Culture

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building
THE FOUNDATIONS
for patient SAFETY
collaboration
communication
education
Redefining the Culture for Patient Safety
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Redefining the Culture for Patient Safety

• A common misconception is that patient safety is
  about reminding people to be more careful.
• But patient safety isnt about cautioning health
  care staff to be more careful.
• In fact, we are some of the most careful people
  on earth.
• Improving patient safety is about changing the
  culture in health care from one of blame to one
  where we examine our systems from beginning to
  end to reduce the opportunities for mistakes.

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Not Who caused the accidentbutWhat caused the
accident?
Medical errors most often result from a complex
interplay of multiple factors. Only rarely are
they due to the carelessness or misconduct of
single individuals. Lucien L. Leape, M.D.
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Redefining the Culture for Patient Safety

• Three concepts to move toward changing the
  culture for patient safety
• Swiss Cheese Model
• Blunt and Sharp End
• Hindsight Bias

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Concept 1 Swiss Cheese Model

• Accidents result from multiple factors not a
  single failure
• Many defenses exist to deflect failures
• But, multiple failures align so error occurs
• System review can help identify how failures get
  through the defenses

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Swiss Cheese Model
Defenses
System
Opportunity for failure
System
System
System
ACCIDENT
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Key Learnings of Swiss Cheese Model

• Systems that rely on error-free performance are
  doomed to failure
• Humans make mistakes
• Continue to strive for perfection but realize
  humans are not perfect

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Concept 2 Blunt End/Sharp End Model

• Blunt End Organizations policies, procedures,
  resource allocations and systems that may
  contribute to an error
• Sharp End Direct caregivers at source of
  contact with patient

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Blunt and Sharp End
Policies, procedures, resource allocation systems
Blunt End
Direct caregiver
Sharp End
ERROR
Monitored Process
Results
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Key Learnings of Blunt/Sharp End

• The blunt end may be a barrier or an enabler
  for caregivers depending on how policies and
  resources are designed
• The sharp end is constantly creating ways to
  safeguard patients and make workaround solutions
  to barriers everyday

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Concept 3 Hindsight Bias

• Prior to the accident/error, many intervening
  factors are evident and must be considered in
  taking action.
• Yet after the accident, it seems clear that a
  different action should have been taken.
• So hindsight bias is the phenomena in which how
  an accident/error occurred seems obvious after it
  has occurred.

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Hindsight Bias
Multiple Factors
Seems So Easy
D
A
C
A
B
B
Before the Incident
After the Incident
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Key Learnings ofHindsight Bias

• Hindsight narrows the focus on the cause of the
  failure/incident/error without considering the
  whole picture, including all of the
  environmental, emotional, political and system
  issues surrounding the event
• Hindsight bias limits a complete and thorough
  investigation
• Hindsight bias creates a tendency to ignore
  system issues and focus on individual action

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Using Concepts and Learnings

• Foundation for leaders to understand how errors
  occur
• Knowledge to assist leaders in creating the right
  safety minded culture
• Resources to support individual organization
  initiatives

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Nonpunitive/ Blameless Culture

• An environment of trust is established
• Non-blaming, responsibility-based approach to
  causation of incidents/errors is created
• Policy for non-blame is developed
• Expectations for timely error and near-miss
  reporting and investigations are set
• Reporting is the norm

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Nonpunitive/ Blameless Culture

• People are rewarded for reporting adverse
  events and near-misses
• Leadership is involved in significant
  investigations
• Learnings are based on system/process
  improvements
• Performance based accountability mechanisms are
  separate processes
• Staff involved in incidents are openly supported
  by leaders (caregiver guilt/grief)

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Nonpunitive/ Blameless Culture

• Empower staff to correct safety hazards
• Leadership communicates with medical staff and
  employees to illustrate nonpunitive approach
• Language changes may reflect a positive approach
  to patient safety and reporting
• Activities of risk and legal counsel are aligned
  with patient safety agenda while protecting the
  organization

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References/Resources

• Redefining the Culture for Patient Safety
  (www.mhhp.com)
• AHA Strategies for Leadership Hospital
  Executives and Their Role in Patient Safety
  (800-242-2626 166924)
• Strategies for Leadership An Organizational
  Approach to Patient Safety (www.aha.org/medication
  safety)

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References/Resources

• AHA Strategies for Leadership Video Series
  (800-242-2626 166921 166922 166923)
• Beyond Blame Video by Bridge Medical
  (www.mederrors.com)
• Elements of a Culture of Safety. Pennsylvania
  Patient Safety Collaborative (717-564-6606)
• AHA Quality Advisory A Culture of Safety
  Disclosure of Unanticipated Outcome Information
  (www.aha.org)

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References/Resources

• Sample survey on culture from Allina Hospitals
  and Clinics (www.ismp.org/Tools/AllinaAssessment.h
  tml) Sample survey on culture from CareGroup
  (contact Dr. Weingart for permission
  sweingar_at_caregroup.harvard.edu)
• Check FHALink at www.fha.org