Improving Patient Safety Culture Through Leadership

Improving Patient Safety Culture Through Leadership

Evidence-Based, Best-Practice Strategies and Tactics for Allina Health System Leaders

“This toolkit is a high-level summary of best practices for improving a safety culture in health care—it is not meant to be all inclusive”

Review of Leadership Opportunities Identified in the 2010 AHRQ Patient Safety Culture Survey

The following categories for improvement were identified from the 2010 AHRQ Patient Safety Culture Survey that were 8-12 points below national average benchmarks:

·  Hospital management support for patient safety

·  Feedback and communication about error

·  Frequency of events reported

·  Supervisor/manager expectations and actions promoting safety

What is “Patient Safety Culture”?

Definition: The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.

Source: Organising for Safety: Third Report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations) Study Group on Human Factors. Health and Safety Commission (of Great Britain). Sudbury, England: HSE Books, 1993.

Key, Evidence-Based Concepts for Using Leadership to Improve Safety Culture

·  Leadership is the most critical element in advancing safety culture within an organization and is non-delegable.

·  Leaders must have a personal connection to safety by seeking out stories about harm to patients.

·  Leaders need to understand the principles of error, i.e. approximately 80% of medical errors are system-derived.

·  Leaders need to promote a culture of transparency by expecting and encouraging all staff to report near misses and harmful events.

·  Leaders need to establish a culture of psychological safety so staffs feel free to speak up when faced with a situation that may harm a patient.

·  Patient safety is not only an ethical and professional responsibility but medical errors have a significant effect on the financial bottom line.

