The Quality Colloquium at Harvard University · The Quality Colloquium at Harvard University...

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The Quality Colloquium at The Quality Colloquium at Harvard UniversityHarvard University

PrePre--Conference Symposium Conference Symposium Patient Safety Officer Patient Safety Officer Certificate TrainingCertificate Training

Paul Barach, MD, MPHPaul Barach, MD, MPHJulie K. Johnson, MSPH, PhDJulie K. Johnson, MSPH, PhD

Davis Balestracci, MSDavis Balestracci, MSGwen Sherwood, PhD, RN, FAANGwen Sherwood, PhD, RN, FAAN

Monday, August 17, 2009Monday, August 17, 2009

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Our AimOur Aim

To start new and meaningful To start new and meaningful conversations about quality and safety conversations about quality and safety ––personally, in our organizations, and with personally, in our organizations, and with our leadersour leaders

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Learning ObjectivesLearning Objectives

By the end of this Patient Safety Officer By the end of this Patient Safety Officer Training, participants will be able toTraining, participants will be able to–– Reflect on current levels of quality and safety Reflect on current levels of quality and safety

in our organizationsin our organizations–– Change practitionersChange practitioners’’ everyday conversations everyday conversations

about safety and the culture of safetyabout safety and the culture of safety–– Discuss how to engage the leadership in Discuss how to engage the leadership in

safety while changing their attitude toward safety while changing their attitude toward safetysafety

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TodayToday’’s Agendas Agenda9:00 am9:00 am Welcome and IntroductionWelcome and Introduction9:15 am9:15 am Mental Models and Mental Models and

Framing of Safety and QualityFraming of Safety and Quality9:30 am9:30 am Small Group Discussion about Small Group Discussion about

the 5 Prethe 5 Pre--Conference QuestionsConference Questions10:00 am10:00 am The Patient Safety Core Curriculum and The Patient Safety Core Curriculum and

Introduction to Lewis Blackman StoryIntroduction to Lewis Blackman Story10:15 am10:15 am BreakBreak10:45 am10:45 am Small group discussion on LewisSmall group discussion on Lewis’’ Story Story

(a Pre(a Pre--Analysis)Analysis)11:15 am 11:15 am Debriefing fromDebriefing from small groupsmall group discussion: discussion:

How are we thinking about safety now?How are we thinking about safety now?11:4511:45 amam Lunch on Your OwnLunch on Your Own1:00 pm1:00 pm Data Data ““InsanityInsanity””

The silent improvement killer The silent improvement killer —— Part 1Part 1

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TodayToday’’s Agendas Agenda1:30 pm1:30 pm Group DiscussionGroup Discussion2:00 pm2:00 pm Engaging Leaders Engaging Leaders -- From Turf Wars to From Turf Wars to

Appreciative Appreciative Inquiry, Principles of Leadership Inquiry, Principles of Leadership for Quality and Safetyfor Quality and Safety

2:30 pm 2:30 pm Small Group ExerciseSmall Group Exercise2:45 pm2:45 pm Debriefing fromDebriefing from small group exercisesmall group exercise3:00 pm 3:00 pm BreakBreak3:30 pm3:30 pm Data Data ““InsanityInsanity””

The silent improvement killer The silent improvement killer –– Part 2 Part 2 4:00 pm4:00 pm Final discussion about the Lewis Blackman StoryFinal discussion about the Lewis Blackman Story4:15 pm4:15 pm Real World Dilemmas in Quality and SafetyReal World Dilemmas in Quality and Safety4:30 pm4:30 pm Concluding Comments, Questions and PostConcluding Comments, Questions and Post--

Colloquium Examination LogisticsColloquium Examination Logistics5:00 pm5:00 pm AdjournAdjourn

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IntroductionsIntroductions

Introduce yourself to your neighborsIntroduce yourself to your neighbors–– Who you are?Who you are?–– Where are you from?Where are you from?–– What is your dayWhat is your day--job?job?–– What did you give up to be here today?What did you give up to be here today?–– What are your expectations of this session?What are your expectations of this session?

We will cull expectations from the groupWe will cull expectations from the group

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What can we learn What can we learn from the from the futurefuture that will that will help us create a better help us create a better presentpresent for healthcare?for healthcare?

A History of the Future ApproachA History of the Future Approach

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History of the Future Approach•

Create a scenario fifteen years from now

•

Ask participants to “look back”

at significant events that brought medicine to this point in 2021

•

Anchor a time horizon in their lives–

Personal milestones

–

Family members

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Who Are We?Who Are We?

We are an overloaded systemWe are an overloaded systemWe cannot keep up with complex We cannot keep up with complex diagnostic and therapeutic technologiesdiagnostic and therapeutic technologiesWe have not changed workflows and roles We have not changed workflows and roles in the past couple of centuriesin the past couple of centuriesWe have placed most emphasis on We have placed most emphasis on sickness control, not on health promotionsickness control, not on health promotionWe face the same challenges everywhere, We face the same challenges everywhere, but are tackling them independentlybut are tackling them independently

1111

No system

beyond this point

10-2 10-3 10-4 10-5 10-6

Civil Aviation

Nuclear Industry

Railways (France)

Chartered FlightHimalayamountaineering

Road Safety

Chemical Industry (total)

Risk

Medical risk (total)

Blood transfusionAnesthesiology

ASA1Cardiac SurgeryPatient ASA 3-5

Fatal Iatrogenicadverse events

Microlight flights helicopters

Very unsafe Ultra safe

Amalberti, R, Auroy, Y, Berwick, D, Barach, P. Five System Barriers To Achieving Ultra-safe Health Care. Annals of Internal Medicine, 2005;142:756-764.

Adverse Adverse Event Rates in HealthcareEvent Rates in Healthcare

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U.S. Adults Receive Half of U.S. Adults Receive Half of Recommended CareRecommended Care

Source: McGlynn et al., “The Quality of Health Care Delivered to Adults in the United States,”The New England Journal of Medicine (June 26, 2003): 2635–2645.

