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April 2017 Archive for High Reliability Healthcare

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

Safety Culture: Shattering the Myths of Perfection and Punishment

Apr 27, 2017 | Comments (0) | 7270 Views

By Gerard Castro, Ph.D., M.P.H.
Project Director
Patient Safety Initiatives
The Joint Commission

This is the second in a series of posts examining the 11 tenets of safety culture discussed in our Sentinel Event Alert and accompanying infographic. This post examines the second tenet: Use clear, just and transparent risk-based processes for separating human error from error arising from poorly designed systems, or unsafe or reckless actions.

In testimony before Congress in 2000 on the topic of patient safety, Dr. Lucian Leape, a professor at the Harvard School of Public Health, said, “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes”.

Dr. Leape later explained that to create an open and fair environment to improve patient safety and prevent future mistakes, we need to dispel two key myths:

  • The perfection myth: If people try hard enough, they will not make any errors.
  • The punishment myth: If we punish people when they make errors, they will make fewer of them.

An internationally recognized leader in the patient safety movement, Dr. Leape was among the pioneers who understood that encouraging the reporting and investigating of errors and resulting adverse events or close calls was an essential way of learning from them and preventing future mistakes.

Framing Opportunities for Improvements
In a safety culture, organizations consider errors, hazards, close calls (“near misses”), and adverse events as opportunities to make improvements, rather than seeing them primarily as occasions calling for the blaming, punishment or termination of team members. Health care team members understand that systemic vulnerabilities exist and that each step in the care process has the potential for a negative outcome.

By cultivating an open and trusting safety culture, health care leaders can encourage team members to identify these weaknesses and find solutions to them before they reach the patient and cause harm. Leaders can also encourage team members to be proactive, continuously trying to anticipate developments and seeking to understand and learn why things go right.

By seeking these types of learning opportunities, an organization begins to exhibit and foster an important trait of a safe culture and learning organization – one in which team members feel able to report patient safety incidents without undue fear of the consequences. Indeed, rather than fearing consequences, team members are encouraged and even rewarded for reporting adverse events and close calls. Leaders, in turn, apply the lessons learned from these mistakes throughout their organizations.

Montefiore Medical Center’s Approach to Adverse Events
One example of this paradigm shift can be found at Montefiore Medical Center, which has developed an easy-to-use just culture tool that unifies and transforms the way this large health system approaches errors., The Montefiore team reviewed the existing tools used in the fields of industrial engineering and healthcare and did not find any that were completely suited for Montefiore’s purposes. Inspired by the work of James Reason and David Marx, they decided to develop Montefiore’s own Just Culture tool, which is simple to learn and use, and supports a fair and balanced approach to analyzing errors. This tool makes the Just Culture concepts tangible to Montefiore’s clinical teams and helps them to analyze errors in the context of a Just Culture framework. The tool helps users that review adverse events to discern the human failures that led to the event from the underlying system failures.

The tool walks the user through two simple questions pertaining to each individual involved in an adverse event to help determine individual accountability. The practitioner’s performance is then put into one of four categories, each of which leads to an intervention- from consoling to coaching to discipline (for the rarely found reckless behaviors). After the individual attributions are assigned, the tool instructs the team to explore the system issues contributing to the event and this becomes the primary focus and lens through which the case is reviewed. The tool is used by front – line nurse managers, Departmental and Institutional safety leaders, HR professionals and Board Members throughout the health system.  

Montefiore’s approach recognizes that individual practitioners should not be held accountable for system failings. In this way, Montefiore creates an environment in which team members are comfortable reporting adverse events, close calls and unsafe conditions. They are confident that these reports will be used to build stronger processes and systems to improve safety.

Resultingly, Montefiore experienced a dramatic rise in adverse event and close call reporting by all types of clinical staff, including physicians. “To sustain this, we need to continue to support a just culture and demonstrate that we are listening and responding to the voice of our front-line clinicians,” said Jeffrey Weiss, M.D., Montefiore’s vice president for medical affairs and senior medical director.

Montefiore’s patient safety model shifts from the traditional culture of individual blame described by Dr. Leape many years ago to one that investigates errors in the context of complex systems.

Montefiore advances patient safety through improved identification of errors, creates an infrastructure for learning about these errors, and translates this learning into meaningful change and system improvement.

By not expecting perfection and by focusing on creating safer systems, Montefiore is preventing errors and making health care safer.