Culture

1
Culture Safety in Medicine

• Robert M. Bell, MD., Ph.C.

2
Introduction

• To discuss how we are all error prone
• To discuss the various aspects of culture in
  hospitals its impact on errors/safety
• To list some factors leading to good and bad
  cultures
• To makes some brief comments about
• private office culture
• changes taking place around the country
• To suggest a way forward

3
Good Things

• Not on staff and not aware of the culture and
  systems in place - anecdotally have heard some
  good things

4
We Should Be Proud!

• Some of the best standards of medicine in the
  world
• Complexity risen exponentially (Merck Manual 192
  pages in 1899 vs 2991 pages in 2006)
• Battered by litigation, Medicare, HMOs,
  paperwork, long hours, decreased payments, safety
  concerns, P4P, etc.
• And we are, in the main, all still reasonably
  sane and doing a good job
• But we are not perfect

5
150 Years Ago

• 1859 Florence Nightingale
• It may seem a strange principle to enunciate as
  the very first requirement in hospital that it
  should do the sick no harm.
• 1857 Ignaz Semmelweis
• implored us to wash our hands - still working on
  it!

6
Difficult Topic

• Much emotion/tension generated
• No one likes to talk too much about
• Errors (basically a blame and shame society)
• CHANGE, standards, and management policies

7
We All Make Mistakes

• Whats absent here? Cant see erasers
• Most pencils have erasers for a reason
• Some have difficulty in
• acknowledging their
• proneness to error
• Acknowledging this
• would seem to be
• STEP ONE to
• changing any hospital
• culture

8
Physicians and Error

• Physicians who are pilots crash their planes more
  than other pilots
• 1 in 7 MDs will accidentally kill someone this
  year (1999 IOM)
• M.D. 7,500 times more likely than a gun owner to
  accidentally kill someone
• Robert Bells error experience!
• Day 1 - Eight Day 2 - Five

9
First Impressions

• First impressions, Snap judgments, Gut feelings.
• Instant analysis. The Blink of an Eye.
• Thin slicing (filtering the few factors that
  matter).
• Doctors very good at this.
• Most often right. However, can be prejudiced, and
  can be VERY wrong.
• That extra question and check can be life saving.
  
• Too thin a slice and in trouble.

10
The Fear Factor in Safety

• Litigation, income, HMO restrictions, paperwork,
  etc. that all lead to intense pressures
• Fear we will make a mistake and be criticized by
  colleagues
• Being sued - risk more related to bedside manner
  than knowledge or training
• Those NOT sued spend 3 minutes longer with
  patients
• Fear leads to stress and problems, that in turn
  impacts safety

11
Robert, Trust No One in Medicine!

• Professor Michael Gelfand, MD
• Very blunt, but was really saying
• If it does not look right - question it

12
Patients Culture

• Language, education, poverty, insurance coverage,
  inner city versus suburbs
• Drug and alcohol use
• Level of
• expectation
• participation
• Compliance, health habits
• History recall
• File of Life can help
• All have impact on hospital culture, errors, and
  outcomes

13
Employees/Staff Culture

• In some places
• underpaid, overworked, fatigued, and angry
• Poor communications (Leo Buscaglia)
• Poor systems
• Lack of leaders
• Lack of role models (MDs very important)
• Resistance to change
• Patients not part of team
• Reverse this and you have a win, win, situation
  in terms of safety

14
Management Culture

• Hierarchical, too bottom-line oriented, my way
  or the highway -- not good
• Board and Management need to be totally committed
  to safety
• Has to be In the DNA of the hospital
• Good leadership at all levels
• Executive rounds can really help
• Support for all safety initiatives
• And above all, have transparency and foster
  communication

15
Conflict Resolution Procedures

• This can produce
• improved clinical outcomes,
• decreased errors, improved morale and job
  satisfaction
• decreased costs, lower stress and improved
  patient/family satisfaction
• Demonstrates respect for employees
• Its a great way to change culture
• reduces fear
• good deal all around
• AzAFP statement recently approved (stress
  non-adversarial)

16
Private Offices

• Many hospital disasters start in the office
• Administrative/system errors account for 80
• Need event and near miss collection system
• Need analysis and then change in system to
  correct
• Could focus on anticoagulants as a start - hear
  from Dr. Linda McCoy
• Appoint someone as a Safety Officer?

17
Real Life

• Son, UW travel clinic. Given Rx.
• Pharmacy left anti-malarial out
• Did not take anything in India
• Covered himself with Deet. It worked
• Anti-malarial not covered - did not tell him
• Problem? Near Miss?
• HMO, benefit manager
• His insurance plan, pharmacy, my son
• Similarly in hospitals. Sure you all have war
  stories

18
Culture in the USA

• Very difficult to ascertain where the nation is
• A survey undertaken on the NPSF list was not well
  answered
• One person said it will take 10 years to change
  culture
• Impression was - hospitals are struggling
• Some incredibly committed (Childrens Hospitals
  and Clinics of MN)
• Some going slowly

19
Culture in the USA continued

• Recent American Medical News article
• 1,155 physician executives surveyed
• Most common obstacles to high quality patient
  healthcare and patient safety.
• Top 5
• 93 - patient compliance and awareness of
  healthy habits
• 90 - lack of resources or money
• 89 - clinician communication and culture
• 88 - physician resistance to use
  evidence-based care
• 87 - desire to maintain status quo

20
Good Culture Enhancers and Diminishers

• See handout
• Lists the basic factors that impact culture, both
  good and bad
• from conflict resolution procedures
• to disruptive behavior
• to patient involvement

21
What Does All This Mean?

• To my mind, all at this hospital should want to
  make it the safest hospital in the WORLD --
  nothing less
• Main points to remember
• Need
• A commitment to good communication
• Totally committed management and board
• Totally committed staff
• Patient involvement
• A kind, just, culture

22
Next Steps?

• Need to understand how tough the challenge is
• Humbly, would recommend
• Assessing where you are, and where you want to be
  with the resources at hand
• Having focus groups at all levels, then
• Developing a LONG-range safety plan

23
References

• Dekker, Sidney W.A. Ten Questions About Human
  Error A New View of Human Factors and System
  Safety 2005 L. Erlbaum Associates, Inc. New
  Jersey
• Gladwell, Malcolm. Blink the power of thinking
  without thinking, 2005. Little Brown and Company.
  NY. NY.
• Dement WC, National Public Radio Interview May
  31, 2007
• Marshall P, Robson R. Preventing and Managing
  Conflict Vital Pieces of the Patient Safety
  Puzzle, Healthcare Quarterly, 2005839
• Many National Patient Safety Foundation list
  server discussions
• Adams D. Safety and quality suffer under
  strained systems. American Medical News July 9,
  2007 50 (26)1
• Short Cuts, Pilot your plane safely BMJ
  2007334822