Key Categories of Leadership Work to Improve Patient Safety Culture

I.  Address system-level/business unit goals, infrastructure, and culture.

II.  Communicate, build awareness, and engage with key stakeholders.

III.  Strengthen reporting and analysis of events.

IV.  Support staff and patients/families impacted by medical errors and harm.

V.  Align system-wide activities and incentives.

VI.  Redesign systems and improve reliability.

I.  ADDRESS SYSTEM-LEVEL/BUSINESS UNIT GOALS, INFRASTRUCTURE, AND CULTURE
Strategies / Current State Eval: green/yellow/red / Evidence-Based Tactics
Set goals that establish patient safety as a strategic priority; hold a clear vision for safety and articulate that vision in a compelling fashion. / £  Key tactics that demonstrate strong commitment:
o  Be informed on safety status in areas of responsibility.
o  Ensure safety is on leadership agendas.
o  Take action on safety issues with rigor and timeliness
o  Commit resources for improvement of safety.
o  Clearly articulate that safety is a part of every employee’s job.
£  Systematically communicate with direct reports about safety and coach direct reports to continue the dialogue with their staffs. Ask six key questions of direct reports:
o  What is the status of the key safety projects?
o  Are safety agenda items followed by action plans with assigned accountabilities?
o  How are safety outcomes displayed for all staff to review (measurement process)?
o  If there are barriers, how can I help you?
o  Are there resources to support improvements that are needed?
o  What successes are you seeing?
o  Do these successes contain lessons for the business unit and/or the Allina System (spread)?
Assess organization culture by:
Þ  Understanding safety culture survey results (at hospital and at unit level). / £  Ensure all units have received unit-level data from the recent AHRQ Patient Safety Culture Survey.
£  Share learnings from units with high culture scores with other units across the business units.
£  Enlist direct reports for development of unit-specific action plans based on opportunities identified on AHRQ Safety Culture Survey results. Coach direct reports to solicit staff input before making decisions about action plans.
£  Include identification of accountabilities and methods for routine evaluation of progress of action plans to advance the safety culture.
£  Ensure updates/discussions of barriers for improving safety culture are a routine agenda item on key committees.
Address organization infrastructure through ensuring:
Þ  Clear identification of safety leads in the organization.
Þ  Safety leads are well-versed in all areas of safety culture and remediation techniques.. / £  Ensure the safety lead role is clearly defined and articulated throughout the organization.
£  Consider identification of a patient safety officer that reports directly to the CEO.
£  Provide resources for safety education to identified staff throughout the organization.
£  Ensure a key committee is responsible for reviewing all safety issues across the organization frequently (monthly); committee should identify trends in order to remediate hazards. This committee should also monitor progress of organization culture work (action plans, reporting information, )
£  Personally carry key safety-related messages to key stakeholders in staff emails, hospital newsletters, employee forums, and other venues.
II.  COMMUNICATE, BUILD AWARENESS, AND ENGAGE WITH KEY STAKEHOLDERS
Strategies / Current State Eval: green/yellow/red / Evidence-Based Tactics
Engage staff:
Þ  Demonstrate personal concern for patients and employees.
Þ  Engage hearts and minds of all staff using safety data and patient stories to guide staff toward a strong safety culture.
Þ  Seek opportunities to take on safety issues.
Þ  Make tough decisions with regard to safety.
Þ  Convey a sense of urgency regarding safety issues and takes action to make safety improvements / £  Provide frequent messages on the importance of speaking up to prevent harm from reaching a patient.
£  Regularly personalize your messages to demonstrate your own personal commitment to this issue. Use the P.E.A. method:
P – PERSONAL – Make the problem personal.
Examples: “Our pressure ulcer number hasn’t moved. I met one of our patients, Joan, who suffered a pressure ulcer—let me tell you about how she was affected.” OR “On this slide you’ll see a photo of John, who wrote the following paragraph describing what happened to him after a fall at our hospital.”
E – EXPECTATIONS – State what you expect to be done.
Example: “I expect that we can achieve a measurable difference in this rate within XX months.”
A – ASK – Ask for feedback.
Example: “Is that reasonable? What can I do to help us get there?”
Engage board of trustees:
Þ  Gain board endorsement of safety agenda.
Þ  Ensure regular board level review of both positive safety outcomes and safety outcomes that are lagging. / £  Ensure board: participates in strategic goal-setting related to quality and safety; reviews data related to goals; reviews critical adverse health events root cause analyses; holds management accountable for addressing safety concerns.
£  Structure board agendas so that quality and safety are given the same amount of attention as financial agenda items.
Engage physicians:
Þ  Seek opportunities for physicians to participate in safety improvements. / £  Invite physician input early on quality and safety issues.
£  Focus first on improvement projects that are important to the medical staff.
£  Ensure medical staff members understand a key safety principle: simply put, errors will occur and good people working harder will not overcome error. Systems/processes must be designed so that errors do not reach the patient.
£  When presenting to physicians about important safety changes include data and patient stories
£  Engage physicians to lead improvement work.
£  Involve physicians in strategic and capital planning for safety.
Increase awareness of safety issues among senior leaders through executive rounding. / £  Consult with front-line personnel about patient safety issues during executive rounding.