55

76

65

54

39

23

45

0

20

40

60

80

Overall BreastCancer

Hypertension Asthma Pneumonia Hip Fracture Diabetesmellitus

Percent of recommended care received

1313

Variation in death rates and Variation in death rates and charges in US hospitalscharges in US hospitals

0

20

40

60

80

100120

140

160

180

200

0 5,000 10,000 15,000 20,000 25,000

Standardized $ charges per admission

Stan

dard

ized

Mor

talit

y R

ate

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CPR Quality During CPR Quality During Cardiac ArrestCardiac Arrest

Two companion studies of CPR qualityTwo companion studies of CPR quality–– Chest compressions were not delivered half of Chest compressions were not delivered half of

the time and compressions were too shallow the time and compressions were too shallow ((““outout--ofof--hospitalhospital””))

–– Quality of multiple CPR parameters was Quality of multiple CPR parameters was inconsistent and often did not meet published inconsistent and often did not meet published guidelines (guidelines (““inin--hospitalhospital””))

Abella BS, Alvarado JP, Hyklebust H, et. al. Quality of Cardiopulmonary Resuscitation During In-Hospital Cardiac Arrest. JAMA, January 19, 2005, 293(3):305-310

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Barriers to Significant Quality Improvement

•

Biases/mental model clinicians bring to the table

•

Variation in Clinical Practice•

High Powered Teams

•

Learning From Our Mistakes•

Service and Technology

•

Linking Incentives with Report Cards

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The Cloak•

Painfully incorporated desire not to appear incompetent

•

Behaviors conferring a sense of protection are greater:

–

The more terrorizing and fatiguing the training or the greater the possibility of catastrophic error on a moment-to-

moment basis

•

“The problem is we get so used to cloaking our irrational decisions in the guise of wisdom and experience, we confuse good luck with good judgment, and that’s where diagnostic errors often begin.”

Wachter,RM and Shojania,KG: Internal Bleeding:

The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. 2004.

"It is incident to physicians, I am afraid, beyond all other men, to mistake subsequence for consequence.“

Samuel Johnson, 1756

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Meaningful Patient andFamily Involvement

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Transformed Hospitals Have Clear Definitions

What do you mean by great performance?Have you established a baseline?Are you improving?If not, why not?How can you improve even faster?Settling upon a consistent and intelligent method of assessing your output results

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It is Impossible to be Ahead of the Pack if you Think about the Future in Today’s Terms

““Well, Well, lemme lemme think... Youthink... You’’ve stumped me, son. Mostve stumped me, son. Mostfolks only folks only wanna wanna know how to go the other way.know how to go the other way.””

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How Do Mental Models How Do Mental Models Affect Our Work?Affect Our Work?

Exploring Mental Models through Exploring Mental Models through Framing and ReframingFraming and Reframing

Julie K. Johnson, MPSH, PhDJulie K. Johnson, MPSH, PhD

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Learning ObjectivesLearning Objectives

By the end of this session, learners will be By the end of this session, learners will be able to:able to:–– Describe the concept of mental modelsDescribe the concept of mental models–– Discuss how individuals use mental models to Discuss how individuals use mental models to

frame issues and how that framing both frame issues and how that framing both contributes to and limits our understanding of contributes to and limits our understanding of a situationa situation

–– Consider the implication of frames for patient Consider the implication of frames for patient care and medical educationcare and medical education

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Before We Begin . . .Before We Begin . . .

Choose an opponent for thumb wrestlingChoose an opponent for thumb wrestlingThe goal is for you to win this competition The goal is for you to win this competition as many times as you can in 15 secondsas many times as you can in 15 secondsWinning means pinning your opponentWinning means pinning your opponent’’s s thumbthumb

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What happened?What happened?

How many points did you get?How many points did you get?What were the assumptions you brought What were the assumptions you brought into this game?into this game?How did your assumptions affect your How did your assumptions affect your behavior?behavior?

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Mental ModelsMental Models

The images, assumptions, and stories we The images, assumptions, and stories we carry in our minds of ourselves, other carry in our minds of ourselves, other people, institutions, and every aspect of people, institutions, and every aspect of the worldthe worldThey determine what we see, and most They determine what we see, and most importantly, importantly, how we acthow we act

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What Might this Mean for What Might this Mean for Our Work?Our Work?

Examples from clinical care, educationExamples from clinical care, education–– Drug seeking behaviorDrug seeking behavior–– Patient nonPatient non--compliance compliance –– ““DifficultDifficult”” patient/familypatient/family–– Born surgeonBorn surgeon–– Born internistBorn internist

–– Other ideas??Other ideas??

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Mental ModelsMental Models

None are perfectly accurate None are perfectly accurate Differences in mental models explain how Differences in mental models explain how two people can understand the same two people can understand the same event differently event differently Are generally invisible to us Are generally invisible to us –– until we look until we look for themfor them

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The Ladder The Ladder of Inferenceof Inference

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What Happens on the LadderWhat Happens on the LadderWe pay attention to some data and ignore other dataWe pay attention to some data and ignore other dataWe impose our own interpretations on these data and We impose our own interpretations on these data and draw conclusions from themdraw conclusions from themWe lose sight of how we do this because we do not think We lose sight of how we do this because we do not think about our own process of thinkingabout our own process of thinkingOur conclusions feel obvious to us Our conclusions feel obvious to us Other peopleOther people’’s conclusions feel obvious to thems conclusions feel obvious to themWhen people reach different conclusions and disagree, When people reach different conclusions and disagree, they often hurl conclusions at each other from the tops they often hurl conclusions at each other from the tops of their respective laddersof their respective laddersThis makes it hard to resolve differences and to learn This makes it hard to resolve differences and to learn from one anotherfrom one another

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How Can We Surface Our How Can We Surface Our Mental Models?Mental Models?

Working with mental models requires surfacing, testing, Working with mental models requires surfacing, testing, and improving our internal pictures of how the world and improving our internal pictures of how the world worksworks3 skills can be helpful3 skills can be helpful–– Reflection Reflection –– understanding your own mental models and the understanding your own mental models and the

implicationsimplications–– Inquiry Inquiry –– learning the questions you can ask to help you test learning the questions you can ask to help you test

othersothers’’ mental modelmental model–– Advocacy Advocacy –– making your thinking and reasoning more visible to making your thinking and reasoning more visible to

others others

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Advocacy and Inquiry are Key to Advocacy and Inquiry are Key to CommunicationCommunication

High

Low High

Adv

ocac

y

Inquiry

OneOne--way Communicationway Communication(Explaining, Imposing)(Explaining, Imposing)

TwoTwo--Way Way Communication Communication

(Mutual Learning)(Mutual Learning)

No Communication No Communication (Observing, Withdrawing)(Observing, Withdrawing)

OneOne--way Communication way Communication (Interviewing, Interrogating)(Interviewing, Interrogating)

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Relationship of Relationship of Mental Models to FramingMental Models to Framing

Mental models frame what we see and Mental models frame what we see and how we respondhow we respondOur mental models are internalOur mental models are internalFraming is the interaction of our mental Framing is the interaction of our mental models and the situation at handmodels and the situation at hand

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Small Group ExerciseSmall Group ExerciseDivide into groups of 4 Divide into groups of 4 –– one person from each group will be one person from each group will be selected to be the observer and note taker for the groupselected to be the observer and note taker for the groupEach group will get a set of 3 postcards Each group will get a set of 3 postcards –– Each postcard is covered with a different frame that reveals onlEach postcard is covered with a different frame that reveals only y

part of the postcardpart of the postcardDonDon’’t uncover the cards or reveal the frame to the groupt uncover the cards or reveal the frame to the groupDiscuss these questions:Discuss these questions:–– What do you see within the frame?What do you see within the frame?–– What is the story you can tell?What is the story you can tell?

