Welcome to the third issue of Patient Safety Tools , an IPRO electronic newsletter delivering patient safety information and resources to health care providers across New York State.
We have adopted this format to increase the reach and effectiveness of our efforts to communicate useful, current information about patient safety initiatives sponsored by IPRO and others. We hope that by bringing key findings, lessons learned, workable strategies, and practical tools to your attention, Patient Safety Tools will highlight proven ways to apply quality improvement processes to achieve "transformational" advances in patient safety.
Return to topEach of these newsletters presents information focused around one of the twelve safety dimensions for hospitals defined by the Agency for Healthcare Research and Quality (AHRQ) as implemented in their Patient Safety Climate Survey.
This survey, available to any hospital, is currently being used by IPRO in a CMS-directed rural hospital initiative to promote an improved hospital patient safety environment. It identifies specific patient safety strengths and vulnerabilities associated with each of the twelve measured dimensions and can facilitate a data-driven plan to engage senior leadership to promote safety improvement activities using specific evidence-based, proven interventions.
Patient safety dimensions that reflect various hospital processes are:
The first issue of Patient Safety Tools focused on using the SBAR technique to improve communication during the many handoffs and transitions that occur during any hospital stay. The second highlighted the absolute need for active, visible participation by hospital senior leadership, especially the CEO, in driving safety culture change efforts, and provided tools that will permit busy executives to do so.
This issue examines the prevailing and toxic environment of blame in hospitals, and how that environment interferes with careful analysis of errors and a better understanding of how errors occur within systems, so that organizational learning can take place. This better understanding is required to make dramatic and sustainable improvements in patient safety.
Moving from a "culture of blame" to a "Just Culture" will make your hospital a better, safer place.
Return to topHave you ever been blamed for anything - a mistake or a misdeed? Can you remember how you felt at the time? How did you respond?
Being the object of blame was probably not a positive or uplifting experience. You may have reacted with emotion first - embarrassment, fear, anger, guilt, shame, sorrow, annoyance, etc. - and then began thinking, "Did I really do this?" and "What do I do now?" You probably came to a fairly quick response - ranging from unqualified denial through disbelief to "well, maybe" to acknowledging the action. It's also likely that you didn't learn anything or teach anything, at least not for a very long time.
Blame, and our response to blame, follows fairly well defined behavioral pathways related to individual survival and re-establishing personal equilibrium. None of these pathways leads to improving safety or systems. It doesn't even matter whether you actually made the mistake or committed the misdeed!
Blaming halts thinking and limits options.Once a mistake or misdeed can be attributed to the actions of an individual (or individuals), solutions are usually limited to one of three Rs of "corrective action" designed to "prevent this from happening again": reprimand, retraining, or release.
All are forms of punishment. Yet punishment prevents real learning and generally leads to silence and resentment.
Blaming inhibits reporting of errors.Given the high emotion and the fear of consequences (including litigation), is it any wonder that health professionals have been and still are reluctant to study, discuss, and disclose errors?
Dr. Lucian Leape flatly stated the case in testimony given to Congress in 1997: "The single greatest impediment to error prevention is that we punish people for making mistakes." i
Return to topAll of the patient safety culture survey research to date has clearly identified the "culture of blame and shame" as the Number One barrier to improving patient safety in hospitals.
Virtually every hospital that has administered the AHRQ survey (several hundred institutions) reports the lowest number of positive responses on the dimension called "Non-Punitive Response to Error." The three survey items in this dimension are designed to measure hospital staff perception of how mistakes and errors are handled in their working environment.
Approximately two-thirds of hospital staff believe the following:
We know that blaming, and the response to blaming, works against reporting and thinking about errors. We also know that at least two-thirds of all hospital staff surveyed think that they work in a punitive, blaming environment. This is not good. Why?
