1. Ron Collins, Kimberly McKinley Allison Muniak, Marlies van Dijk Quality Forum 2014 Acting Out for Patient Safety

2. Defining Culture “…an integrated system of learned behavior patterns which are characteristic of the members of a society and which are not the result of biological inheritance.” “…a complex system of behaviors, values, beliefs, traditions and artifacts which is transmitted through generations.”

3. Creating a ‘Loose End’ “…cultures-and the specific norms that define these cultures-emerge as unintended byproducts of interpersonal interaction.” Lehman et al., Ann Rev Psych 2004;55:689-714 “…then the specific contents of cultures are likely to be influenced by individual-level processes that govern the contents of communication.” Culture is what happens when we interact!

4. Culture Impacts Safety and Quality

5. Situational Leaders Any team member who has the skills to manage the situation “The principle role of a situational leader is to mobilize and support the Situational Awareness of the team.”

6. A Tale from St. Elsewhere…. Very experienced OR RN Recent stress leave due to ‘Bullying’ Circulating in Orthopedic OR In the midst of the ‘Timeout’….

8. Power Distance Index The higher the power distance in a culture, the less likely those in subordinate roles will question the actions or directions of individuals in authority. “Power distance is the extent to which the less powerful members of organizations and institutions accept and expect that power is distributed unequally.”

9. High PDI Cultures Those in authority openly demonstrate their rank. Subordinates expect clear guidance from above. Subordinates are expected to take the blame for things going wrong (Collateral damage). The relationship between boss and subordinate is rarely close or personal. Politics is prone to totalitarianism. Class divisions within society are accepted.

10. Mitigation in Communication Command Team Obligation Statement Team Suggestion Query Preference Hint

11. What to say….?

12. Example A patient has been prepped and draped, and as the surgeon reaches for the scalpel to begin a right total hip arthroplasty, the circulating nurse notes that the X-Ray on the screen is of a left hip! This nurse must now assume the role of situational leader; her role is to raise the situational awareness of the entire operating team. The question is this: “What does she say?”

13. Look under your chair for an envelope

14. The Rules 1.The one holding the envelope is the leader 2.As a group, come up with the best examples you can 3.Go crazy!! Make it real, make it funny, and definitely entertaining 4.Nominate at least one person in your team to be the nurse / team to act it out for the larger group

16. Hint

17. A hint in terms of this exercise is intended to be very general. A hint does not have any personal reflection or engagement in it; it is not a personal statement! Think “insinuation, innuendo, pointer, whisper….” For example: “It would be nice to get through the day without making any mistakes.”

18. Preference

19. A preference in terms of this exercise is a weakly stated request that recognizes that several options exist. The person stating the preference does take personal ownership of their idea or request, but it lacks a really strong stance. For example: “I wish I was in another OR right now!”

20. Query

21. A query in terms of this exercise is a question to draw other’s attention to a situation without being very direct. The person asking the question is weakly attempting to raise the situational awareness of the rest of the team by calling into question the validity or accuracy of an emerging situation. For example: “Is that the correct X-Ray?”

22. Team Suggestion

23. In terms of this exercise, the team suggestion elevates the personal statement of one member of the team to engage the situational awareness of the rest of the team. It may be couched as a personal statement, but it clearly raises the comment to the level of the team; look for ‘we’!The suggestion is not a command and does not suggest an obligation to act: it is only raising awareness. For example: “Can we check the X-Ray please?”

24. Team Obligation Statement

25. In terms of this exercise, the team obligation statement is a strong call to mobilize the situational awareness of the team. It involves a ‘we’ but includes a ‘must’ or a ‘should’ as well. For example: “Before we go any further, we need to verify which side this patient has consented to.”

26. Command

27. In terms of this exercise, a command is the highest form of one member of a team raising the situational awareness of the team. It is an imperative to either act or to not act due to impending harm. For example: “Stop! We are about to make a mistake that will harm this patient

28. Leadership is about…. Having a vision of what is possible… Maintaining ‘situational awareness’ ‘Stepping up’ to support situational awareness Maintaining communication and team processes Innovation Breaking down the barriers!

29. Liberating Structures http://www.liberatingstructures.com

31. Is this a Cultural Intervention? Address the ‘quality’ of our social interactions: unlearn! Communication without Mitigation! Reduce the PDI: ‘Silence Kills!’ Ask, Request, Concern, Command. Organizational support processes.

32. Contact Ron Collins, MD FRCP(C) Clinical Consultant, BCPSQC Chair, Enhanced Recovery Working Group, BCMA Anesthesiologist, KGH RCollins@bcpsqc.ca