1. Quality and Safety: Are you creating an environment for safe, high quality care?
Carolyn O’Brien, MSN, RN

2. Mayo Clinic International reputation for excellent patient care
Long tradition of focus on quality care, putting the patient first
Primary Value:
“The needs of the patient come first”

3. Mission and Vision
To inspire hope and contribute to health and well-being by providing the best care to every patient through integrated clinical practice, education and research
Mayo will provide an unparalleled experience as the most trusted partner for healthcare
In order to be trusted, we must be safe

4. How does Mayo define Quality?
Service
Outcomes
Safety

5. Service Patient Satisfaction
Awarded #1 hospital in patient satisfaction in 2010 and 2011 by Professional Research Consultants, Inc. (PRC) –patient satisfaction vendor
Strong organizational focus and leadership involvement

6. Outcomes Quality Improvement (QI)
Strongly woven into the fabric of our organization
Improve outcomes by improving systems and processes
Positive, healthy culture is determining factor in success or failure of performance improvement interventions

7. Safety Foundation of Quality Care Mayo’s Commitment to Safety
Healthy culture, where staff speak up about safety concerns and work in an environment where we learn from and respond fairly to errors
Safe behaviors
Safe systems and processes
How many of you have been practicing for more than 12 years? 1999 is when the IOM report “ To Err is Human” was published and gave birth to the patient safety movement. That report told the world that 100,000 people died every year from preventable medical errors. I’ve been practicing since we can all tell stories of things were when we started in nursing. My first job we used med cards, and poured our pills for the day into little white paper cups and kept them on a metal tray- that makes me really sound old! When I worked in the MICU/CCU at Boston University hospital in 1990, we mixed our own cardiac gtts, Ntg, Doobutamine, Heparin- things have changed tremendously. In 2000, I worked in risk Management for investigating sentinel events and conducting root cause analysis. As training for that role, I attended a seminar in Tampa that that opened my eyes to how medical errors happen- that systems and processes need to be improved to provide for better outcomes. We’ve learned that certain processes, certain drugs, certain transitions in care are high risk for errors to occur-

8. 10 years about 44,000 to 98,000 people died each year as a result of preventable medical errors
Today, the number of patients harmed in hospitals may be 10 times greater than was previously estimated
What contributes to patient harm?
Insufficient teamwork among clinicians
Ineffective communication among clinicians and between clinicians, patients, and families
Poor hospital safety cultures (cultural norms and behaviors that do not demonstrate a commitment to patient safety at every level of the organization (Pascal Metrics) 8

9. Culture and Patient Safety
Required elements for a healthy culture
Psychological safety
Organizational fairness
Transparency

10. Psychological Safety
Definition: “people’s perception of the consequences associated with taking personal risks.” (TEM Field Manual, 2012)
Present when people feel free to speak up and questions are welcomed
Mutual respect is key
Professional tone of communication
Flattened hierarchy between disciplines
Management of disruptive behavior

11. How do we know if we have psychological safety?
Staff are not hesitant to speak about patient safety concerns
Staff are treated with respect when concerns are expressed
Concerns are acted on

12. How do we promote psychological safety?
Unit and organizational leaders encourage staff to raise concerns and welcome it
Encourage feedback and act on it
Celebrate and praise new ideas

13. Organizational Fairness
Historically- healthcare has been a culture of blame and punishment, a punitive culture
A punitive culture discourages staff from speaking up
Safety depends on people speaking up
Reporting errors
Reporting and identifying “near misses”

14. Just Culture
“Leaders, managers and staff all value safety and create an environment where mistakes can be shared and learning occurs through identification of faulty processes and at-risk behaviors (J of Nurs Qual Vol 22, No.3 pp )
Encourages staff to use their unique position on the “frontline” to identify safety issues and speak up

15. Fair and Just Culture Moving from culture of blame, to “fair and just”
Responding to errors in a fair and consistent manner
System of accountability
Systems and behaviors are examined
Not individuals and outcomes
(Mayo Clinic and Pascal Metrics, Inc. 2012)
A balance between punitive and blame-free culture