Don Norman, author of The Design of Everyday Things , says "...people do make mistakes, but as I and many others have repeatedly pointed out, in complex systems, there is seldom a single point of failure, so to trying to assess "the" cause of an error is counterproductive. Yes, it feels good to be able to blame some person or thing, but this is what I have called the "blame and train" philosophy. It fails to fix the complex underlying causes."
Fixing these "complex underlying causes"iii is what leads to high reliability in any organization.
Return to topDuring the last decade, more than a few individuals (as well as organizations, foundations, hospitals, and hospital systems) have taken on the hard work of approaching patient safety from a "cultural" perspective - viewing individual errors and mistakes as opportunities to learn how to prevent patients from being harmed, as opposed to adverse events to be avoided and explained.
The names of these individuals are well known in the world of patient safety: Lucian Leape, Don Berwick, Jim Bagian, Peter Pronovost, David Marx, Michael Leonard, Sorrel King, among others. They have been the early adopters of safety culture change activities and have already done a lot of the "heavy lifting" for the rest of us. They have been very successful in their own worlds - clearly demonstrating the value of culture change in making measurable and sustainable organizational improvements. They have also demonstrated how difficult culture change can be, and how difficult it has been to spread change outside their "spheres of influence." Nonetheless, the direction is well marked and unmistakably clear: leadership must foster and develop an open learning culture where it is possible to learn from mistakes. This simple statement of demonstrated fact belies a complex undertaking.
Return to topJames Reason, in his book Managing the Risk of the Organizational Accident ,iv coined the term "Just Culture" to bridge the gap between reasonable accountability and no-fault reporting. David Marx expanded the concept further and has provided guidance for health care organizations. His seminal work, Patient Safety and the "Just Culture": A Primer for Health Care Executives ", discusses creating a culture of safety in which leadership must foster and develop an open learning environment where it is possible to learn from mistakes. He characterizes a just culture in terms of a set of three beliefs and five duties:
A fair and just culture, fostered in a team-based environment by engaged leadership, seems a robust recipe for achieving high reliability.vi
The question remains: how do we get there?
Moving ForwardWhen you're immersed in the culture of health care, and particularly if you've been immersed in that culture for a long time, even thinking about change is difficult. All of us in health care were motivated and trained to do something good with our professional lives - and that's what we all think we are doing every day. We have to be right, do things correctly, and not make mistakes. First of all, we must do no harm!
And yet, if we're all doing everything right, why does the evidence clearly demonstrate that up to 4% of hospital patients encounter a serious error in their carevii , often leading to injury or death? Why do patients receive only 45% of recommended careviii ? Why does our health care system not compare favorably with international benchmarks?ix
The Commonwealth Fund's recently published first annual scorecard examined how the United States' national average compared with the top 10% of industrialized nations, as well as states, hospitals and insurance plans here at home. We scored 66 on a 100-point scale that looked at 37 indicators. That's a "D." The study also broke down how we fared on the following five dimensions on the same 100-point scale:
It is important to remember that these results include the many hospitals and providers that do meet or exceed all benchmarks. However, given that many hospitals and health systems are doing well, the challenge is not insurmountable. "Top Performing" facilities come in all sizes, are found all over the country, and share the following common characteristicsx :
The key to making health care safer is changing the way we think about what we do, then doing something about it. Patient safety culture change begins in the mind and then translates into action.
Here's a quote that may make you think differently about what you do:
"No one comes to work intending to harm another. We are, however, all players in an imperfect and complex system. Almost by definition, these systems predispose patients to medical errors. Only by fundamentally changing the underlying systems can we get to the root of the problem and prevent future errors." - Marlene Miller, MD, M.Sc, Director of Quality and Safety Initiatives, Johns Hopkins Children's Center
You can demonstrate your commitment to bringing about safety culture change in practical ways:
Remember, patient safety culture change is not just another project that starts today and ends tomorrow. Safety culture change is about "fundamentally changing" ("transforming") the systems, processes, and outcomes of care for the better.
