Creating a Just Culture of Safety


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  • IHINPSFECRI – Emergency Care Research InsitituteMITSS – Medically induced trauma support services
  • Safety improvements – medication reconciliation Bar coding safe dispensing – profiling scanning for correct patient identification drug libraries Smart infusion pumps
  • Creating a Just Culture of Safety

    1. 1. 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
    2. 2. 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.
    3. 3. Overview 1. Quality & Safety a) Definitions b) Adverse events 2. Professional Accountability 3. Just culture a) Influences b) Characteristics c) Examples 1. MGH a) Just culture in action b) Innovation initiatives
    4. 4. 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)
    5. 5. IOM 6 Aims of Quality Care (2001) Efficient Equitable Effective Safe Timely Quality Care Patient Centered
    6. 6. 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/knowledge 3. customization • Measures - difficult to measure due to dependence on selfreporting.
    7. 7. Safety Culture Influences
    8. 8. 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.
    9. 9. 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.
    10. 10. 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
    11. 11. 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
    12. 12. 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
    13. 13. Reason’s Swiss Cheese Model (
    14. 14. 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 Leape Professor, Harvard Medical School of Public Health Testimony before Congress on Health Care Quality Improvement
    15. 15. 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 Norman Author, the Design of Everyday Things
    16. 16. 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
    17. 17. 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.
    18. 18. 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
    19. 19. 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?
    20. 20. Fair evaluation & response (Frankel & Leonard
    21. 21. Allen Frankel’s Algorithm (2010)
    22. 22. 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
    23. 23. 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
    24. 24. Adverse Drug Events $3.5 Billion in costs (CDC, 2012) 700,000 ED visits 120,000 admissions Yellow- no error Purple- Error, no harm Blue- Error, Harm Orange- Error, Death
    25. 25. 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
    26. 26. 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
    27. 27. 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
    28. 28. Professional Practice Model
    29. 29. Magnet Recognition: External Evaluation
    30. 30. 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
    31. 31. Guiding Principles • 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.
    32. 32. “Patient Journey” Framework Before Preadmission Care During Admission Process: ED, Direct Admits, Transfers Patient Stay; Direct Patient Care, Tests, Treatments, Procedu res, Clinical Support, Operational Support Post Discharge Process 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. Where Are There Opportunities to Reduce Costs Across These Processes of Care? Post Discharge Care
    33. 33. Innovations in Care Delivery Patient Journey Framework Discharge process Intervention Patient stay; direct patient care; tests; treatments; procedures; clinical support; operational support After Intervention Admission process: ED, direct admits, transfers Intervention Preadmission care During Intervention Before Postdischarge care Goal: High-performing, inter-disciplinary teams that deliver safe, effective, timely, efficient, and equitable care that is patient- and family-centered The Interventions •Enhance clinical datacollection 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 Relationship-based care Increased accountability through the attending nurse role Utilization of Evidence Based staffing and care delivery; Utilization of the Hand-Over Rounding Checklist
    34. 34. 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
    35. 35. 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.
    36. 36. 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
    37. 37. 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
    38. 38. Innovation Unit Dashboard 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 Massachusetts General Hospital - PCS Innovation Units Dashboard Measures Pediatrics Ortho Oncology Medicine NICU Surgery White 6 Lunder 9 Ellison 16 Blake 10 Ellison 17 Ellison 18 White 7 CICU ICU Obstetrics Psych Vascular Ellison 9 Blake 12 Blake 13 Blake 11 Bigelow 14 QUALITY AND SAFETY Patient-Centered Outcome Measures Falls per 1,000 Patient Days Total Fall Rate Observed (N) Falls with Injury per 1,000 Patient Days Falls with Injury Rate Observed (N) 4.50 11 1.46 3 4.95 13 0.77 1 1.92 2 1.32 2 2.16 5 1.79 2 TBD 0.65 2 4.85 10 0.45 1 0.41 1 0.49 1 1.52 4 0.00 0 0.96 1 0.00 0 0.00 0 0.89 1 TBD 0.00 0 1.45 3 0.45 1 0.0% 0 6.9% 2 0.0% 0 0.0% 0 0.0% 0 0.0% 0 7.7% 1 TBD NA 4.8% 1 4.2% 1 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 7.7% 1 TBD NA 4.8% 1 4.2% 1 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 7.7% 1 TBD NA 0.0% 0 0.0% 0 NA NA 0.0% 0 0.0% 0 0.0% 0 NA NA NA NA NA NA 2.90 1 4.76 1 0.00 0 1.10 1 1.70 2 TBD NA 0.00 0 0.00 0 Hospital Acquired (HA) Pressure Ulcers Total HA Pressure Ulcer Prevalence Rate 0.0% Observed (N) 0 Hospital Acquired (HA) Pressure Ulcers Type II or Greater Total HA Pressure Ulcer Type II or Greater Prevalence Rate 0.0% Observed (N) 0 Restraints Total Restraint Prevalence Rate Observed (N) 0.0% 0 Peripheral Intravenous (PIV) Infiltrations - Pediatric/Neonatal Total PIV Infiltration Prevalence NA Observed (N) Central Line-associated Bloodstream Infections per 1,000 Line Days (CLABSI) Total CLABSI Rate 6.54 NA 1.36 Observed (N) 1 1 Quality and Safety Note: metrics to be reported beginning FY 2012 Color Shading relative to Benchmark:  Unplanned Return to OR Rate is worse (higher) than benchmark. Catheter-associated Urinary Tract Infections per 1,000 Device Days  Readmission Rate Rate is better (lower) than benchmark. Ventilator-associated Pneumonia per 1,000 Vent Days  Restraint Free Rate  Falls/Pressure Ulcer Reduction Innovation Unit Dashboard  Foley Catheter Days July – September 2011  Hard-stop Time Out Performance
    39. 39. 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 levels 3. 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
    40. 40. References • • • • • • • • • • Agency for Healthcare Research and Quality. Available at: 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: Institute for Healthcare Improvement, Available at: 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.