Now, look at the cards and discuss:Now, look at the cards and discuss:–– How did your frame limit what you know?How did your frame limit what you know?–– How does someone elseHow does someone else’’s frame contribute to, or disrupt, your s frame contribute to, or disrupt, your

understanding of the issue?understanding of the issue?

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DebriefingDebriefing

What was your groupWhat was your group’’s experience with the s experience with the exercise?exercise?–– What surprised you?What surprised you?–– What did you learn?What did you learn?

How do your mental models affect the frames you How do your mental models affect the frames you use?use?How might your professional framework limit what How might your professional framework limit what you know?you know?

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The PreThe Pre--Conference Conference QuestionsQuestions

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Small Group DiscussionSmall Group Discussion

The 5 PreThe 5 Pre--Conference QuestionsConference Questions––

What are the most important patient safety issues What are the most important patient safety issues facing yourfacing your��institution?institution?��

––

How does the culture of your institution affect your How does the culture of your institution affect your ability toability to��implement change?implement change?��

––

What are 3 patient safety initiatives that you've read What are 3 patient safety initiatives that you've read about, heardabout, heard��about, or seen that you believe will about, or seen that you believe will make an impact in your institution?make an impact in your institution?��

––

What are 3 patient safety initiatives you would like to What are 3 patient safety initiatives you would like to implement inimplement in��the next year?the next year?��

––

Describe the composition of the team that will be Describe the composition of the team that will be necessary tonecessary to��accomplish each of those initiatives in accomplish each of those initiatives in your institutionyour institution

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Debriefing Debriefing

4141

The Patient Core Curriculum The Patient Core Curriculum and Introduction to the and Introduction to the LewisLewis Blackman StoryBlackman Story

Paul Barach, MD, MPHPaul Barach, MD, MPH

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Institute of Medicine Institute of Medicine November 1999November 1999

Human Error and performance Human Error and performance limitationslimitationsEstablish near miss voluntary reporting Establish near miss voluntary reporting systems and protect from discoverysystems and protect from discoveryCreating Safety systems in health care Creating Safety systems in health care organizationsorganizationsErrors lead as major cause of death, Errors lead as major cause of death, injuryinjuryCreate a safety cultureCreate a safety cultureCreate and inculcate a safety Create and inculcate a safety curriculumcurriculumTeam training and simulationTeam training and simulationEstablish national safety authorityEstablish national safety authorityAnesthesiologyAnesthesiology——only clinical domain to only clinical domain to make patient safety central to its make patient safety central to its missionmissionAltman, et al. 2004Altman, et al. 2004------five years laterfive years later----IOM most important report in 2 IOM most important report in 2 decadesdecadesWachterWachter, 2006, 2006------C+ grade on report C+ grade on report cardcard

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Patient Safety Domains Knowledge, Skills, Attitudes

1. Theoretical Foundations Microsystems, historical trends, chaos, complexity, competency and learning

2. Behavioral Aspects of Medical Professionalism

Ethics, patient quality of life, resolution of conflict

3. Interpersonal Issues Communication, stress and coping4. Human Factors and

ErgonomicsDesign history, error taxonomies, safety tools, decision support systems, fatigue factors, user centered design

5. Systems Analysis Usability criteria , organizations and learning disasters, place for human error

6. QI Learning Pareto/flow charts, and other QI tools, best practices, act cycles7. Injury Epidemiology Workplace hazards, worker safety, phases of injury, medico-legal

aspects8. Medication Safety Adverse and near-miss reporting, ISMP tools and website,

look/sound-alikes9. Crisis Management Tools Team work, shared decision making, situational awareness10. Simulations Micro-, macro-, debriefing, immersion levels, scripting, role playing

THE PATIENT SAFETY CORE CURRICULUM

Gilula, M. and Barach P. Creating a Patient Safety Curriculum: Purposive Sampling of Patient Safety Experts. 79th Clinical and Scientific IARS Congress. S-143. Honolulu, Hawaii. March 12, 2005.; Gilula, Barach, 2009.

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Case I: The Role of Human Case I: The Role of Human Factors in an Unexpected MIFactors in an Unexpected MI

A 45A 45--yearyear--old women for parathyroidectomy old women for parathyroidectomy with no past medical history, under general with no past medical history, under general anesthesia anesthesia After uneventful induction of anesthesia, the After uneventful induction of anesthesia, the patient became patient became hypotensivehypotensiveResident gave 1 cc of Resident gave 1 cc of phenylephrinephenylephrineHR went to 150HR went to 150’’s and VTs and VTCPR requiredCPR requiredEpinephrine givenEpinephrine givenST changes; TEEST changes; TEE--severe LV hypokenesissevere LV hypokenesis

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Similar Vials: Atropine & Similar Vials: Atropine & Phenylephrine Phenylephrine

4646

Elements of Organizational Elements of Organizational FailureFailure

Incompatible GoalsIncompatible GoalsOrganizational Structural DeficiencyOrganizational Structural DeficiencyInadequate CommunicationsInadequate CommunicationsPoor Planning and Scheduling Poor Planning and Scheduling Inadequate Control and MonitoringInadequate Control and MonitoringDesign FailuresDesign FailuresDeficient Training Deficient Training Inadequate Maintenance ManagementInadequate Maintenance Management

JT Reason 1993

4848

Elements of Organizational Elements of Organizational AccidentsAccidents

James T. Reason. The Human Factor in Medical Accidents. Medical Accidents.

