Creating a Just Culture of Safety

Colleen K. Snydeman RN, MSN, PhD(c), NE-BC

Director , Patient Care Services Office of Quality & Safety

Massachusetts General Hospital

Objectives

At the conclusion of the presentation the participant will be able to :

1. Describe the influences in advancing the safety culture in healthcare.

2. Describe characteristics of a just culture of safety.

3. Identify examples of a just culture of safety.

Overview

1. Quality & Safety a) Definitionsb) Adverse events

2. Professional Accountability

3. Just culturea) Influencesb) Characteristicsc) Examples

4. MGH a) Just culture in actionb) Innovation initiatives

Quality (IOM, 2001)

Quality- the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with professional knowledge.

Quality/Cost = Value

Measures – Structure, Process & Outcomes (Donabedian, 1988)

IOM 6 Aims of Quality Care (2001)

Quality

CareSafe

Effective

Efficient

Equitable

Timely

Patient Center

ed

Safety (IOM,2000)

• Safety – “Freedom from accidental or preventable

injury” – the first domain of quality

• Patient Safety – prevention of harm to patients – critical subset of quality patient care– Includes:

1. safe care 2. practice that is consistent with current

evidence/knowledge3. customization

• Measures - difficult to measure due to dependence on self-reporting.

Safety Culture Influences

Institute of Medicine

(2000)

# Errors in Healthcare

Joint Commission

Professional Accountability

Patient Safety Orgs: IHI,

NPSF, AHRQ, ECRI, Leapfrog, MITSS, ISMP,

Clarity

Safety Leaders: J. Reason, D.

Marx, L. Leape, etc…

Affordable Care Act (March,

2010)Public demands Aviation

Industry

Professional Accountability

• There is a social contract between society and a profession.

• Professions are the property of society and are responsible to society.

• Professions acquire recognition and relevance from society.

• It is society that determines what professional skills and knowledge are most needed and desired of a profession.

• Society grants professions authority over functions vital to itself and allows for autonomy in the conduct of their own affairs.

Nursing Accountability

• Nursing is a profession and therefore responsible to society.

• Nursing must be perceived as serving the interests of society.

• Professions are therefore expected to act responsibly and mindful of the public’s trust.

• Self-regulation assures high quality performance and is the hallmark of a mature profession.

Nursing is:

The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.

American Nurses Association

Errors and Adverse Events

• 98,000/year deaths estimated from medical errors (IOM, 2000)

• 210,000 deaths/year associated with preventable harm in hospitals (James, 2013: J Pt Safety).

• Error - (process) an act of commission ( doing something wrong) or omission (failing to do the right thing) leading to an undesirable outcome or significant potential for such an outcome (AHRQ, 2013). – Not all errors lead to adverse events.

• Adverse Event – (outcome) Unintended physical injury resulting from or contributing to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment, or hospitalization, or that results in death (IHI, 2013).– Not due to an underlying disease– Unpreventable– Preventable

• Negligent – care falling below a professional standard

– Side effects – may not be preventable or a medical error

Moving toward a safer culture

James Reason• Goal: to create a safer culture consisting of:

• Reporting• Learning• Flexibility• Just Culture

• Swiss Cheese Model

David Marx• Just culture algorithm – systems, behavioral choices, injury

severity & not blame-free but just• Core principles:

• To err is human –human errors, systems• To drift is human – well intentioned, cut corners, fast

paced, creates risk• Risk is everywhere• We are all accountable

Reason’s Swiss Cheese Model(emeraldinsight.com)

Just Culture – Human Error

The single greatest impediment to error prevention in the medical

industry is“that we punish people for making

mistakes.”

Dr. Lucian LeapeProfessor, Harvard Medical School of Public HealthTestimony before Congress on Health Care Quality

Improvement

Just Culture – Systems thinking

“People make errors, which lead to accidents.

Accidents lead to deaths. The problem is seldom the fault of the individual; it is the

fault of the system. Change the people without changing the

system and the problem will continue.”

