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Culture Eats Strategy…Why Transforming Culture is the Key
To Improving Patient Safety
Robert M. Wachter, MDProfessor and Associate Chairman, Department of Medicine
University of California, San Francisco
Chief of the Medical Service, UCSF Medical Center
Safety Culture:
The Usual Questions
Are errors reported?
Is there a “systems focus”?
Is there “no blame”?
Safety Culture: My Questions
Is the hospital more like the IHOP or SFO?
Are the physicians more like Chuck Yeager
or John Glenn?
Are stories of errors turned into action?
Is there a “culture of low expectations?”
How steep are the hierarchies?
Is there thoughtful balancing of “no blame”
and “accountability”?
Safety Culture: My Questions
Is the hospital more like the IHOP or SFO?
Are the physicians more like Chuck Yeager
or John Glenn?
Are stories of errors turned into action?
Is there a “culture of low expectations?”
How steep are the hierarchies?
Is there thoughtful balancing of “no blame”
and “accountability”?
Production
Pressures
Safety Culture: My Questions
Is the hospital more like the IHOP or SFO?
Are stories of errors turned into action?
Is there a “culture of low expectations?”
How steep are the hierarchies?
Is there thoughtful balancing of “no blame”
and “accountability”?
The Right Stuff
“In fact, considerable attention had been
given to a plan to anesthetize or tranquilize
the astronauts, not to keep them from
panicking but just to make sure they would
lie there peacefully with their sensors on
and not do something that would ruin the
flight.”
Tom Wolfe, The Right Stuff
Safety Culture: My Questions
Is the hospital more like the IHOP or SFO?
Are the physicians more like Chuck Yeager
or John Glenn?
Is there a “culture of low expectations?”
How steep are the hierarchies?
Is there thoughtful balancing of “no blame”
and “accountability”?
Reporting Systems:
Why We Had It Wrong
Flawed notion that reporting has any intrinsic value
– Create stories
– Generate action
– A feedback loop (extra credit!)
Huge opportunity to waste time, money, and promote wrong paradigm
– Early experience in PA, UK, many hospital systems
Some successes
WebMM.ahrq.gov
UCSF’s Root Cause Analysis
Process
Prompted by state reporting requirement
Weekly 2 hour meeting
– First hour: detailed RCA of error from prior wk
– Second hour: series of 15 minute progress reports
Senior leadership/experts on committee
Participants not only present their case, they
learn about RCAs, systems thinking,
organization‟s commitment to improvement
Safety Culture: My Questions
Is the hospital more like the IHOP or SFO?
Are the physicians more like Chuck Yeager
or John Glenn?
Are stories of errors turned into action?
How steep are the hierarchies?
Is there thoughtful balancing of “no blame”
and “accountability”?
The “Culture of Low Expectations”
“We suspect that these physicians and nurses had
become accustomed to poor communication and
teamwork. A „culture of low expectations‟ developed
in which participants came to expect a norm of faulty
and incomplete exchange of information [which led
them to conclude] that these red flags signified not
unusual, worrisome harbingers but rather mundane
repetitions of the poor communication to which they
had become inured.”
Drs. Mark Chassin and Elise Becher
Annals of Internal Medicine, 2002
“It must be right…”
Safety Culture: My Questions
Is the hospital more like the IHOP or SFO?
Are the physicians more like Chuck Yeager
or John Glenn?
Are stories of errors turned into action?
Is there a “culture of low expectations?”
Is there thoughtful balancing of “no blame”
and “accountability”?
A Hypothetical Scenario
Lowest person on the totem pole
Something seems glitchy
Head of CT or Neurosurgery
He drives a Hummer
He has a temper
He‟s been known to throw things
He‟s got good aim
The Extra Credit Scenario, cont.
She stops the presses, and it delays
the first case in the OR…
and it turns out that everything
was OK.
Here’s the Question:
What Happens to Her?
A)People whisper about her at the
watercooler for the next few days
B) The hospital CEO, CNO, or CMO
(and the surgeon!) come by later that day
to pat her on the back
Safety Culture: My Questions
Is the hospital more like the IHOP or SFO?
Are the physicians more like Chuck Yeager
or John Glenn?
Are stories of errors turned into action?
Is there a “culture of low expectations?”
How steep are the hierarchies?
Safety Culture is Unit-Based
Safety Climate Across
100 Hospitals
Safety Climate Across
49 Units in One Hospital
Pronovost/Sexton, QSHC 2005