Vincent C, Ennis M, and Audley R. Oxford University Press 1993

Task and Environmental

Conditions

Individual Unsafe Acts

Organizational Processes

Failed Defenses

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Human Error RatesHuman Error Rates

Error of commission (misreading a label)Error of commission (misreading a label) 3/10003/1000

Error of omission (item embedded in Error of omission (item embedded in procedure)procedure)

3/10003/1000

Error of omission (without reminders)Error of omission (without reminders) 1/1001/100

Error in simple arithmetic (with self check)Error in simple arithmetic (with self check) 3/1003/100

Personnel on different shift fail to check Personnel on different shift fail to check conditions unless directed by a checklistconditions unless directed by a checklist

1/101/10

Errors under very high stress when Errors under very high stress when dangerous activities are occurring rapidlydangerous activities are occurring rapidly

25/10025/100

Adapted from: Park, K. Human Error. In Salvendy, G, ed. “Handbook of Human Factors and Ergonomics”, New York. John Wiley & Son, Inc. 1997: 163.

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Human vs. Design FlawsHuman vs. Design Flaws

Human errors (7%) can be reduced by Human errors (7%) can be reduced by rigorous practices, standardization, rigorous practices, standardization, simulation training, building a safety simulation training, building a safety culture, etc.culture, etc.

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Organizational Organizational Design Design 93%93%

The 93% vs. 7% RuleThe 93% vs. 7% Rule

Negligent Conduct

Knowing ViolationsReckless

Conduct

Human Error

(People)

(People)

(People)

(People)

5353

Performance Shaping Factors Performance Shaping Factors Affecting Human Vigilance Affecting Human Vigilance

FatigueFatigueEnvironmental Conditions/BuiltEnvironmental Conditions/BuiltEnvironmentEnvironmentTask DesignTask DesignPsychological ConditionsPsychological ConditionsCompeting DemandsCompeting DemandsHand offs/Sign outsHand offs/Sign outs

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Tools and Methods of AnalysisTools and Methods of Analysis

Numerous methods and tools are available Numerous methods and tools are available for analyzing adverse events, near misses, for analyzing adverse events, near misses, and the context of careand the context of careRegardless of the tool used, the goal is to Regardless of the tool used, the goal is to determine at the organizational level how determine at the organizational level how to prevent errors from occurring in the to prevent errors from occurring in the futurefuture

5555

Types of ToolsTypes of ToolsLatent Errors

Latent Errors

Active Errors

Active ErrorsAdverse Events

Adverse EventsDirect Direct ObservationObservation Clinical Clinical

SurveillanceSurveillance

Incident Incident ReportingReporting

Autopsies and Autopsies and M&M ConferencesM&M Conferences

Malpractice Malpractice Claims Files Claims Files AnalysisAnalysis

Administrative Administrative Data AnalysisData Analysis

Information Information TechnologyTechnology

Chart ReviewChart Review

Peterson et al.

5656

Tools and Methods of AnalysisTools and Methods of Analysis

Retroactive AnalysisRetroactive Analysis–– Root Cause Analysis (RCA) is a thorough Root Cause Analysis (RCA) is a thorough

retrospective investigation to identify factors retrospective investigation to identify factors that contributed to the occurrence of an errorthat contributed to the occurrence of an error

Proactive AnalysisProactive Analysis–– Failure mode and effects analysis (FMEA) Failure mode and effects analysis (FMEA)

identifies potential contributing factors to identifies potential contributing factors to potential adverse eventspotential adverse events

5757

Consider the MicrosystemConsider the Microsystem

Small group of clinicians and staff working Small group of clinicians and staff working together with a shared clinical purpose to together with a shared clinical purpose to provide care for a defined set of patientsprovide care for a defined set of patientsThe clinical purpose defines the essential parts The clinical purpose defines the essential parts of the microsystemof the microsystem–– Clinicians and support staffClinicians and support staff–– Information and technologyInformation and technology–– Care processesCare processes

Source of excellence in health care organizationsSource of excellence in health care organizations

Mohr(Johnson) J, Batalden P, Barach P. Qual Saf Health Care 2004;13 Suppl 2:34-8.

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What Are the Essential Elements What Are the Essential Elements of a Microsystem?of a Microsystem?

Core team of health professionalsCore team of health professionalsDefined population of patients they care Defined population of patients they care forforInformation & information technologyInformation & information technologySupport staff, equipment, environmentSupport staff, equipment, environmentProcesses, activities specific to Processes, activities specific to accomplishing the aimaccomplishing the aim

5959

A Microsystem Framework for A Microsystem Framework for Analyzing EventsAnalyzing Events

One method that we have found to be One method that we have found to be useful for systematically looking at patient useful for systematically looking at patient safety events builds on Haddonsafety events builds on Haddon’’s s overarching framework on injury overarching framework on injury epidemiologyepidemiology

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The Haddon MatrixThe Haddon Matrix

HumanHuman VehicleVehicle EnvironmentEnvironment

PrePre--eventevent

EventEvent

PostPost--eventevent

Source: Haddon, W. A Logical Framework for Categorizing Highway Safety Phenomena and Activity. J. Trauma 1972; 12:197.

Alcohol intoxication

Braking capacity

Visibility of hazards

Resistance to injury insults

Sharp, pointed edges and surfaces

Flammable materials

Hemorrhage Rapidity of energy dissipation

Emergency medical response

6161

Haddon Matrix adapted to Patient Haddon Matrix adapted to Patient Safety in the MicrosystemSafety in the Microsystem

Patient/Patient/ FamilyFamily

Health Care Health Care ProfessionalProfessional

Systems/Systems/EnvironmentEnvironment

PrePre--eventevent

EventEvent

PostPost--eventevent

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Patient/Patient/ FamilyFamily

Health Care Health Care ProfessionalProfessional

Systems/Systems/EnvironmentEnvironment

PrePre--eventevent

Orientation to the Orientation to the processprocess

ProbablisticProbablistic Risk Risk Assessment (PRA)Assessment (PRA)Scenario BuildingScenario BuildingHazard AnalysisHazard AnalysisChecklistsChecklists

Failure Modes Failure Modes Effects Analysis Effects Analysis (FMEA)(FMEA)Human Factors Human Factors EngineeringEngineering

EventEventInterviewInterview Crew Resource Crew Resource

Management (CRM)Management (CRM)ChecklistsChecklists

Root Cause Root Cause Analysis (RCA)Analysis (RCA)

PostPost-- eventevent

Interview, Interview, Focus Group Focus Group InterviewsInterviews

Microsystem Analysis Microsystem Analysis Morbidity and Mortality Morbidity and Mortality Conference (M&M)Conference (M&M)

Root Cause Root Cause Analysis (RCA)Analysis (RCA)

6363

ManagementDecisions

& Organisational

process

Accidents

DefensesPerson/teamWorkplaceOrganization

Latent conditions pathway

Organizational Accident Causation Organizational Accident Causation ModelModel

6464

ManagementDecisions

& Organisational

process

Accidents



Error &Violation

Producingconditions

Organization Accident Causation Organization Accident Causation ModelModel

6565

Workplace Conditions Workplace Conditions Promoting Unsafe ActsPromoting Unsafe Acts