Don NormanAuthor, the Design of Everyday Things

Just Culture – Reckless behavior

“…No person may operate an aircraft in a careless or reckless manner so as to endanger the life or property of another.”

Federal Aviation Regulations 91.13 Careless or reckless operation

Just Culture

1. Emphasizes quality and safety over blame and punishment.

2. Promotes a process where mistakes/errors do not result in automatic punishment but a process to uncover the root cause of the error.

3. Human errors that are not deliberate or malicious result in coaching, counseling, and education to decrease the likelihood of a repeated error.

4. Promotes increase error reporting that leads to system improvements to create safer environments for patients and staff.

Proactive Learning Culture

• Not seeing events as things to be fixed

• Seeing events as opportunities to improve our understanding of risk– System risk– Behavior risk

Blame vs. Accountability

1. Was the individual impaired?2. Did the individual consciously decide to engage in

an unsafe act?3. Did the caregiver make a mistake that other

similar individuals would make in similar circumstances?

4. Does the individual have a history of unsafe acts?

Fair evaluation & response (Frankel & Leonard

Allen Frankel’s Algorithm (2010)

Examples

• Unintentional Error– RN draws blood, gown slips over

tourniquet, finds arm swollen• At-Risk Behavior

– RN draws blood, patient complains of noise, takes blood out of room and labels at desk with wrong label, without checking 2 identifiers at bedside

• Reckless Behavior– During medication administration, bar

code scanning alerts nurse to wrong medication, nurse ignores alert and administers wrong medication without re-checking

Evidence- Based Patient Safety Improvements (2012, Gosbee, J.)

Weak

• Double checks

• Warnings• Training• New

procedures

Intermediate

• Redundancy• Increase

staffing• Checklists• Standardize

communication tools

• Education

Strong

• Simplify processes

• Standardize equipment and processes

• Force functions

• New devices with usability testing

• Physical plant changes

• Tangible involvement of leadership

Adverse Drug Events

Yellow- no errorPurple- Error, no harmBlue- Error, HarmOrange- Error, Death

$3.5 Billion in

costs (CDC, 2012)700,000

ED visits

120,000 admissions

MGH Culture of Safety

• Edward P. Lawrence Center for Quality and Safety

• Just Culture embraced• Robust safety reporting – over 19,000

reports filed in 2012• Safety Culture Perception Survey• Model to address professional

conduct issues• Root Cause Analysis• Communication and Apology• Executive Leadership Safety Rounds

Patient Care Services Quality and Safety

• Office of Quality and Safety• Safety reporting notification structure and follow

up– Root cause analysis

• Data driven– Nurse-sensitive indicators– Hospital-acquired conditions– Patient satisfaction– Nurse satisfaction

• Regulatory requirements• Practice alerts- red flag

– SBAR

MGH Sentinel Event

Event• 90 year old male surgical

patient with complete heart block sent to CICU

• Plan for pacemaker in a few days

• Transferred back to surgical unit on a cardiac monitor

• Found in cardiac arrest• Code Blue activated• Patient expired

Post-event• RNs discovered monitor alarms

were off– Filed safety report– Alerted leadership

• Monitors, pumps etc… investigated

• Root cause analysis initiated• Conversations with family begin• Reported to Department of

Public Health• Boston Globe report• MGH launches Interdisciplinary

Physiologic Monitoring Tiger Team– Physiologic Monitoring

Criteria– Physiologic Monitoring

Assessment– Physiologic Monitoring

Practice Standards• Clinical Technology Oversight

Committee

Professional Practice Model

Magnet Recognition: External Evaluation

Staff Perceptions of the Professional Practice Environment Survey: Internal Evaluation • Evaluate the effectiveness of the Professional

Practice Model based on eight professional practice environment (PPE) characteristics: - autonomy - control over practice - clinician-physician relationships - communication - teamwork - conflict management - internal work motivation - cultural sensitivity• Identify opportunities for improvement• Trend data over time• Provide report card for reflection and future

direction

• Care delivery should always be: patient and family-focused, evidence-based, accountable and autonomous, coordinated and continuous.