16. Individual Behavioral Choice
Human error
Inadvertent action
Lapse, slip, mistake
Often involve underlying system issues
Increases with complexity of task

17. Individual Behavioral Choice
Risky (Drift)
Behavioral Choice that increases risk where risk is unrecognized or mistakenly believed to be justified
Drift- “individual drifts away from what has been taught through the human desire to accomplish more or through a fading perception of risk as the individual becomes increasingly comfortable or competent in their work”
(Outcomes Engineering, LLC, 2007)

18. Individual Behavioral Choices
Reckless
Behavioral choice to consciously disregard a substantial and unjustifiable risk
Putting self-interest above that of the patient or organization

19. Management Response Thoughtful deliberation related to staff choices
Human error
Console and Learn
Risky
Coach/Learn
Reckless
Corrective Action

20. Transparency
Leaders conduct rounds to seek out and discuss current processes and opportunities for improvement
Outcomes, adverse event, near misses are openly discussed on regular basis and data is shared with all caregivers
Learning is visible - Boards on units that show active work on process improvement

21. Behavioral Competency Diffusion of Best Practices
This is Mayo Clinic’s Commitment to Safety
System Competency
Safe Care & Value
Behavioral Competency
Standardization &
Diffusion of Best Practices
Commitment to Safety
in a fair & just culture
Clearly Defined Behaviors
Pay attention to detail
Communicate clearly
Have a questioning and receptive attitude
Hand-off effectively
Support each other
Accountability for Behavior
Handoffs and transitions
Medication errors
Rapid response team and deteriorating patient
Mayo Clinic’s Commitment to Safety builds on the great work we are doing developing system competencies. Our work to standardize and diffuse best evidence-based practices - our system competencies – have shown substantial success over the past few years.
We realize that even the best systems cannot work successfully if safe behaviors and a strong culture of safety are not in place.
Through feedback received from the Culture of Safety survey, five clearly defined safe behaviors have been established that ALL Mayo staff must adopt.
Along with the behaviors, we will begin using a more fair and just system of accountability when errors occur.
Preventable Harm
Approved by BOG/Management Team 1/24/2011 21

22. Pay Attention to Detail
Intentional focus on specific task to avoid errors
Mindful of task and ramifications
Eliminate distractions-noise, interruptions, other thoughts
(Mayo Clinic and Pascal Metrics, Inc.)

23. Communicate Clearly
Accurate exchange of information that ensures comprehension
Communication is intentional, respectful
Be aware of body language and tone
Verify accuracy and understanding
(Mayo Clinic and Pascal Metrics, Inc.)

24. Have a Questioning and Receptive Attitude
Empowerment to speak up without fear in order to prevent harm
Open and respectful to those asking questions
Responsive and appreciative for concerns raised
Mutual respect
(Mayo Clinic and Pascal Metrics, Inc.)

25. Hand off Effectively
Interactive process of passing on specific information from one person to another, transferring responsibility
Watch body language, tone, respectful, non-intimidating
(Mayo Clinic and Pascal Metrics, Inc.)

26. Support Each Other
A spirit of teamwork, collaboration and cooperation across professions and at all staff levels
Mutually supportive and respectful behavior- keeping a common goal first- the patient
(Mayo Clinic and Pascal Metrics, Inc.)

27. Safe Behaviors = How we communicate
Effective communication is integral part of a healthy, safe culture
Communicate clearly- “speak up”
Handoff effectively
Questioning and receptive attitude
Support each other

28. How do nurse leaders at every level contribute to safe, high quality care?
Create environment and culture where staff feel empowered to:
Speak up
Question the way we do things
Support one another
Are accountable for choices/actions
Learn from errors, don’t blame others

29. Leadership
Unit and organizational culture is shaped by leaders attitudes and behaviors
Effective leaders
Set a positive tone on unit
Share the plan, think out loud and elicit staff input related to their expertise, ideas and concerns
Are approachable, encourage open communication

30. Teamwork and Communication
The next steps in keeping our patients safe and preventing harm focuses on teamwork
High performing, effective teams have
Team Behaviors
Structured communication
“Hard-wire” performance improvement into everyday work
Team Attitudes
Ensure psychological safety
Set expectation of excellence