High WorkloadHigh WorkloadInadequate Knowledge, Ability or ExperienceInadequate Knowledge, Ability or ExperienceInadequate Supervision or InstructionInadequate Supervision or InstructionStressful EnvironmentStressful EnvironmentMental StateMental StateChangeChange

6666

WorkplaceWorkplace Error Producing ConditionsError Producing Conditions

Unfamiliarity(x17)Unfamiliarity(x17)Time Shortage(x11)Time Shortage(x11)Poor HumanPoor Human--System System Interface (x8)Interface (x8)Information Overload (x6)Information Overload (x6)Negative Transfer(x5)Negative Transfer(x5)Misperception of Risk (x4)Misperception of Risk (x4)

Inexperience Not Lack of Inexperience Not Lack of Training (x3)Training (x3)Inadequate Checking (x3)Inadequate Checking (x3)Poor Instructions(x3)Poor Instructions(x3)Educational Mismatch (x2)Educational Mismatch (x2)Disturbed Sleep (x1.6)Disturbed Sleep (x1.6)

6767

Work EnvironmentWork Environment Violation Producing ConditionsViolation Producing Conditions

Lack of Safety CultureLack of Safety CultureManagement/Staff Management/Staff ConflictConflictPoor MoralePoor MoralePoor SupervisionPoor SupervisionCondones ViolationsCondones ViolationsMisperception of HazardMisperception of HazardLack of Management Lack of Management ConcernConcern

Little Pride in WorkLittle Pride in WorkMacho CultureMacho Culture““Bad outcomes Bad outcomes WonWon’’t Happent Happen””Low SelfLow Self--EsteemEsteemLicense to Bend License to Bend RulesRulesAmbiguous or Ambiguous or Meaningless RulesMeaningless Rules

6868


ManagementDecisions

& Organisational

process

Accidents



Error &Violation

Producingconditions

Errors &violations

6969

Person /TeamPerson /Team Individual Unsafe ActsIndividual Unsafe Acts

ErrorsErrors–– AttentionalAttentional Slips and memory lapses (Intrusions, omissions)Slips and memory lapses (Intrusions, omissions)–– MistakesMistakes

Rule Rule ––basedbasedKnowledgeKnowledge--basedbased

Violations( deliberate deviation from regulation)Violations( deliberate deviation from regulation)–– Routine ( shortcuts)Routine ( shortcuts)–– Optimizing Violations Optimizing Violations –– ExceptionalExceptional–– DeliberateDeliberate

7070

ManagementDecisions

& Organisational

process

Accidents



Error &Violation

Producingconditions

Errors &violations


7171

Team videoTeam video

7272

What are important What are important team competency team competency

requirements?requirements?

7373

Medical Team TrainingMedical Team Training Team CompetenciesTeam Competencies

Knowledge Competencies Knowledge Competencies –– The principles and concepts that underlie a teamThe principles and concepts that underlie a team’’s s

effective performanceeffective performance

Skill CompetenciesSkill Competencies–– The learned capacity (psychomotor and cognitive) to The learned capacity (psychomotor and cognitive) to

interact with other team membersinteract with other team members

Attitude CompetenciesAttitude Competencies–– Internal states that influence team members to act in Internal states that influence team members to act in

a particular waya particular way

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The The TeamSTEPPSTeamSTEPPS FrameworkFramework

KnowledgeKnowledge–– Shared Mental ModelShared Mental Model

AttitudesAttitudes–– Mutual TrustMutual Trust–– Team OrientationTeam Orientation

PerformancePerformance–– AdaptabilityAdaptability–– AccuracyAccuracy–– ProductivityProductivity–– EfficiencyEfficiency–– SafetySafety

Baker D, Salas E, Battles J, King H, Barach P, 2005, 2007

7575

MillerMiller’’s Pyramids Pyramid

Does

Shows How

Knows How

Knows

7777

See Handout with LewisSee Handout with Lewis’’ StoryStory

QuickTime™ and a decompressor

are needed to see this picture.

7878

BreakBreak

7979

Small Group DiscussionSmall Group Discussion

A Pre-Analysis of the Lewis Blackman Story–

In small groups discuss the case

–

Discuss how you would approach the analysis (e.g., the types of tools you are familiar with in analyzing adverse events)

–

Prepare to report back

8080


How are we thinking about safety now?

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Disclosure of Adverse Disclosure of Adverse Events: What Do You Do Events: What Do You Do

When Bad Things Happen?When Bad Things Happen?

Paul Paul BarachBarach, MD, MPH, MD, MPH

8282

Adverse Event Management PlanAdverse Event Management Plan

ActivationEvent Crisis Mgt Team

Containment Plan• Render care to pt• Staff Support• Contain risk of

harm/recurrence• Notification• Securing scene

Investigation & RCA

Communication Plan•Patient•External Audience•Internal Audience•Notify Billing to hold bills

Corrective Action & Prevention

RecoveryMonitoringRestitution

Disclosure/OrganizationalRecovery

Immediate Response Follow‐up Response

8383

Disclosure ProcessDisclosure Process

Identify incidence of patient harm or Identify incidence of patient harm or a potentially compensable event a potentially compensable event Initial disclosure and apologyInitial disclosure and apologyCase ReviewCase ReviewFollowFollow--up disclosureup disclosureDiscuss restitutionDiscuss restitution

8484

What do patients want?

1. To know what happened

2. To receive an apology

3. To know what is being done to prevent it from happening again

8585

Disclosing Adverse EventsDisclosing Adverse Events

Disclosure is required whenDisclosure is required when–– Has a perceptible effect on the patient not Has a perceptible effect on the patient not

discussed in advanced with patientdiscussed in advanced with patient–– Necessitates a change in patient careNecessitates a change in patient care–– Poses risk to patientPoses risk to patient’’s future healths future health–– Involves nonInvolves non--consented treatment or procedureconsented treatment or procedureReduces chances of being suedReduces chances of being suedTransparency in process helps the team address guiltTransparency in process helps the team address guiltNew laws in 22 states requiring disclosureNew laws in 22 states requiring disclosure

Cantor M, Barach P, et al. Jt Comm Qual Patient Saf 2005;31:5-12. Barach, P, Cantor M, 2007

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Disclosure Conversation PlanningDisclosure Conversation Planning

Review disclosure principlesReview disclosure principlesDecide who, when, whereDecide who, when, where–– Decide who will be point contact person for patient/familyDecide who will be point contact person for patient/family