• It’s important to know the patient.

• Inpatient and family care is provided by a designated nurse and physician who are accountable and responsible for continuity of care.

• Continuity of the team is a basic precept.

• Every novice team member deserves mentoring from an experienced clinician.

• Every patient deserves the opportunity to participate in the planning of his/her care.

• Advancements in technology create opportunity for improved provider communication and efficiency.

Guiding Principles

Before During Post

Where Are There Opportunities to Reduce Costs Across These Processes of Care?

Admission Process: ED,

Direct Admits,

Transfers

Patient Stay; Direct Patient Care, Tests, Treatments, Procedures,

Clinical Support, Operational Support

Discharge Process

Post Discharge Care

Preadmission Care

Support Functions: Finance, Information Systems, HR

Goal: High-performing interdisciplinary teams that deliver safe, effective, timely, efficient and equitable care that is patient and family centered.

“Patient Journey” Framework

Before During After

Admission process: ED, direct admits,

transfers

Patient stay; direct patient care; tests; treatments; procedures;

clinical support; operational support

Discharge process

Post-discharge

care

Pre-admission

care

Inte

rve

nti

on

Inte

rve

nti

on

Inte

rve

nti

on

Inte

rve

nti

on

Innovations in Care DeliveryPatient Journey Framework

The Interventions

Relationship-based careIncreased accountability through the attending nurse roleUtilization of Evidence Based staffing and care delivery;

Utilization of the Hand-Over Rounding Checklist

• Enhance clinical data- collection before admission• Create Innovation Unit Welcome Packet• Engage Patients and families in redesign

• Revise Domains of Practice• Implement inter-disciplinary team rounds• Install unit census and in room whiteboards• Utilize communication devices• Utilize wireless laptop computers• Business cards• Hourly rounding• Quiet hours

• Implement Discharge Follow-up Call Program

Goal: High-performing, inter-disciplinary teams that deliver safe, effective, timely, efficient, and equitable care that is patient- and family-centered

Relationship Based Care

• Mary Koloroutis: a model for transforming practice

• 3 Crucial relationships– Care provider’s relationship with patients and

families– Care provider’s relationship with self– Care provider’s relationship with colleagues

• Incorporates a formula for leading change with:– Inspiration– Infrastructure– Education– Evidence– Bolstered by 5 Cs – clarity, competence,

confidence, collaboration, commitment

Relationship-Based Care

Patient safety is most effectively safe guarded when an advocate (most often the nurse) in the health care system knows the patient, family, and what matters most to them.

Attending Nurse Role

Responsible Nurse/Attending Nurse Expand staff nurse role. • Accountable for patient/family continuity and progression

along the developed overall plan of care from admission to discharge

• Ensures, along with the Attending MD, that patient care meets the unit’s clinical standards and vision of patient- and family-centered care

• Develops and revises the patient care goals with the clinical care team daily

• Coordinates meetings with clinicians for timely decision making and connects nurses to optimize handoffs across the continuum

• Is the primary bedside communicator with the patient and family, discussing plan of the day, care progress, potential discharge, and answers questions/teaches/coaches

Evaluation

• Dashboards - outcomes• Nurse Director walk rounds• Patient & Family Advisory Councils

(PFAC) • Patient interviews – follow up phone

calls, on-site interviews• Focus groups• Audits• Retreats• Weekly meetings with Attending RNs

Throughput and Efficiency LOS TSI bud/flex Wait time for bed to be ready Admits Medication turnaround time

Patient & Staff Satisfaction MD & RN Communication Responsiveness Cleanliness Noise reduction Staff perception of support Equitable care

Quality and Safety Unplanned Return to OR Readmission Rate Restraint Free Rate Falls/Pressure Ulcer Reduction Foley Catheter Days Hard-stop Time Out Performance

Innovation Unit Dashboard

Ellison 17 Ellison 18

QUALITY AND SAFETY

Patient-Centered Outcome MeasuresFalls per 1,000 Patient Days

Total Fall Rate 4.50 1.46 4.95 0.77 1.92 1.32 2.16 1.79 TBD 0.65 4.85 0.45Observed (N) 11 3 13 1 2 2 5 2 2 10 1