£  Regularly ask two key questions of staff members on units: What is the next event that could occur on this unit that would cause patient harm? What can I do as a leader that would make the work you do safer for our patients? What do you worry about?
£  Prioritize safety concerns gathered during rounding and assign responsibility for action to an accountable leader.
£  Enlist safety staff to document safety concerns, assign accountabilities to carry out action plans.
£  Provide feedback to staff members who reported safety concerns.
Standardize discussions among caregivers to ensure critical clinical information is communicated effectively. / £  Evaluate current status of the use of SBAR during handoffs/transitions.
£  Develop a plan for hard-wiring SBAR communication across clinical units.
III.  STRENGTHEN REPORTING AND ANALYSIS OF EVENTS
Strategies / Current State Eval: green/yellow/red / Evidence-Based Tactics
Promote a culture of learning / Leadership and staff are held accountable for their actions but not unjustly blamed when error occurs. Error is analyzed to ascertain failures in system processes
Measure harm over time. / £  Harm index established as 2011 strategic Allina wide goal.
Improve analysis of adverse events. / £  Ensure use of robust root cause analysis in critical event reviews to understand system problems that contributed to the event.
£  Develop action plans to include accountability and measurement.
£  Spread event review learnings within hospital, if applicable to the system.
Strengthen incident reporting mechanisms and increase reporting of events and near misses. / £  Actively expect reporting of patient events and near misses through regular communications to staff, utilizing examples to reinforce reporting behavior.
£  Ensure safety reports are analyzed, trends are identified, and clear accountability for changes are assigned.
£  Reward managers for increasing the numbers for near miss and PVSR reporting with resultant improvements
(Strategic goal for 2011: Increase near miss reporting by 8% from 2010.) / £  PVSR System in redesign for 2011. with the goal of increasing end user satisfaction. (System accountability). Date of completion—June 1, 2011.
£  Establish process for feedback to employees on actions taken as a result of reporting near misses-to be contained in Near Miss Toolkit being developed at system office
£  Use near miss stories in communications, employee forums, etc.
£  Encourage submission of near miss events to the MHA Good Catch Award Program
IV. SUPPORT STAFF AND PATIENTS/FAMILIES IMPACTED BY MEDICAL ERRORS AND HARM
Strategies / Current State Eval: green/yellow/red / Evidence-Based Tactics
Provide support to impacted staff and patients/families. / £  Follow Allina policy on disclosure of medical errors.
£  Ensure frequent communication and support occurs with patient and family regarding medical error
£  Have process to provide support to physicians and staff involved in a medical error (second victims).
Commit to safety of staff. / £  Routinely discuss employee safety issues at employee forums, utilizing near miss stories related to employee injury
£  Ensure root cause analysis is performed on employee injuries with subsequent action plans, evaluation, and spread of learnings.(approved March Quality Council)
V. ALIGN SYSTEM-WIDE ACTIVITIES AND INCENTIVES
Strategies / Current State Eval: green/yellow/red / Evidence-Based Tactics
Align safety measures, strategy, and projects. / £  Ensure that leader’s and direct reports’ strategic safety goals, hospital safety goals, and unit safety goals are in alignment, and contain reliable measurement, accountabilities, and reporting structures for outcome evaluation.
Align incentives w/Safety / £  Incentive plan incorporating quality/safety indicators for executive staff.
VI. REDESIGN SYSTEMS AND IMPROVE RELIABILITY
Strategies / Current State Eval: green/yellow/red / Evidence-Based Tactics
Redesign care processes to increase reliability and compensate for human vulnerabilities. not only to manage the effects of failures but to go upstream to redesign systems to prevent the conditions that lead to the failure where ever possible and eventually to develop a model where employees are looking at their work to try to prevent failures that have not yet happened. / £  Utilize human factor principles when developing processes. (See references.) Ask staff members about error reduction strategies during redesigns of processes; include the following:
o  Avoid reliance on memory.
o  Simplify processes as much as possible.
o  Standardization reduces human error.
o  Use constraints/forcing functions to engineer error out of a process.
o  Use of protocols and checklists to avoid reliance on memory.
o  Use of structured communication processes during critical patient transitions (SBAR).
o  Increase use of closing the loop, asking questions, repeating back during high risk operations.
o  Add redundancy to processes, i.e. independent double checks.
£  Gather staff input early in the process for any bedside redesign.
Utilize formal model for improvement. / £  Ensure staff members utilize evidence-based improvement strategies such as PDSA cycles, Lean principles, or other evidence-based strategies.

To receive additional assistance in any of the above categories, please contact your local Quality and Safety Director/Manager

Additional tools are also available upon request. Please call System Office For Quality and Safety at 612 262 5924

References

Strategies and goals adapted from Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2006. Available at www.ihi.org.

Krause, Thomas, Hidley, John Taking the Lead in Patient Safety-How Healthcare Leaders Influence Behavior and Create Culture Hoboken, New Jersey: Wiley Press, 2009.

Leonard, Michael, Frankel,Allen, Simmonds, Terri, Achieving Safe and Reliable Healthcare-Strategies and Solutions Chicago, Ill: Health Administration Press, 2004

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