What to say and how to say itWhat to say and how to say itAnticipate questionsAnticipate questionsPlanning next stepsPlanning next stepsDebriefing/emotional support for the individual(s) doing Debriefing/emotional support for the individual(s) doing the disclosingthe disclosing

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Disclosure ConversationDisclosure Conversation

Learn to effectively communicate and Learn to effectively communicate and explain the factsexplain the facts

Expression of concern/responsibilityExpression of concern/responsibility

Discuss present/future needsDiscuss present/future needs

Describe actions taken and explain specific Describe actions taken and explain specific process for finding the answersprocess for finding the answers

8888

Risk Management SupportRisk Management Support

Manage contact with patient and/or family Manage contact with patient and/or family

Coordinate regulatory/accreditation Coordinate regulatory/accreditation requirementsrequirements

Managing reputation risksManaging reputation risks–– Media/Crisis communication Media/Crisis communication –– Internal Internal and and externalexternal

Managing complaints and claims Managing complaints and claims –– Early Early non non litiginous settlementlitiginous settlement

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ResourcesResourcesCantor M, Cantor M, Barach Barach P, P, Derse Derse A, et al. JCAHO 2005;31:5A, et al. JCAHO 2005;31:5--13.13.Kramam Kramam SS, SS, Hamm Hamm G. G. Ann Ann Intern Intern Med Med 1999;131:9631999;131:963--967.967.Clinton Clinton H, H, Obama Obama B. NEJM 2006.B. NEJM 2006.Gallagher Gallagher T, et al. NEJM 2007.T, et al. NEJM 2007.http://http://www.sorryworks.netwww.sorryworks.netRisk Management Pearls on Disclosure of Adverse Risk Management Pearls on Disclosure of Adverse Events. American Society for Healthcare Risk Events. American Society for Healthcare Risk Management at Management at http://www.ashrm.orghttp://www.ashrm.org

http://www.sorryworks.net/

http://www.sorryworks.net/

http://www.ashrm.org/

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LunchLunchReconvene at 1 pmReconvene at 1 pm

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Data Data ““InsanityInsanity”” -- The Silent The Silent Improvement KillerImprovement Killer

Part IPart I

Davis Davis BalestracciBalestracci, MS, MS

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Group DiscussionGroup Discussion1.1. How does your organization react to, report, and How does your organization react to, report, and

analyze analyze ““incidents?incidents?””2.2. Have you ever considered Have you ever considered ““safetysafety”” in a processin a process--

oriented context?oriented context?3.3. Have you, with the best of intentions, been using Have you, with the best of intentions, been using

““special causespecial cause”” strategies? Could you strategies? Could you ““plot the dotsplot the dots”” to see whether you have been successful? to see whether you have been successful?

4.4. Does this material suggest situations in your Does this material suggest situations in your organizations that might respond better to organizations that might respond better to ““common common causecause”” strategies?strategies?

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Engaging Leaders Engaging Leaders -- From Turf Wars to From Turf Wars to Appreciative Appreciative Inquiry, Inquiry,

Principles of Leadership for Principles of Leadership for Quality and SafetyQuality and Safety

Gwen Sherwood, PhD, RN, FAAN Gwen Sherwood, PhD, RN, FAAN

95

Engaging Leaders: From Turf Wars to Appreciative Inquiry

Principles of Leadership for Quality and Safety

Harvard Safety Certificate Program 2009

Gwen Sherwood, PhD, RN, FAAN

96

Gwen Sherwood, PhD, RN, FAAN

Professor and Associate Dean for Academic Affairs

The University of North Carolina at Chapel Hill

School of Nursing

[email protected]

97

Framing new roles and skills

Appreciative Inquiry to build culture

Reflection for transformation

98

Changing conversations, Changing minds, Changing culture

Creating transformation

99

Quality and safety have moral, ethical, and economic considerations that require examination of contextual factors: work force preparation,

culture, and transformative leaders.

100

Considering QualityHealth care is value based; quality is an essential value.

When quality erodes, joy in work diminishes, contributes to disengagement and departure.

Health professionals are willing to help improve systems when they have what is needed to make quality improvement a part of daily work

101

Working in systems with poor quality lowers satisfaction: American Association of Critical-

Care Nurses (AACN), CQ HealthBeat

Retention

Quality impacts the work force

102

Framing new roles and skills

Complexity of care means no one discipline can provide care, need to clarify and understand roles

Patients and families partnering in care

New RN graduates need different skills for emerging system redesigns

Longer and costly orientations

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Nurses’ Role in Quality and SafetyQuality and Safety Education for Nurses (QSEN)

www.qsen.org (funded by RWJ)

National expert panel defined quality and safety competencies and knowledge, skills and attitudes required for nurses in health care organizations

Based on IOM competencies for all health professions education

Adopted by nursing education credentialing agencies

http://www.qsen.org/

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Cronenwett et al, Nursing Outlook, May-June 2007 (special topic issue)

Patient centered careTeamwork and collaborationEvidence base practiceQualitySafetyInformatics

Updates due in Nov. 2009

New views of familiar

concepts require curricula

transformation

106

Example: 2 definitionsQuality improvement: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems

Safety: Minimize risk of harm to patients and providers through both system effectiveness and individual performance

107

Selected: Quality Improvement KSAsKnowledge Skills Attitudes

Describe strategies for learning about the outcomes of care in the setting in which one is engaged in practice-----------------------------*Describe strategies for improving outcomes of care in the setting in which one is engaged in practice

**Explain common causes of variation in outcomes of care in the practice specialty

Seek information about outcomes of care for populations served in care setting------------------------------*Use a variety of sources of information to review outcomes of care and identify potential areas for improvement

**Assert leadership in shaping the dialogue and providing leadership for the introduction of best practices

Appreciate how unwanted variation affects care-----------------------------*Appreciate the importance of data that allows one to estimate the quality of local care

**Appreciate that all improvement is change but not all change is improvement

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Selected: Safety KSAsKnowledge Skills Attitudes

Discuss effective strategies to reduce reliance on memory---------------------------*Evaluate effective strategies to reduce reliance on memory

**Describe best practices that promote patient and provider safety in the practice specialty

Participate appropriately in analyzing errors and designing system improvements-----------------------------*Design and implement microsystem

changes in response to identified hazards and errors

**Report errors and support members of the health care team to be forthcoming about errors and near misses

Value own role in preventing errors------------------------------

*Value own role in reporting and preventing errors

**Appreciate the importance of being a safety mentor and role model

**Value the use of organizational error reporting systems

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Shaping organizational contextWork takes place in a given context which influences our responses.Culture is the behavior and beliefs/values of the groupCulture is built from the connection of consequences with behavior, what is valued and rewarded.Leaders create and manage the culture, and deconstruct when needed to change outcomes.