Falls with Injury per 1,000 Patient DaysFalls with Injury Rate 0.41 0.49 1.52 0.00 0.96 0.00 0.00 0.89 TBD 0.00 1.45 0.45Observed (N) 1 1 4 0 1 0 0 1 0 3 1

Hospital Acquired (HA) Pressure UlcersTotal HA Pressure Ulcer Prevalence Rate 0.0% 0.0% 6.9% 0.0% 0.0% 0.0% 0.0% 7.7% TBD NA 4.8% 4.2%Observed (N) 0 0 2 0 0 0 0 1 1 1

Hospital Acquired (HA) Pressure Ulcers Type II or GreaterTotal HA Pressure Ulcer Type II or Greater Prevalence Rate0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.7% TBD NA 4.8% 4.2%Observed (N) 0 0 0 0 0 0 0 1 1 1

RestraintsTotal Restraint Prevalence Rate 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.7% TBD NA 0.0% 0.0%Observed (N) 0 0 0 0 0 0 0 1 0 0

Peripheral Intravenous (PIV) Infiltrations - Pediatric/NeonatalTotal PIV Infiltration Prevalence NA NA NA 0.0% 0.0% 0.0% NA NA NA NA NA NAObserved (N) 0 0 0

Central Line-associated Bloodstream Infections per 1,000 Line Days (CLABSI)Total CLABSI Rate 6.54 NA 1.36 2.90 4.76 0.00 1.10 1.70 TBD NA 0.00 0.00Observed (N) 1 1 1 1 0 1 2 0 0

Note: metrics to be reported beginning FY 2012 Color Shading relative to Benchmark:Catheter-associated Urinary Tract Infections per 1,000 Device DaysVentilator-associated Pneumonia per 1,000 Vent Days

Massachusetts General Hospital - PCS Innovation Units Dashboard

Rate is better (lower) than benchmark.

Rate is worse (higher) than benchmark.

VascularBigelow 14

ObstetricsBlake 13

ICUBlake 12

NICUBlake 10

CICUEllison 9

MeasuresOrtho

White 6OncologyLunder 9

MedicineEllison 16

Pediatrics SurgeryWhite 7

PsychBlake 11

Innovation Unit DashboardJuly – September 2011

A Strong Safety Culture

1. Creates a learning culture • Foundation of patient safety

2. Creates an open, fair and just culture• Encourage reporting • Reinforce accountability for safety at all

levels3. Designs safe systems

• Systems have the greatest influence on patient safety

4. Manages behavioral choices• Critical thinking and decision making

emphasizes the continuous evaluation of risk

• Choices lead to desired safety outcomes

References

• Agency for Healthcare Research and Quality. Available at: http://webmm.ahrq.gov/glossary.aspx

• Committee on Health Care in America, Institute of Medicine (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington D.C.: National Academies Press.

• Committee on Quality of Health Care in America, Institute of Medicine (2000). To Err is Human: Building a Safer Health System. Washington D.C.: National Academies Press.

• Donabedian, A. (1988). The quality of care. How can it be assessed? JAMA 1988;260:1743-1748.

• Gosbee, J. (2012). Assessing the strength of healthcare facility improvement actions. Massachusetts Board of Registration in Medicine Quality and Patient Safety. Retrieved from: www.patientsafety.gov

• Institute for Healthcare Improvement, Available at: http://www.IHI.org• James, J. (2013). A new, evidence-based estimate of patient harms associated

with hospital care. Journal of Patient Safety 9(3) 122-128.• Koloroutis, M. (Ed.) (2004). Relationship-based Care: A model for

transformational practice. Minneapolis, MN: Creative Healthcare Management Inc.

• Leonard, M.W. & Frankel, A. (2010). The path to safe and reliable healthcare. Patient Education and Counseling 80: 288-292.

• Wachter, R.M. (2012). Understanding Patient Safety 2nd ed. New York, NY: McGraw Hill|LANGE.