Culture Change

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Culture Change

• Frances A. Griffin, RRT, MPA
• Director
• The Institute for Healthcare Improvement

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Culture

• Systems of knowledge shared by a relatively large
  group of people (Gudykunst and Kim 1992)
• Culture is communication, communication is
  culture. (Edward T. Hall)
• A set of values, attitudes and beliefs that
  governs behavior.

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Culture

• A way of life of a group of people--the
  behaviors, beliefs, values, and symbols that they
  accept, generally without thinking about them,
  and that are passed along by communication and
  imitation from one generation to the next.
• NASA
• At the most basic level, organizational culture
  defines the assumptions that employees make as
  they carry out their work.

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Impact of Culture

• Absenteeism
• Turnover
• Reporting
• Practice
• Service
• Satisfaction
• Mortality
• LOS

COST
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How did we get here?

• Traditional approach to errors
• Blame of the individual
• Response of agencies
• National Practitioner Data Bank
• JCAHOLicensing Boards
• Malpractice
• Reporting Punitive Response
• Reporting

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Development of Culture

• Leadership
• Events
• Rumors
• Reporting
• Hierarchy

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Why errors happen

• Design
• Complexity
• Human Factors

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The Three Buckets James Reason
SELF
CONTEXT
TASK
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The Three Buckets James Reason
Custodial attention Discretional energy
(extra mile) Experience Knowledge Fitness Self
awareness limited commodities eroded by
bad stuff
Clear instructions Good briefing Good
teamwork Available time Good rapport Able to
question Good kit, etc
Forcing functions Standardization Alerts
reminders
Preoccupation Inexperience Lack of
knowledge Under the weather Fatigue Emotional
state Life events
Distractions Interruptions Change Harassment Hand-
offs Authority gradient Poor workplace
Multiple steps
SELF
CONTEXT
TASK
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Rene Almerberti

• Safe Zone
• Agreed upon consenus
• Defined in policies, procedures, SOP, guidelines
• Acceptable Risk
• Based on optimism perceived by experience

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Systemic Migration to Boundaries
Expected safe space of action as defined by
professional standards
VERY UNSAFE SPACE
ACCIDENT
PERFORMANCE
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Accident
Mitigation
Recovery
Prevention
Selon Jean Pariès, Dédale SA
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Accident
Mitigation
Recovery
Prevention
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Errors Adverse Events

• How are they handled?
• System issue or individual blame?
• What is discussed and shared?
• How do staff PERCEIVE they are handled?

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Communication Failure Factors

• Suboptimal systems
• Hierarchy / power distance
• Failure to communicate differences in
  communication style RN-MD
• Lack of common mental model
• Not having a voice, lack of respect
• Transitions of care

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Who is the team?
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Experience with Lack of Sharing

• When we dont share our experiences, we dont
  learn from the lessons of others
• the same events keep occurring
• over and over again.

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Practical Tools for Changing Culture
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• Leadership Walkrounds
• Safety Briefings
• Pre-procedural Briefings
• SBAR
• Daily Goals Multidisciplinary Rounds

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Leadership Walkrounds

• Weekly rounds by senior leadership
• Focused on patient safety
• Direct interaction with front-line staff
• Coordinated with middle management
• Feedback !
• Scripted questions
• Link to briefings

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Safety BriefingsWhat Do We Want to Accomplish?

• Increase staff awareness of medication safety
  issues
• Bring staff together to discuss medication safety
• Create an environment where staff freely share
  information without fear of reprisal
• Integrate safety into daily routine
• Design for self-use 24 x 7 x 365

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How Will We Know That a Change Is an Improvement?

• Safety issues identified by staff
• Information shared
• Potential errors identified and prevented
• Patients involved in process
• Staff perceive as valuable

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Key Elements

• Non-punitive
• No identifying documentation
• Time-limited
• Patient care must be first priority
• Pre-identified list of safety issues
• Evidence-based
• Easy to use
• Staff must be able to use on own
• Applicable to other safety issues

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Briefing Start of Shift

• Explain purpose of briefing
• Reinforce non-punitive aspect
• Collect data
• Time for briefing (goal 5 minutes)
• Number of issues raised by staff
• Staff perception of usefulness and value

• Reconvene staff
• Reinforce non-punitive aspect
• Encourage sharing
• Collect data
• Time
• safety issues
• near-misses
• patient questions
• Was it a near miss?

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Data from an 8-Day TestWeekdays Only, 7am-3pm
Shift
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Observations Learnings

• Perception problem
• Staff vs. management
• Multiple issues identified
• More near misses than Adverse Drug Events
• Staff learned from each other
• Follow-up communication are key elements to
  success
• Staff must see results benefits
• Link to Leadership Walkrounds

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Pre-Procedural Briefings

• Different type of briefing
• Specific to current situation
• Applies beyond the O.R.
• High-risk, invasive procedures
• Low frequency procedures
• Most analogous to aviation

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Role of Pre-procedural Briefing

• Establish sense of team
• Introduce everyone
• Open door to communication
• Review the plan, including known risks
• Ensure that everyone is on the same page
• Provide mechanism for conflict resolution

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Briefings - Key Elements

• 1. Involve others
• 2. Explicitly ask for inputs
• 3. Ask knowable information
• 4. Share information with others
• 5. Use first names
• 6. Make eye contact - face the person
• 7. Emphasize responsibility to offer inputs

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Situational Brief

• S-B-A-R
• Situation
• Background
• Assessment
• Recommendation

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Situational Brief Example

• Situation Dr. Jones, Im Paul, the respiratory
  therapist. In my HF training, I was told to get
  help if I am worried about a patient. Theres
  someone downstairs whos in serious respiratory
  distress.
• Background He has severe COPD, has been going
  downhill, and is now acutely worse..

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• Assessment His breath sounds are way down on the
  right side I think he has a pneumothorax and
  needs a chest tube pronto before he stops
  breathing.
• Recommendation Id like you to come with me now
  and see himI really need your helpthis guys in
  real trouble.

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Assertion The Bottom Line

• Looking back after something has gone wrong, we
  usually find
• CONCERN was expressed
• The PROBLEM was stated, often not clearly
• A PROPOSED ACTION didnt happen
• A DECISION was not reached

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Daily Goals Multidisciplinary Rounds
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Comprehensive Patient Safety Program (Pronovost
et al., 2000)
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Target Safety Climate

• Peter Pronovost, M.D., Ph.D., et al. at Johns
  Hopkins
• Administered Safety Climate Scale before and
  after the intervention
• Post intervention
• Marked improvement in Safety Climate at each ICU
• Reduced number of medication errors
• Reduced LOS by 50

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Impact on ICU Length of Stay
Pronovost (2002)
654 New Admissions 7 Million Additional Revenue
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A Safety Conscious Culture

• Reporting
• Events, errors, unsafe conditions
• Education
• All staff, new and on-going
• Design
• Incorporation of human factors
• Leadership
• Driving Force

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• Unsafe acts are like mosquitoes. You can try to
  swat them one at a time, but there will always be
  others to take their place. The only effective
  remedy is to drain the swamps in which they
  breed.
• James Reason

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