110

Positive approach to building culture, Appreciative Inquiry (AI)

Discovers and builds on what works in the organization, a system perspective consistent with quality and safety

Positive perspective change management to manage context to influence work that happens

Flexible process to engage people in building an organization and world they want to live in

Reflective, generative and life-enriching through collaborative, inclusive discovery into what gives “life”to the organization to vision the future

111

Magnet Hospitals for nursing excellenceDeveloped by identifying successful strategies at hospitals with no nursing vacancies to replicate at other hospitals:

positive work environments, nurse leadership, continuous quality improvementacademic and practice partnerships.

Higher satisfaction Lower staff vacancyImproved patient outcomes

112

Problem Solving:See organization as a problem to be solved

Appreciative Inquiry: View organization as a mystery to embrace

Felt need, problem identification

Appreciate and value the best of what is

Analysis of causes Envision what might be

Analysis of possible solutions

Dialogue what should be

Action planning, treatment Innovate what will be

Solution oriented Seeks transformation

113

Appreciative InquiryAppreciate: Value

Energizes by recognizing the best Affirming past or present strengths, successes, and potentials which give life to living systems

Inquire: QuestionQuestion are the first part of changeExplores new possibilities based on successful events

114

AI is a reflective process that allows participants to own their world by sharing what works.

Clarify what is desiredAsk for what is wantedListen to what is attainedRecycle to maintain goals

4 D Cycle of

115

The 4-D Cycle of AIDiscovery— “What gives life (for topic)?”appreciating and valuingDream—“What might be?” envisioningDesign— “How can it be?” co-creating the futureDestiny— “What will be?” learning, empowering, and improvising to sustain the future

116

Reflection: Critically consider one’s beliefs or knowledge in light of supporting evidence.Raise awareness about what one does to be able to make better choices in the future.Bridge actual and desired practice/actions.Monitors reactions to lead to intentional, conscious, deliberate actions.Learn from successful and unsuccessful events.

117

Reflective Leadership: journey of the self towards transformation

Begins with uncomfortable feeling about the way one does something or reacts.Critically reflect on the action.Discover meaning within what happened.Integrate into context as one changes perspective.Act from one’s internal compass of what is right.Emotional intelligence is building block of reflection.

118

Self-Reflection:In your usual day, do you spend more time with a focus on what is working or what is not working? Cite specific examples.

119

Discovery: Changing conversationsIdentify and appreciate the best of “what is”

Share stories of accomplishments and success, when people have experienced (the topic) at its best.

Create Meaning through sharing story.

What is the common mission or purpose that unites the group? How is this communicated and nurtured?

120

Dream: Changing mindsChallenge the status quo by envisioning potential results and bottom line contributions to the world

Through collective sharing, images of the future emerge out of grounded examples from the positive past

Give life to the organization through positive history (can be expressed in multiple ways such as story boards)

It is the opportunity to Dream Big!

121

Design: Changing cultureCreate ways to replicate themes in successful stories and events to expand potentialDevelop together a plan for a transformed approach (to the topic) with integration of quality and safety.

122

The conversations we have shape how we see the world, how we behave, and what we see as reality.

Inquiry is change. The first question we ask is fateful.

We create our reality by the stories we tell.

We act according to perceptions of our current reality AND what we anticipate/imagine will happen in the future; we move toward the reality we imagine.

Moving to Change: Creating Transformation

123

Creating our realityBuilding and sustaining momentum for change requires large amounts of positive affect . . . . Hope, excitement, inspiration, camaraderie, urgent purpose.Wholeness (inclusiveness) brings out the best in people and organizations.

To really create change, we must “be the change we want to see.”

124

There is a time and place for multiple ways of examining quality issues.

It depends on what you are trying to see, what you are trying to change, and how you want to shape the culture and context.

125

Opening to new ways of viewing context

Changing conversationsChanging mindsChanging cultureCreating transformation

126

Get Out of the Box to Build Quality and Safety

127

Additional ReferencesSherwood & Horton-Deutsch. (2008). Reflective practice: The route to nursing leadership. In Freshwater, D., Taylor, B., & Sherwood, G. International textbook of reflective practice in nursing. Oxford, England: Blackwell Publishing & Sigma Theta Tau Press. Pp. 157-176.

Hammond, S. (1998).The Thin Book of Appreciative Inquiry. Bend, OR: The Thin Book Publishing Co.

Bolman & Deal. (2004). Leading with Soul.

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Small Group ExerciseSmall Group ExerciseReflect on the time you have been in your current organization. Reflect on the time you have been in your current organization. What gives life to this organization? Why do you want to belong?What gives life to this organization? Why do you want to belong?Think for a moment about what you value deeplyThink for a moment about what you value deeplyWithout being humble, describe what you value most about your Without being humble, describe what you value most about your self, your work and your contribution to the organizationself, your work and your contribution to the organizationLocate a high point when you felt most effective and engaged in Locate a high point when you felt most effective and engaged in contributing to the life of the organizationcontributing to the life of the organizationDescribe how you felt and what makes this possibleDescribe how you felt and what makes this possibleHow does this contribute to a culture of safety?How does this contribute to a culture of safety?How do you individually add value to the safety culture of your How do you individually add value to the safety culture of your organization?organization?What are your three concrete wishes for insuring a culture of saWhat are your three concrete wishes for insuring a culture of safety fety in your organization?in your organization?What are the forces and factors that can make these best practicWhat are the forces and factors that can make these best practices es happen?happen?

129129


130130

BreakBreak

131131

Data “Insanity”: The silent improvement

killer –

Part 2 Davis Balestracci, MS

132132

The Lewis Blackman The Lewis Blackman Story revisitedStory revisited

What have we learned today that would What have we learned today that would help us approach this event differently?help us approach this event differently?

133133

Facilitated DiscussionFacilitated Discussion

Real World Dilemmas in Quality and Safety

What are the day-to-day issues that members of the audience face?

