Culture of Teamwork and Safety in Healthcare

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Culture of Teamwork and Safety in Healthcare

• J. Bryan Sexton, Ph.D.
• Johns Hopkins University

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Error is Inevitable Because of Human Limitations

• Limited memory capacity 5-7 pieces of
  information in short term memory
• Negative effects of stress error rates
• Tunnel vision
• Negative influence of fatigue and other
  physiological factors
• Cognitive performance after 24 hrs. without sleep
  equivalent to blood alcohol of .10 !
  Dawson et al, Nature, 1997
  
• Limited ability to multitask cell phones and
  driving

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Perceptions Drive Reality
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What of frontliners agree?

• The administration of this hospital is doing a
  good job
• Hospital administration supports my daily efforts
• Hospital management does not knowingly compromise
  the safety of patients

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• We tend to over-rely on technology

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Teams and Technology
Hi-tech band-aids dont replace teams
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• Rather than being the main instigators of an
  accident, operators tend to be the inheritors of
  system defects.. Their part is that of adding
  the final garnish to a lethal brew that has been
  long in the cooking.
• James Reason, Human Error, 1990

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Culture at Work in Medicine
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Annual US Health
Research Funding
Millions of Dollars Spent
Sources ACP-ASIM Observer, 2001,
http//www.acponline.org/journals/news/feb01/clinr
esearch.htm Federal Funding and
Priorities for Health Services Research,
AcademyHealth, March 10, 2003.
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Learning to embrace the wisdom of the frontline
caregiver
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What is Culture? The way we do things around
here
1 attitude opinioneveryones attitude
culture
aka Climate
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Comparing Culture Surveys
SAQ 22 out of 23 characteristics
Qual. Saf. Health Care 200514364-366
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Executive Perceptions vs. Frontline
Perceptions Executives overestimate Teamwork
Climate 4X Safety Climate 2.5X
Executive Confidence vs. Executive
Accuracy -Often wrong but rarely in
doubt -Currently no incoming data-streams -Halo
Effects -Frontline data fills the gap
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Hospital Wide Culture

• Interesting
• Not the best unit of analysis masks variability
  between work units

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of respondents reporting positive safety climate
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of respondents reporting positive safety climate
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2005 Safety Climate across Clinical Areas
Goal 80
 
of respondents that agree safety climate is
positive
Needs improvement 19
27. My suggestions about safety would be acted
upon if I expressed them to management.
 
of respondents that agree
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Suits meet Scrubs Executive Partnership
Executive WalkRounds
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Improving Safety Climate

• Executive Partnership
• Select the executive for the unit carefully
• Level of executive
• Clinical vs. non-clinical
• Ability to connect with front-line workers
• Long-term commitment

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of respondents reporting positive safety climate
EWRExecutive Walk Rounds
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Teamwork Climate Perceived quality of
collaboration between personnel in this unit
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of respondents reporting positive teamwork
climate
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80 or higher is climate goal 23 reached it
 
of respondents reporting positive teamwork
climate
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Teamwork Climate Across Michigan ICUs
The strongest predictor of clinical excellence
caregivers feel comfortable speaking up if they
perceive a problem with patient care
of respondents within an ICU reporting good
teamwork climate
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Teamwork Climate across 250 ICUs from the past 18
months
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Teamwork Climate Across
ICUs
 
of respondents within an ICU reporting good
teamwork climate
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3. Nurse Input Is Well Received In This ICU.
 
of respondents within an ICU that agree
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3. Nurse Input Is Well Received In This ICU.
 
of respondents within an ICU that agree
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Heeding input from others
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32. Disagreements In This ICU Are Resolved
Appropriately (i.e. not who is right, but what is
best for the patient).
 
of respondents within an ICU that agree
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Conflict Resolution in the OR

• Conflict was observed in 10 of flights and 10
  of surgeries

• Resolved in 80 of instances in cockpit

• Resolved in 20 of instances in operating room

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40. The Physicians And Nurses Here Work
Together As A Well-Coordinated Team.
 
of respondents within an ICU that agree
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Teamwork Climate Annual Nurse Turnover
 
reporting positive teamwork climate
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of respondents reporting above adequate teamwork
ICU RN/MD OR RN/Surgeon
CRNA/ Anesthesiologist
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Teamwork Disconnect

• RN Good teamwork means I am asked for my input
• MD Good teamwork means the nurse does what I say

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Have you ever..
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Familiarity with others is a critical component
of effective teamwork

• 74 of all commercial aviation accidents happen
  on the first day of a crew flying together
• Familiarity trumps fatigue
• Highlights the importance of predictable patterns
  of behavior

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I know the names of all the personnel I worked
with during my last shift
Agree
 
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Does it get better?
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CUSP at work in MI

• BSI from 50th percentile to the 10th percentile
  in first year
• Safety Climate improved 20 statewide

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Safety Measures

• How often do we harm patients?
• BSI and VAP
• How often do we do what we should?
• Vent bundle sepsis bundle
• How often do we learn from defects?
• Learn from one per month
• How well do we improve culture?
• SAQ

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JHH Surgery and ACCM August Safety Dashboard
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The Johns Hopkins Comprehensive Unit-based Safety
Program (CUSP)

• Engage- make harm real
• Execute- standardized interventions that includes
  tools for culture change
• Evaluate- scientifically sound measures

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The Johns Hopkins Comprehensive Unit-based Safety
Program (CUSP)

• Evaluate culture of safety
• Educate staff on science of safety
• - http//www.jhsph.edu/ctlt/training/patient_saf
  ety.html
• Identify defects
• - survey and incident reports
• Assign executive to adopt unit
• Learn from one defect per month
• - measure how often we learn from defects
• - tool www.safetyresearch.jhu.edu/qsr/
• 6. Evaluate culture

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Keystone ICU CUSP Statewide Michigan Improvement
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80 Reduction in BSI in One Year
433 prevented infections 108 deaths
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Safety Climate Across Michigan ICUs
 
of respondents within an ICU reporting good
safety climate
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Safety Climate Across Michigan ICUs
 
of respondents within an ICU reporting good
safety climate
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Safety Climate Across Michigan ICUs
 
of respondents within an ICU reporting good
safety climate
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OR Briefing Intervention to Improve Teamwork
Climate
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Agree
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Agree
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Agree
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Agree
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Kaiser Permanente LD Unit Scores
 
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Take Home

• Respect the wisdom of the front line workers
• Culture is related to clinical and operational
  outcomes
• Culture is local work unit culture trumps
  hospital culture
• Lots of variability across work units
• Familiarity improves predictable patterns of
  behavior (improves performance)
• Perceptions of teamwork differ by role, whereas
  perceptions of safety climate are consistent
  within a work unit
• Senior leader contact with front-line workers is
  key to improving perceptions of safety climate
• Frontline providers have demonstrated a striking
  ability to improve culture in an relatively short
  time, when they are leading the effort
• Answer the question Are We Safer than Last
  Year?

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Questions?
Hey whats a mountain goat doing way up here in
a cloud bank?
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Culture Tools Modules of CUSP

• Daily Goals
• Executive Partnerships with Units
• Analyze a Defect Root Cause Light
• Multi-Disciplinary Shadowing
• AM Briefing About Last Night
• T-List for Effective Communication
• Observe Rounds
• In-service culture results highlight the
  culture conversation with data