Return to topResearch has shown that human errors in hospitals occur within complex systems of care in which there are multiple contributors to any failure - the "Swiss cheese" model. Pointing the finger at any one human error as the cause of harm and correcting that defect as a primary preventive strategy has not, and will not, help us achieve the level of safety and quality we all seek.
These brief articles by David Woods and Richard Cook articulate a way of thinking about error that is a much better fit with the wider understanding we now possess of this problem:
The New Look at Error, Safety, and Failure: A Primer for Health Care and Primer Graphics From Counting Failures to Anticipating Risks: Possible Futures for Patient SafetyAdditional resources that touch upon the key issues involved in moving from a "culture of blame" to a fair and just culture include:
1. Key Learning from the Dana-Farber Cancer Institute's 10-Year Patient Safety Journey
A brief summary describing the six most critical elements of patient safety learning experienced by Dana Farber following two tragic patient deaths in 1995.
2. A Typology of Organizational Cultures
An article by R. Westrum from the journal Quality and Safety in Health Care that provides a useful way to describe organizational culture and to think about what drives organizational culture change.
3. Patient Safety and the "Just Culture": A Primer for Health Care Executives
A 28-page primer developed by David Marx, JD, for Columbia University under a grant provided by the National Heart, Lung and Blood Institute; explores this concept, it's impact on event reporting systems, and application of the concepts in creating a culture of safety in healthcare.
4. Sensemaking Guidelines
Sensemaking conversations can provide an opportunity for hospital leadership and staff to explore and understand unexpected, ambiguous, or novel events within an
organization. Nancy Dixon, of Common Knowledge Associates, developed the Sensemaking Guidelines as part of a CMS Patient Safety Learning Pilot. The Guidelines explain the concept of sensemaking, outline clear steps to creating sensemaking conversations, and provide practical examples of how this powerful tool can be used as part of creating a culture of safety. Click here to access the guide on MedQIC.org.
5. When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals
Risk Managers have long known that an effective response to an adverse event could not only prevent a costly and traumatic malpractice suit (which is their focus), but also prevent future patient harm and improve care by identifying breakdowns in the system and opportunities for safety and quality improvement (which is everybody's focus). Virtually everybody agrees that we need to develop better hospital practices that can accomplish both objectives. Especially important is that we all become more open and comfortable with how we respond when things go wrong. To provide evidence-based guidance to hospitals about how they can best respond to patients and their families in situations in which an adverse event has occurred, a group of risk managers and clinicians from several Harvard teaching hospitals met to develop a consensus statement. The Massachusetts Coalition for the Prevention of Medical Errors
(www.macoalition.org ) released this statement.
Return to topi Leape LL. Testimony, United States Contress, House Committee on Veterans' Afffairs; 1997 Oct 12
ii Norman, D. The Design of Everyday Things. New York: Basic Books (Perseus): 2002
iii Don Norman . Fri, 18 Mar 2005
iv Reason, J. Managing the Risk of the Organizational Accident . Aldershot, England. Ashgate: 1997
v Marx D. Patient Safety and the "Just Culture": A Primer for Health Care Executives . New York, NY: Columbia University; 2001
vi Frankel, A. Leonard, M. Denham, C. Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability. Health Services Research , August 2006
vii Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med . 1991;324:370-376
viii Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, McGlynn EA. Who Is at Greatest Risk for Receiving Poor-Quality Health Care? N Engl J Med . 2006;354:1147-1156
ix The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from a National Scoreboard on U.S. Health System Performance. The Commonwealth Fund, September 2006
x High Performing Hospitals: A Summary of Related Studies
Return to topRichard Corcoran, Safety Project Lead, rcorcoran@nyqio.sdps.org
Charles Stimler, MD, MPH, Medical Officer, cstimler@nyqio.sdps.org
Marguerite Shaffer, RN, Senior Director, mshaffer@nyqio.sdps.org
Patient Safety Tools is produced by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-NY-TSK1C1-06-10.
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