134134

Improving Safety, Improving Safety, Implementing ChangeImplementing Change

Creating a Patient Safety PlanCreating a Patient Safety Plan

Paul Paul BarachBarach, MD, MPH, MD, MPH

135135

Patient Safety PlanPatient Safety Plan

Reliable Design

Teamwork / Human Factors

High Reliability Organization Culture/Leadership

2

PatientCenteredness

Knowledge Sharing

Identify Failures

Manage Failures

Adapted from Kaiser Permanente

136136

Getting StartedGetting Started

SelfSelf--assessmentassessment–– Alignment with organizational strategyAlignment with organizational strategy–– Program InfrastructureProgram Infrastructure–– Inventory of current patient safety activitiesInventory of current patient safety activities

Resource allocationResource allocationCapacityCapacity

–– ResultsResults

137137

Safety ProgramSafety Program

Linkage with Leadership/Organizational Linkage with Leadership/Organizational CultureCultureOversight responsibility/infrastructureOversight responsibility/infrastructureStakeholder EngagementStakeholder EngagementWork Plan DevelopmentWork Plan DevelopmentExecution Model(s)Execution Model(s)Monitoring/MeasurementMonitoring/MeasurementParticipation/accountabilityParticipation/accountabilitySpread/SustainabilitySpread/Sustainability

138138

Creating a Patient Safety WorkPlanCreating a Patient Safety WorkPlan

AIM: Safest HospitalAIM: Safest Hospital

Objective: Zero incidence of harmObjective: Zero incidence of harm

TacticsTactics–– Crew resource management (CRM)Crew resource management (CRM)–– SBARSBAR–– Rapid response teamsRapid response teams

Source: Institute for Healthcare Improvement at http://www.ihi.org

139

Transformed Hospitals Have Clear Definitions

What do you mean by great performance?Have you established a baseline?Are you improving?If not, why not?How can you improve even faster?Settling upon a consistent and intelligent method of assessing your output results

140140

ResourcesResources

Advanced Advanced Training Program, Training Program, Intermountain Intermountain HealthcareHealthcare, , Salt Lake Salt Lake City. City. http://intermountainhealthcare.org/xp/public/institute/courses/ahttp://intermountainhealthcare.org/xp/public/institute/courses/atp/tp/#objectives#objectives

Leadership Guide to Patient Safety from the Leadership Guide to Patient Safety from the Institute for Healthcare Improvement at Institute for Healthcare Improvement at http://www.ihi.orghttp://www.ihi.org

The University of Michigan Healthsystem Patient The University of Michigan Healthsystem Patient Safety Toolkit at Safety Toolkit at http://www.med.umich.edu/patientsafetytoolkit/http://www.med.umich.edu/patientsafetytoolkit/

http://intermountainhealthcare.org/xp/public/institute/courses/atp/#objectives



http://www.ihi.org/

http://www.med.umich.edu/patientsafetytoolkit/

141141

Concluding comments, Concluding comments, questions, and Post Test questions, and Post Test

logisticslogistics

142142

What do you think is on the horizon What do you think is on the horizon for patient safety in the next 5 for patient safety in the next 5

years?years?

143143

WhatWhat’’s on the Horizon for Patient s on the Horizon for Patient Safety?Safety?

The role of the built environmentThe role of the built environmentPatient centered processesPatient centered processesSmart automationSmart automationAdaptive informaticsAdaptive informaticsFocus on the team and simulationFocus on the team and simulationFull disclosureFull disclosureTelemedicine/remote careTelemedicine/remote care

144144

Patient Safety Domains Knowledge, Skills, Attitudes

1. Theoretical Foundations Microsystems, historical trends, chaos, complexity, competency and learning

2. Behavioral Aspects of Medical Professionalism

Ethics, patient quality of life, resolution of conflict

3. Interpersonal Issues Communication, stress and coping4. Human Factors and

ErgonomicsDesign history, error taxonomies, safety tools, decision support systems, fatigue factors, user centered design

5. Systems Analysis Usability criteria , organizations and learning disasters, place for human error

6. QI Learning Pareto/flow charts, and other QI tools, best practices, act cycles7. Injury Epidemiology Workplace hazards, worker safety, phases of injury, medico-legal

aspects8. Medication Safety Adverse and near-miss reporting, ISMP tools and website,

look/sound-alikes9. Crisis Management Tools Team work, shared decision making, situational awareness10. Simulations Micro-, macro-, debriefing, immersion levels, scripting, role playing

THE PATIENT SAFETY CURRICULUM

Gilula, M. and Barach P. Creating a Patient Safety Curriculum: Purposive Sampling of Patient Safety Experts. 79th Clinical and Scientific IARS Congress. S-143. Honolulu, Hawaii. March 12, 2005.; Gilula, Barach, 2007.

145145

Rules for Health Care Design in Rules for Health Care Design in the 21st Centurythe 21st Century

Current ApproachCurrent Approach–– Do no harm is an individual Do no harm is an individual

responsibilityresponsibility–– Information is a recordInformation is a record–– Secrecy is necessarySecrecy is necessary–– The system reacts to needsThe system reacts to needs–– Professional autonomy Professional autonomy

drives variabilitydrives variability

New ApproachNew Approach–– Safety is a system Safety is a system

propertyproperty–– Knowledge is shared Knowledge is shared

and information flows and information flows freelyfreely

–– Transparency is Transparency is necessarynecessary

–– Needs are anticipatedNeeds are anticipated–– Decision making is Decision making is

evidenceevidence--basedbased

IOM. Crossing the Quality Chasm. National Academy Press,

2001.

146

•

Do staff feel safe about reporting health care errors or care related injuries and deaths? If not, what are we doing to create a “culture of safety”

–

a “just culture”?

•

What happens when a heath care error occurs?

•

What serious care related adverse events have occurred during the past year?

•

What did we learn from these events? What did we do?

•

What systems related quality and patient safety improvements have occurred during the past year?

What You Should Ask About Quality and Patient Safety

147147

Barriers To Achieving UltraBarriers To Achieving Ultra--safe safe HealthcareHealthcare

Acceptance of limitations on maximum Acceptance of limitations on maximum performanceperformanceAbandonment of professional autonomyAbandonment of professional autonomyTransition from mindset of craftsman to Transition from mindset of craftsman to that of an equivalent actorthat of an equivalent actorDevelop a culture of safetyDevelop a culture of safetySimplify professional rules and regulationsSimplify professional rules and regulations

Amalberti R, Berwick D, Barach P. Annals of Internal Medicine 2005;142:756-764.

148

““There are known There are known knownsknowns. These are . These are things we know that we know. There things we know that we know. There are known unknowns. That is to say, are known unknowns. That is to say, these are things we know we donthese are things we know we don’’t know. t know. But there are also unknown unknowns. But there are also unknown unknowns. These are things we donThese are things we don’’t know we dont know we don’’t t know know ””

-- Donald Rumsfeld Oct 3, 2006

Getting Serious About Hospital Quality

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The Quality Colloquium at Harvard University · The Quality Colloquium at Harvard University...

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