lecture 1A

Editor's Notes

• #2: Welcome to Quality Improvement: Reliability, Culture of Safety, and HIT.
• #3: The Objectives for Reliability, Culture of Safety, and HIT are to: Discuss reliability as a tool for ensuring safety. Examine how ultra-safe organizations operate. Identify how teams make wise decisions.
• #4: We can learn lessons from the Navy with respect to reliability and culture of safety. Please take a moment to watch the video that is provided by your instructor.
• #5: The coordination of safety activities in highly complex environments by multisystem teams is a hallmark of high-reliability organizations. The safety of a hospitalized patient is dependent on the effective coordination of all members of the health care team. When working on IT projects, this team includes you as the HIT professional. High-reliability organizations are also tightly coupled. That is, team members depend on tasks across the entire team. Roles are very clearly defined and differentiated in high-reliability organizations. Intense coordination is required for the team to work cohesively. There is no “I,” only “we.” Complete reliance on the team is the hallmark of high-reliability organizations. Decisions are made by the person with the most direct expertise, not necessarily the team “leader.” There are multiple decision makers in high-reliability organizations, therefore, processes must be in place to allow these decision makers to communicate with each other.
• #6: High-reliability organizations have complex communication networks. Because they have a high degree of accountability, when errors occur, there are severe consequences. It’s not always easy to differentiate patients who die from error from those whose deaths were inevitable due to the course of their disease. Immediate and frequent feedback to team members is another defining characteristic of a high-reliability organization. Such immediate feedback is critical to detecting and then ameliorating problems before they result in a crisis situation. Finally, high-reliability organizations have compressed time constraints that pose challenges.
• #7: Reliable teams: Demonstrate sensitivity to operations, Are preoccupied with failure, Defer to expertise, Are resilient, And are reluctant to simplify issues. These attributes are necessary to achieve safe, consistently high-quality care. While it may not sound like a good thing to be preoccupied with failure, such attentiveness allows teams to pick up on near misses or to identify potentially risky situations. Reliable teams are adept at dealing with failures because they have been trained to recognize a need for additional expertise, they have practiced in dealing with system failures, and – working as a team – they have learned to quickly assess a situation that could lead to less than optimal outcomes.
• #8: AHRQ maintains a website that includes many resources pertaining to Patient Safety and Medical Errors. The last slide and the next several slides highlight some key points from the presentation, Becoming a High Reliability Organization. “Sensitivity to operations includes more than just checks of patient identity, vital signs, and medications. It includes awareness by staff, supervisors, and management of broader issues that can affect patient care, ranging from how long a person has been on duty, to the availability of needed supplies, to potential distractions.”
• #9: “A preoccupation with failure means that near misses are viewed as invitations to improve rather than as proof that a system has enough checks to prevent a catastrophic failure.”
• #10: “Oversimplifying explanations for how things work risks developing unworkable solutions and failing to understand all the ways in which a system may fail, placing a patient at risk.”
• #11: “In many situations, different staff members as well as the patient and family may have information essential to providing ideal care. Deference to expertise entails recognizing the knowledge available from each person and deferring to whoever's expertise is most relevant to the choices being made.”
• #12: The final point here, drawn from the website, is: “A good boater never leaves the dock without preparing for many situations that are unlikely but possible. Oars, pump, lifejacket, and fire extinguisher ensure that the boater can quickly respond to unexpected system failures.”
• #13: In a recent journal article, Riley and colleagues defined culture as, “the shared perceptions of the individuals within the team or organization about what is good, right, important, valued, supported, or expected at any given time. Over time we have seen a shift in the culture of healthcare from one of blame to a culture of safety.”
• #14: A nurse relayed this story, “I remember vividly the first time I made a medication error. I don’t know how it happened. Maybe I was too much in a hurry. Maybe I was tired. Maybe I got distracted. Whatever. I gave the drug to the wrong patient. Something I always swore I never would do. Maybe I shouldn’t have become a nurse. I was lucky this time because the patient didn’t have a bad reaction to the drug, but what if it happens again? How could I be so careless?” Mistakes hurt. Not only the person the mistake is directed to, but also the person who makes the mistake. In times past, the focus was immediately on blame. Who made the mistake? What was wrong with that nurse? Or that doctor? What was wrong with me?
• #15: Blame significantly limits our ability and the ability of others to learn from our mistakes. When we are blamed, we stop talking about the mistake. The quieter we become, the less we can learn. The less we learn, the less we have an opportunity to improve conditions that may have contributed to the error. And when we leave conditions as they were, mistakes continue and someone else will be blamed. Fortunately, health care is making great strides to shift from a culture of blame to a culture of safety.
• #16: No one wins the blame game. We don’t learn from our mistakes if we play this game. Therefore, we’ll continue to make errors. And blaming behaviors completely drives self-reporting of errors underground.
• #17: One recent resource on the AHRQ website went into some detail about the culture of blame. “The culture of individual blame still dominant and traditional in healthcare undoubtedly impairs the advancement of a safety culture. One issue is that, while ‘no blame’ is the appropriate stance for many errors, certain errors do seem blameworthy and demand accountability. In an effort to reconcile the twin needs for no-blame and appropriate accountability, the concept of “just culture” is being introduced. A just culture focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability by establishing zero tolerance for reckless behavior. It distinguishes between human error (for example, slips), at-risk behavior (for example, taking shortcuts), and reckless behavior (for example, ignoring required safety steps), in contrast to an overarching ‘no-blame’ approach still favored by some. In a just culture, the response to an error or near miss is predicated on the type of behavior associated with the error, and not the severity of the event. For example, reckless behavior such as refusing to perform a ‘time-out’ prior to surgery would merit punitive action, even if patients were not harmed.”
• #18: You can help to promote a culture of safety. First, accept responsibility for ensuring patient safety. Value learning from mistakes. Often HIT designs need to be reconfigured when the current configuration does not support patient safety. Learn to recognize risky behaviors in others and in yourself.
• #19: Speak up if you see that something is not right. Perhaps someone is using the electronic health record in a way that differs from the intent. Speak up and provide information to that individual so that she understands the way in which the system was designed. Listen to her and discuss ways to prevent errors.
• #20: Report errors and near misses that come to your attention. Encourage others to do the same. Help change unrealistic policies or rules.
• #21: There are two extremely important characteristics of a culture of safety. They typify the attributes of high-reliability organizations by requiring a high degree of mindfulness, teamwork, and communication. First, all people must listen carefully to concerns to determine if corrective action is necessary. Second, every member of the team must recognize when a concern is expressed by anyone and stop.
• #22: Take a moment to view the video provided by your instructor to learn some final lessons from nature on how teams make wise decisions in a culture of safety.
• #23: This concludes Reliability, Culture of Safety, and HIT. In summary, in this unit we explored the characteristics of high-reliability organizations and learned more about establishing an organizational culture of safety.
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