1. Vicki S. Good, MSN RN CENP CPPS Past President AACN System Adm Director Quality/Safety CoxHealth Courageously Building a Culture of Safety

2.  Identify the elements of a healthy work environment and their impact on patient safety.  Understand the science of safety.  Describe key steps to build a culture of safety on your unit. OBJECTIVES

3.  The speaker has no actual or potential conflicts of interest to disclose. DISCLOSURE

4.  In U.S. Healthcare system  7% of patients suffer a medication error 2  On average, every patient admitted to an ICU suffers an adverse event 3,4  44,000- 98,000 people die in hospitals each year as the result of medical errors 5  Nearly 100,000 deaths from HAIs 6. 2007 CDC: 99,000 people die annually from hospital acquired infections.  Estimated 30,000 to 62,000 deaths from CLABSIs 7  One in 10 will get a HAI: Cost of HAIs is $28-33 billion 7  8 countries report similar findings to the U.S.  Healthcare harm is the 3 rd leading cause of death – that is equivalent of 20 jet airliners full of passengers going down every week THE PROBLEM IS LARGE 2. Bates DW, Cullen DJ, Laird N, et al., JAMA, 1995 3. Donchin Y, Gopher D, Olin M, et al., Crit Care Med, 1995. 4. Andrews L, Stocking C, Krizek T, et al., Lancet, 1997. 5. Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999. 6. Klevens M, Edwards J, Richards C, et al., PHR, 2007 7. Ending Health Care-Associated Infections, AHRQ, 2009.

5. 14. Statistical Summary of Commercial Jet Airplane Accidents, Aviation Safety Boeing Commercial Airplanes, June 2011. http://www.boeing.com/news/techissues/pdf/statsum.pdf

6.  People are fallible  Medicine is still treated as an art, not science  Need to view the delivery of healthcare as a science  Need systems that catch mistakes before they reach the patient  Highly complex system with numerous interruptions  CULTURE HOW CAN THESE ERRORS HAPPEN?

7. Well-intentioned practitioners choose not to speak up when they are concerned with behavior, decisions, or actions of a colleague. 1,700 nurses, physicians, clinical-care staff, and administrators in 2004  50% of workers witnessed co-workers break rules, make mistakes, fail to support, demonstrate incompetence, show poor teamwork, disrespect them, and micromanage.  10% of workers were confident in their ability to raise crucial concerns.

8.  Broken Rules  Mistakes  Lack of Support  Incompetence  Poor Teamwork  Disrespect  Micromanagement SILENCE KILLS 7 MOST CRUCIAL CONCERNS

9.  Skilled Communication  True Collaboration  Effective Decision Making  Appropriate Staffing  Meaningful Recognition  Authentic Leadership AACN HWE STANDARDS AACN. (2005). AACN’ standards for establishing and sustaining healthy work environments: a journey to excellence. Am J. Critical Care, 14(3), 187-197.

10.  Which is strongest on your unit?  Which still needs some attention? AACN HWE STANDARDS AACN. (2005). AACN’ standards for establishing and sustaining healthy work environments: a journey to excellence. Am J. Critical Care, 14(3), 187-197.

12. SAFETY SUCCESSArcingArcing

13.  Courage to speak up  “Three to go, one to say no” principle  “This is Stupid”  “Let’s go home”  Eliminate the fear to report TEAMWORK & SAFETY CULTURE

14.  Every system is perfectly designed to achieve the results it gets  Understand principles of safe design  standardize, create checklists, learn when things go wrong  Recognize these principles apply to both technical skills and teamwork/culture  Teams make wise decisions when there is diverse and independent input HOW CAN WE IMPROVE? UNDERSTAND THE SCIENCE OF SAFETY Caregivers are NOT to blame

15. Systemic Migration of Boundaries: Deviation is Normal Usual Space Of Action Safety Reg’s & good practices, accreditation standards 100% Expected safe space of action as defined by professional standards ‘Illegal normal’ Real Life standards 60-90% 100% Agreement Non- acceptable Rene Amalberti, MD, PhD HIGH Production Performance LOW LOW Individual Benefits HIGH ACCIDENT VERY UNSAFE SPACE