31. A Team is a Group with: MAYO’S 5 SAFE BEHAVIORS ARE NORMS
Common goals and a game plan
Agreed upon behaviors
Agreed upon attitudes
MAYO’S 5 SAFE BEHAVIORS ARE NORMS
What do teams do:
Teams have a common goal with a game plan in place and know where the team wants to go
They have diverse roles that synergize
They have agreed upon behavioral and attitudinal norms. 31 31

32. A Team: Plans Forward Briefings (huddle, pause, timeout, check-in)
The associated behaviors:
Plans Forward
Briefings
(huddle, pause, timeout, check-in)
Reflects Back
Debriefings
Communicates Clearly
Using Structured Critical Language
In order to do this teams demonstrate certain behaviors:
Plan forward: by briefing or huddling
Reflect forward: Debrief
Communicate clearly: Using structured communication SBAR and Repeat Back
Manage conflict: using structured and critical language.
Ask: What types of critical language does your team use?
Examples: Stop the line.
We have a problem
I need some clarity
Let’s talk about each of these team components in a little bit more detail 32 32

33. Also known as: Huddle Pause Timeout Check-in Briefings COMPONENTS
Everyone knows the game plan
Psychological Safety is ensured
Expectation of excellence is set 33 33

34. Debriefings Debriefings can be the best tool for learning
Three Questions
What did we do well?
What could we do better?
What do we want to do differently tomorrow or next time?
When we are debriefing there are three questions that we should be asking:
What did we do well?
We tend to look at the negative, but we should equally acknowledge what went well.
What could we do better?
There is always room for improvement
What do we want to do differently tomorrow?
What are the goals -- what can we do better for the patient and for ourselves
As a team we should be doing this each day. 34 34

35. Critical Language: Positive Assertion A PHRASE THAT STOPS THE WORK
“I just need a little clarity.”
“I am concerned, unclear, this is unsafe.”
SBAR
Situation, Background, Assessment, Recommendation
Structured, predictable method of communication
Repeat Back
Critical labs, medication dosages
A team member uses critical language to indicate to their team that something is wrong or they don’t know the game plan. Using an agreed-upon phrase, it signals to the entire team that they need to stop work and re-evaluate.
Some examples of critical language include: 
I need clarity
I’m concerned,
I’m unclear
This is unsafe 35 35

36. “Mayo’s Model of Teamwork” Team Training
ID unit, collect data, share results, team training
Ensure psychological safety
Embed team behaviors
Briefings, debriefings, critical language
Improve processes
Make work visible- transparent
Learning boards
Set goals
PDSA
Display knowledge gained
Sustainable process to effect needed improvement

37. Implement Team Behaviors Display the Data (learning boards)
Team-Based Engagement
Implement Team Behaviors
Identify
Unit
Collect
Data
Team
Training 1
Culture & Teamwork 3
Display the Data (learning boards)
Systems
Improve Systems (based on debriefings)
Eliminate Preventable
Harm 2

38. Learning Board
3 North
©2011 MFMER | slide-38

39. Ongoing Work: Further shifting our culture
Model of teamwork
How we….
do our work
communicate
identify safety concerns
improve safety
improve outcomes
improve quality
It is a journey……

40. Questions?

41. References
Mayo Clinic and Pascal Metrics, “Commitment to Safety Team-based Engagement Model (TEM)” PowerPoint, July 31, 2012.
Mayo Clinic. (2012). Mayo Clinic Commitment to Safety. Retrieved July 28, 2012 from Mayo Clinic Web site:
Mayo Clinic and Pascal Metrics, Inc., Team-based Engagement Model (TEM) Field Manual, 2012.
Outcomes Engineering, LLC. (2007). Just Culture Training for Healthcare Managers. Plano, TX: Outcome Engineering, LLC.
Volgesmeier, A., Scott-Cawiezell, J. (2007). A Just Culture The Role of Nursing Leadership. Journal of Nursing Quality, Vol 22, No.3 pp