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June 2014 Archive for High Reliability Healthcare

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Observations and Lessons Learned on the Journey to High Reliability Health Care.

Culture Trumps Policies

Jun 04, 2014 | Comments (0) | 7758 Views

blog-PZiaya1By Paul Ziaya, M.D.
Field Director
The Joint Commission

In April, the office of Senator Barbara Boxer published a report that highlighted the continuing problems with "medical errors" and the impact on patient morbidity and mortality. 

Her staff queried 283 acute care hospitals in California, asking them to indicate what actions they were taking to address nine of the most common health-care-associated adverse events. Fifty-three percent responded, with multiple organizations describing progress made through programs they have created. All responding hospitals described "at least some steps to address the most common medical errors."

This sounds like good news, right? After all, sound policies and systematic processes implemented and followed are proven to make a difference. Yet, risk remains, and there is much work to be done.

Recently, an organization’s ICU staff were going between rooms using the same stethoscope without cleaning it, and in one room, staff dropped a patient’s pillows on the floor and reused them on the patient without changing the pillow cases. This same organization had a strong policy and excellent data showing improvement in hand hygiene.

Another organization had a comprehensive policy on falls prevention. One patient had been evaluated and was rated as a "high" fall risk. There was a designation on her door and one on the message board in her room. The organization even had a policy on hourly rounding, and nursing staff faithfully documented those hourly rounds.

At 7:30 a.m. a nurse rounded, and the patient didn’t indicate needing anything. Through multiple medication administrations, staff had been working to help the patient regain elimination. At 7:45 a.m., the patient called indicating the urgent need to do so. A nurse popped in saying she would be right back with help to get the patient to the bedside commode.  By the time staff returned for their hourly rounds at 8:30 a.m. it was too late. The patient had followed instructions and not gotten up, but the bed now needed changing. The nurse documented the hourly rounding and there was no fall, but it was only due to the compliance of the patient.

These are just a couple examples of things that will not show up in any data. They will not appear in any incident reports or on any dashboard unless the patients complain. These organizations all had policies in an effort to prevent these things, but they happened anyway.

Organizations can make large inroads to improvement through the policies they create and the practices they expect, but if we are truly to get to "zero" we must do more than create policies. We must do more than create metrics.

To get to zero, we must change culture. Culture will always triumph over policy, because a culture of safety is the mindfulness by each individual to look for and eliminate risk. Policies and processes give us framework, but care is delivered by individuals, and it is through the mindfulness of individuals and the appreciation and celebration of that mindfulness that we have a chance of getting to zero.