16.  Standardize  Eliminate steps if possible  Use checklists when appropriate  Create independent checks  Learn when things go wrong, investigation, RCAs.  What happened  Why, Why, Why, Why, Why  What did you do/change to reduce risk  Sustain the change PRINCIPLES OF SAFE DESIGN

17.  Engaged Leadership  Effective Communication  An environment where anyone can speak up anytime  Respect / Trust  Shared goals  Expertise  Role clarity WHAT ARE THE ATTRIBUTES OF A HIGHLY EFFECTIVE TEAM?

18. BUILDING A CULTURE OF SAFETY

19.  AHRQ Patient Safety Culture Survey  Measures 12 domains of culture ASSESS THE CULTURE http://www.ahrq.gov/professionals/quality-patient-safety/surveys/hospital/2012/hospsurv121.pdf

20.  Strengths:  Teamwork within units  Sup/Mgr promoting pt safety  Org Learning/Continuous Improvement  Opportunities  Nonpunitive response to error  Hand-off and Transitions  Staffing HSOPS 2014 CULTURE ASSESSMENT http://www.ahrq.gov/qual/hospsurvey10/hosp10chart5-1.htm

21.  CUSP  Designed to improve safety culture and learn from defects by integrating safety practices into the daily work of a unit or clinical area.  Powerful framework  Flexible to fit any environment  Respects the local wisdom of frontline providers  Partnership with Senior Leaders  Partnership for Patients  40% decrease in Adverse events  20% decrease in readmissions  TeamSTEPPS  Just Culture BUILDING YOUR CULTURE

22. 1.Form Team: a.Executive Partnership b.Multidisciplinary front line staff 2.Educate Staff on the Science of Safety 3.Learn from defects – Process a.Ask staff – “how will the next patient be harmed” b.Incident reports, claims, sentinel event c.No more than one defect per month 4.Implement 1.TeamSTEPPS or other crew resource model 2.Just Culture 3.CQI 4.Lean TEAM ACTIVITIES

26.  AACN, AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence Am J Crit Care May 1, 2005 14:187-197  AACN. (2005). AACN’ standards for establishing and sustaining healthy work environments: a journey to excellence. Am J. Critical Care, 14(3), 187-197.  Andrews LB, Stocking C, Krizek T, et al., An alternative strategy for studying adverse events in medical care. Lancet. 349:309-313,1997.  Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274(1):29-34.  Donchin Y, Gopher D, Olin M, et al., A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 23:294-300,1995.  Ending Health Care-Associated Infections, AHRQ, Rockville,MD, 2009. http://www.ahrq.gov/qual/haicusp.htm. http://www.ahrq.gov/qual/haicusp.htm  Health Research & Educational Trust, John Hopkins University Quality and Safety Research Group. Eliminating CLABSI A National Patient Safety Imperative. AHRQ Publication No: 11-0037-1-EG. Sept. 2011.  Hospital Survey on Patient Safety Culture: 2010 User Compartive Database Report, http://www.ahrq.gov/qual/hospsurvey10/, Accessed: 9.19.2011. http://www.ahrq.gov/qual/hospsurvey10/  Klevens M, Edwards J, Richards C, et al., Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. PHR.122:160-166,2007.  Kohn L, Corrigan J, Donaldson M. To Err Is Human: Building a Safer Health System. Washington, DC: National Acad Pr; 1999.  Reason J, Hobbs A. Managing the risks of organizational accidents. Burlington, VT: Ashgate Publishing Company, 2000.  Sexton, J. B., Thomas, E. J., & Helmreich, R. L. (2000). Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ, 320, 745-749.  Statistical Summary of Commercial Jet Airplane Accidents: Worldwide Operations 1959-2008. Boeing News Releases/Statements. July 2009. Aviation Safety Boeing Commercial Airplanes, Web. 21 Jan 2010..  Tucker, A. L., Spear, S. J. (2006). Operational failures and interruptions in hospital nursing. Health Services Research 41(3), p. 643-662. REFERENCES