 5:00 AM the morning of surgery,
doesn’t want to disturb the other patient, doesn’t turn on
the light in the room and draws the type and cross on the
wrong patient.
She is transfused in the OR, wrong blood.
Reliable Processes of Care
GENERATIVE
• Safety is built at all levels of the
Organization wired for safety and
improvement
PROACTIVE
•
Playing offense - thinking ahead,
anticipating, solving problems
SYSTEMATIC
•
Systems in place to manage hazards
REACTIVE
Playing defense – reacting to events
UNMINDFUL
No awareness of safety culture
•
•
organization, continuous risk
assessment and learning
Active situational awareness
leads to early problem
detection and resolution
Healthcare systems are
complex, risk must be actively
managed
Adverse events stem from
human error – who did it?
If smart people try hard and
know what they’re doing, they
won’t make mistakes
Process Improvement
GENERATIVE
• Unit level learning systems,
Organization wired for safety and
improvement
PROACTIVE
Playing offense - thinking ahead,
anticipating, solving problems
•
•
SYSTEMATIC
Systems in place to manage hazards
REACTIVE
•
Playing defense – reacting to events
UNMINDFUL
No awareness of safety culture
•
continuous learning aligned
with organizational 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
The Ideal Unit
Debriefing – Linking teamwork and
Improvement
• What did we do well ?
• What did we learn so
we can do it better the
next time ?
• What got in the way
that needs to be fixed ?
Acute Medicines Unit, Ninewells Hospital, Dundee, Scotland
Arun Chaudhur, Medical Director
O2 Prescribing
DVT Prescribing
Compliance
Compliance with
Med. Reconciliation
Early Warning
Scores Bundle
SNAP-CAP
Blood Culture
ABX Prescribing Contamination
Compliance
Hand Hygiene
Pressure Ulcer
Prevention Bundle
ICU Percent of Patients Receiving
all Four Aspects Of Ventilator Bundle
Annotations
Marked beds at 30 degree angle
2: Fact Sheet for staff education
3: Poster with weekly data feedback
4: Vent bundle posted in all vent patient rooms
5: Began initial trials of Daily goal sheet and pre-extubation sheet
6: Initiated Powerpoint education for RT/RN
7: Initiated Clinical Pharm rounds
8: 1st test of multidisciplinary rounds
9: Expanded use of Pre-extubation sheet
1:
10: Staff education on Goal sheet; mini inservices on unit on SBT and Preextubation sheet
11: Incorporated Goal Sheet into Multidisciplinary Rounds
12: Impact Extravaganza (staff/MD education)
13: Expanded multidisciplinary rounds to include additional disciplines
14: Check compliance on night shift past 2 weeks
15: New sign at HOB,
16: One on one follow up by Nursing & RT managers on collaboratiion in
weaning process
The Defect or Learning Board
© Mercy Medical Center2010 ‘Turtle Board’
Summary
• The importance of having a framework or roadmap to guide
our safety and improvement work. People often don’t know
how to move from where they are to where they want to be.
• Look broadly, act narrowly
• Remember Edgar Schein: If you want to change behavior,
two conditions must be met – be respectful and give people
explicit advice.
• Culture is behavior over time – embed the behaviors that
create value in teamwork ( briefing / debriefing) - link the
defects and opportunities to the Learning System so the
process of learning and improvement is visible and builds
trust – then it becomes sustainable.