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Model for Improvement
Patient Safety Officer Executive Development Program
Institute for Healthcare Improvement
Using Safety Culture to
Drive Habitual Excellence
Michael Leonard, MD
September 9, 2012
Disclosure: I am a Principal in a company called Pascal Metrics Inc. that
develops and implements safety metrics. We will disclose the commercial
interests we have, and present a balanced view of the topic.
Objectives
• Understand why high quality safety culture
data is essential to drive behavioral
change
• Learn why unit level data showing the
perceptions of caregiver groups is
essential
• Know that debriefing with measurable
action is a valuable part of the process
Model for Improvement
Patient Safety Officer Executive Development Program
Institute for Healthcare Improvement
3*Adapted from Safeskies 2001, “Aviation Safety Culture,” Patrick Hudson, Centre for Safety Science, Leiden University
PATHOLOGICALWho cares as long as we’re not caught
Chronically Complacent
REACTIVESafety is important. We do a lot every
time we have an accident
CALCULATIVEWe have systems in place to manage all
hazards
PROACTIVEAnticipating and preventing problems before
they occur
GENERATIVESafety is how we do business around here
Constantly Vigilant
Evolution of A Culture of Safety and
Reliability
Where are you?
Safety Culture Instruments
• SAQ
• HSOPS
• Manchester
• All are validated instruments – psychometrically
• 60% response rate minimum
• Unit level – caregiver specific
Model for Improvement
Patient Safety Officer Executive Development Program
Institute for Healthcare Improvement
What’s Your Experience?
• Survey instrument
• Response rates
• Unit level data
• Captured by caregiver types
• What is the measurable action loop?
Culture of Safety
• No one is ever hesitant to voice a concern about a patient
• Caregivers – capable, conscientious and playing by the
rules – feel comfortable to speak up regarding errors, near
misses and adverse events
• When people do speak up, they have a high degree of
confidence that the organization will act on their concerns
and tell them.
• There is a cyclic flow of information that leads to analysis,
action and feedback – a learning organization – to
reinforce well defined behaviors and values
Model for Improvement
Patient Safety Officer Executive Development Program
Institute for Healthcare Improvement
Psychological Safety
• Psychological safety is a belief that one will not be
punished or humiliated for speaking up with ideas,
questions, concerns, or mistakes.
• A shared sense of psychological safety is a critical input
to an effective learning system
Psychological Safety and Learning Behavior in Work Teams. Administrative
Science Quarterly, Vol. 44, No. 2 (Jun., 1999), pp. 350-383
Amy Edmondson
8
What is Culture?
• The visible attributes
• The espoused values
• The hidden values• —Edgar Schein
“The way we do things
around here.”
Model for Improvement
Patient Safety Officer Executive Development Program
Institute for Healthcare Improvement
Where Do You Have Opportunity?
• Leadership
• Psychological Safety
• Learning from error
• Teamwork
• Human factors
• Learning and improvement
Courtesy Natasha Scott, PM
Model for Improvement
Patient Safety Officer Executive Development Program
Institute for Healthcare Improvement
% o
f re
spo
nd
ents
rep
ort
ing
ab
ove
ad
equ
ate
team
wo
rk
Teamwork in the eye of the beholder: ICU RNs and ICU MDs rate each other
62 Michigan ICUs 2004Only ICUs with 5 or more physicians
reported here (all had 5 or more RNs)
Teamwork Climate Across
Michigan ICUs
No BSI 21%
No BSI = 5 months or more w/ zero
The strongest predictor of clinical excellence: caregivers feel comfortable
speaking up if they perceive a problem with patient care
No BSI 31% No BSI 44%
Attribution: J. Bryan Sexton
Model for Improvement
Patient Safety Officer Executive Development Program
Institute for Healthcare Improvement
Attr: Margaret Vigorito
ICU’s that did NOT reflect on their SAQ scores:
─ Increased their SAQ scores
in 5 of 6 domains
─ Achieved a 10.2%
decrease in BSI rates
─ Achieved a 15.2%
decrease in VAP rates
─ Increased their SAQ scores
in 1 of 6 domains
─ Achieved a 2.2% decrease
in BSI rates
─ Achieved a 4.8% increase in
VAP rates
Linking Culture and Outcomes:
RI ICU Effort to Decrease Infection
Attribution: Margaret Vigorito, MS, RN
ICU’s that reflected on their
SAQ scores and took action:
Model for Improvement
Patient Safety Officer Executive Development Program
Institute for Healthcare Improvement
15Courtesy Natasha Scott PM
16
Courtesy Natasha Scott, PM
Model for Improvement
Patient Safety Officer Executive Development Program
Institute for Healthcare Improvement
17
Courtesy Natasha Scott PM
18
Courtesy Natasha Scott PM
Model for Improvement
Patient Safety Officer Executive Development Program
Institute for Healthcare Improvement
19
Courtesy Natasha Scott PM
20
Courtesy Natasha Scott PM
Model for Improvement
Patient Safety Officer Executive Development Program
Institute for Healthcare Improvement
Debriefing Culture Data Locally
- CONFIDENTIAL-
21
Local debrief sessions target improvement at the clinical area level
Sessions empower caregivers to “own the data”Use the DEBRIEFer Tool
Link to specific action
The DEBRIEFer tool, Page 1
• Focuses on a single clinical area
• Highlights extremes in the data:
• Presents some of the least positive
items
• Presents some of the most positive
items
• Helps affirm what people feel and
encourages them to discuss things that
are felt by many but rarely talked
about
• Encourages an improvement-focused
discussion grounded in the data
Model for Improvement
Patient Safety Officer Executive Development Program
Institute for Healthcare Improvement
The DEBRIEFer tool, Page 2
• Discussion form guides a structured
reflection on a single item
• Narrows focus
• Identifies a manageable problem
to work on
• Meeting members create an action
plan targeting a single, chosen item
• One actionable step that they
commit to taking
• Specific date by which they will
have taken the action
Workforce Engagement – 7S Surgical Floor
2009 Percent Favorable 2010 Percent Favorable 2010 Hospital Partner
Attribution: Jill Cooper PSPH
Model for Improvement
Patient Safety Officer Executive Development Program
Institute for Healthcare Improvement
What Are You Going to Do ?