1. A Culture of “Surgical” Patient Safety
Joseph F. Golob Jr. MD FACS CPHQ
Medical Director of Patient Safety
Medical Director of SICU and TICU
Program Director – Surgical Critical Care Fellowship
MetroHealth Medical Center

2. Objectives
What is culture and specifically what is a culture of safety?
Describe the key components to a patient safety culture: leadership, psychological safety, accountability, teamwork and negotiation.
Google’s model of culture
What can you do to foster a culture of safety?

3. “The equivalent of a jumbo jet crashing everyday with no survivors”
1999 IOM report: 44,000 to 98,000 deaths per year from preventable medical mistakes
“The equivalent of a jumbo jet crashing everyday with no survivors”

4. © 2016 BMJ Publishing Group LTD
Makary MA, Michael D. Medical error-the third leading cause of death in the US. BMJ 2016; 353:i2139

5. a system of clinical excellence which is preoccupied with failure
How do we improve?
By creating
a system of clinical excellence which is preoccupied with failure
© 2017 Institute for Healthcare Improvement and Safe & Reliable Healthcare

6. The way of life, especially the general customs and beliefs, of
What is culture?
The way of life, especially the
general customs and beliefs, of
a particular group of people
at a particular time
The definitions includes a ‘particular group of people’ and a ‘particular time’. This suggests the group can evolve and cultures can change over time. Because of this, I view culture as a verb rather than a noun. I hope that after this talk you will agree that culture is alive and continually evolving
“Surgical Dogma”
“Because we have done it that way for years”

7. What is a patient safety culture?
“A culture in which healthcare professionals are held accountable for unprofessional conduct, yet not punished for human mistakes; errors are identified and mitigated before harm occurs; and systems are in place to enable staff to learn from errors and near-misses and prevent recurrence”
(AHRQ PSNet Safety Culture – 2014)

8. What is a patient safety culture?
No one is hesitant to voice a concern about the patient ---psychological safety
Skilled caregivers playing by the rules feel safe to discuss and learn from errors – members of a successful cultures of safety acknowledge both their individual and system VULNURBILITIES and have no fear of discussing them

9. Why is culture so important?
American management consultant, educator and author.
“Founder of modern management”

10. Framework for Clinical Excellence: Leadership

11. Leaders (Surgeons) and Culture
Leaders have 4 main responsibilities:
Guard the learning system – transparency, applying improvement and reliability science, and inspiring staff
Creating psychological safety – making sure everyone including patients/families can voice concerns
Fostering trust – creating environment of non-negotiable trust
Ensuring value alignment – applying organization values to every decision

12. Surgeons and Culture
Performance
Behaviors
Values

13. Framework for Clinical Excellence: Psychological Safety

14. It is more than “I can speak up about concerns”
Psychological Safety
Originated with James Reason’s book, Managing the Risks of Organizational Accidents.
Popularized by Amy Edmondson’s book, Teaming
It is more than “I can speak up about concerns”

15. Psychological Safety

16. Psychological Safety and Retained Surgical Sponges
Steelman VM, et al. Retained Surgical Sponges: a descriptive study of occurrences and contributing factors from 2012 to Patient Surg. 12:20, 2018

17. Key Components of Psychological Safety
Anyone can ask questions without looking stupid
Anyone can ask for feedback without looking incompetent
Anyone can be respectfully critical without appearing negative
Anyone can suggest innovative ideas without being perceived as disruptive
Adopted from Amy Edmondson, Teaming

18. Framework for Clinical Excellence: Accountability

19. Accountability
We are held accountable for our actions, but we are not accountable for system flaws!
Comes together with psychological safety
You can’t have true psychological safety without accountability

20. Fair and Just Culture Requires a simple and precise algorithm
Fosters an environment in which staff members accept responsibility for their own actions…
But know the organization will treat them fairly and not blame them for things out of their control
The literature presents a few different accountability algorithms
David Marx, Just Culture Algorithm
James Reason, Incident Decision Tree

21. Framework for Clinical Excellence: Teamwork

22. TeamSTEPPS

23. Teamwork Huddles, Briefs and Debriefs Backbone of culture
Plan forward
Reflect back
Communicate clearly
Manage risk
Backbone of culture
Must permeate through the entire organization

24. Teamwork and Communication
Complete
Communication all relevant information
Clear
Convey information that is plainly understood
Brief
Be concise
Timely
Offer / request information in the appropriate time

25. Framework for Clinical Excellence: Negotiation

26. Negotiating Styles

28. Learning from Google: Building the Perfect Culture
Project Aristotle
Multimillion-dollar project conducted from
Data gathered and assessed from 180 different Google teams
No patterns of types of team members detected why some teams succeeded and others failed

29. Learning from Google: Building the Perfect Culture
“Group Norms” or unwritten and often unspoken rules guiding behavior were identified as the key to success
Culture = Group Norms
Who is on a team matters less than how the team members interact, structure their work, and view their contributions

30. Google’s 5 Keys to Success

31. What Can You Do to Get There?
Know thy self
Be aware of your patterns and how it affects the team culture
Make small adjustments that will increase the quality and productivity of interactions
Recognize your vulnerabilities and be open with them in your team
Be preoccupied with failure – never settle for average care
Support psychological safety in your teams and throughout the hospital

32. Valuable Culture Lesson
Technical expertise alone is inadequate to keep our patients safe, non-technical skills are just as important