A Blueprint for Creating a Culture of Safety Soaring over the Safety and Quality Chasm with Cultures

1
A Blueprint for Creating a Culture of Safety
Soaring over the Safety and Quality Chasm with
Cultures that Support Safe Practice

• A presentation by
• Capt. Stephen Harden

2
What about my baby?
A patients story
3
What Do You Think?

• If you were the surgeon, would you want the Scrub
  Tech to speak up?
• Based on the culture you believe exists at your
  hospital, and the personalities experience
  levels, will she speak up?
• Why or Why Not?
• If she does speak up, what do you want her to
  say?

4

• Our Systems are too complex to expect merely
  extraordinary people to perform perfectly 100 of
  the time. We, as leaders, have a responsibility
  to put into place systems to support safe
  practice.

James Conway, IHI Senior Fellow
5
What is the Culture Needed to Support Safe
Practice?

• Thoughts Actions Habits Character
• Culture

6
Aviations Culture Changing Solution
Understanding of the Human Condition
plus
Teamwork Skills
plus
Systems
7
When the Culture is Changed
(References on request)
8
System Error Rates Improve
When the Culture is Changed
DPMO 1,000,000 100,000 10,000 1000 100 10 1
SIGMA 1 2 3 4 5 6
Galvin, Robert. MD. ltURL http//conferences.mc.du
ke.edu/2000dpsc.nsf/contentsnum/gt (2000)
9
When the Culture is Changed the System Becomes
Extremely Safe and Reliable

• 2002, 2003, 2004 Zero deaths for jet airline
  operations in the U.S.

10
Sowhat happens when a healthcare institution
changes their culture based on best practices
from aviation?
11
The Results of Culture Change In Healthcare
Better Teamwork Teams
Fewer Errors, Rework and Waste
Greater Efficiency Reliability
Better Care Outcomes
12
A Case Study
13
The Pre-Culture Change Picture2002 Quality
and Accountability Ranking
Group 2
(n21)
Median Score 63.22
Group 3
(n20)
Max 65.09
Median Score 60.28
Min 61.34
Max 61.22
Group 4
(n20)
AMCs included 2, 7, 8, 16,
Min 58.88
Median Score 56.86
21, 32, 34, 39, 40, 42, 48, 54,
AMCs included 1, 5, 6, 12,
Max 58.78
Group 5
(n10)
57, 71, 79, 83, 89, 179, 236,
14, 17, 19, 26, 29, 33 ,38 ,43
Min 56.27
Median Score
240, 336
, 60, 67, 69, 73, 80, 180, 214,
AMCs included 4, 9, 10,
54.63
234
Max 55.77
15, 22, 23, 28, 45, 52, 53,
Min 52.25
58, 61, 70, 72, 74, 77, 82,
AMCs included
91, 92, 218
13, 35, 37, 46, 47,
56, 78, 84, 87, 163
31
34
37
40
43
46
49
52
55
58
61
64
67
70
73
76
79
14
Revenue Needed to Pay Malpractice Claims
Annual Malpractice Payments/Profit Margin Lost
Revenue
15
What did they do to change the Culture?
16
What were the results?
17
Better, more satisfied teams to work with (and
a better place to practice medicine)
18
Improved Employee Satisfaction
Statistically significant difference in response
to these questions by those who have attended the
CRM training

• The person I report to encourages teamwork.
• I am a member of a group that works well
  together.
• The medical center provides opportunities for
  career development.
• I am satisfied with on-going training for my
  present job.
• I am proud to tell people I work for the medical
  center.
• My job makes good use of my skills and abilities.
  
• I am satisfied with my involvement in decisions
  that affect my work.

Lower Nurse turnover
19
Better care for their patients
20
Deaths with Expected Risk of Mortality lt 10
Start
21
Surgical Infections and Prophylactic Antibiotics
05 06
22
Better efficiency and use of time (to see more
patients or spend more time with the patients
they have)
23
Main OR Turnover Time
24
Fewer serious mistakes that harm patients
25
Reduction in Wrong Surgeries
Days between Wrong Surgeries
26
50 reduction in open claims files for
potentially compensable events
27
How their culture looks now
Pre-procedure Timeout Brief
28
The Post-Culture Change Picture 2006 Quality
and Accountability Ranking
Group 2
(n21)
Median Score 63.22
Group 3
(n20)
Max 65.09
Median Score 60.28
Min 61.34
Max 61.22
Group 4
(n20)
AMCs included 2, 7, 8, 16,
Min 58.88
Median Score 56.86
21, 32, 34, 39, 40, 42, 48, 54,
AMCs included 1, 5, 6, 12,
Max 58.78
Group 5
(n10)
57, 71, 79, 83, 89, 179, 236,
14, 17, 19, 26, 29, 33 ,38 ,43
Min 56.27
Median Score
240, 336
, 60, 67, 69, 73, 80, 180, 214,
AMCs included 4, 9, 10,
54.63
234
Max 55.77
15, 22, 23, 28, 45, 52, 53,
Min 52.25
58, 61, 70, 72, 74, 77, 82,
AMCs included
91, 92, 218
13, 35, 37, 46, 47,
56, 78, 84, 87, 163
31
34
37
40
43
46
49
52
55
58
61
64
67
70
73
76
79
29
What About Jane?
30
"The names of the patients whose lives we save
can never be known. Our contribution will be
what did not happen to them. And, though they
are unknown, we will know that mothers and
fathers are at graduations and weddings they
would have missed, and that grandchildren will
know grandparents they might never have known,
and holidays will be taken, and work completed,
and books read, and symphonies heard, and gardens
tended that, without our work, would never have
been." Don Berwick, MD, MPP, President and
CEO Institute for Healthcare Improvement
31
Thank You