obtaining results desire vessel execute culture is a vessel to cross the quality chasm

Obtaining Results

• Desire

• Vessel

• Execute

Culture is a vessel to cross the quality Culture is a vessel to cross the quality chasm chasm

Aviation Accidentsper million departures

Primary accident causes (%)

0 10 20 30 40 50 60 70 80

Flight Crew

Airplane

Maintenance

Weather

FAA

Other

Today, pilots can fail their certification based on poor interpersonal, or “non technical” aspects of their performance.

Teamwork by Edict:

Lessons Learned: • Focus on interpersonal improvements

• Frontline staff must assume responsibility for quality and safety

• Safety interventions must be goal directed

• Culture changes incrementally in an organization

• Document (measure) improvements

Johns Hopkins Comprehensive Patient Safety Program

The Johns Hopkins Comprehensive Safety Program

1. Evaluate culture of safety

2. Educate staff on science of safety

3. Identify staff’s safety concerns

4. Executive adopt an ICU

5. Prioritize improvement efforts

6. Implement improvements

7. Share stories and disseminate results

8. Evaluate culture

Summary of Science of Safety

• We will make mistakes• We need to create a culture where

mistakes are identified• We must focus on systems rather than

people• Leaders control the potential to change

systems

www.icusrs.org

What can we do to improve safety

• Accept that we make mistakes

• Focus on Systems– Prevent mistake from occurring– Make mistake visible– Mitigate harm should it occur

Helmreich, Nolan

Culture in Safe Organizations

• Commit to no harm• Focus on systems not people• Communication/teamwork

– Assertive communication– Teamwork– Situational awareness– Disclosure– Open communication

• Celebrate safety– Workers viewed as heroes

Teamwork Climate Across Positions

Res

pir

ato

ry T

her

Bed

sid

e N

urs

e

Nu

rse

in C

har

ge

Nu

rsin

g A

ssis

tan

Res

iden

t

Oth

er

ICU

Ph

ysic

ian

0

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50

60

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100

R e sp ira to ry T h e r B e d sid e N u rse N u rse in C h a rg e N u rsin g A ssista n R e sid e n t O th e r IC U P h ysic ia n

% o

f res

pond

ents

with

in a

clin

ic re

port

ing

good

team

wor

k cl

imat

e

ICU Physicians and ICU RN Collaboration

51%

88%

0

10

20

30

40

50

60

70

80

90

100

K P L &D

RN rates ICU Physician ICU Physician rates RN

% o

f res

pond

ents

repo

rtin

g ab

ove

adeq

uate

team

wor

k

Simple Rules for Redundancy

1. Identify Key Processes– EBM– Bottlenecks

2. Independent Redundancy to ensure process occurs

• Physicians, nurses, pharmacist, patient, family

• Examples, medication reconciliation, goals, ventilator care

Johns Hopkins Comprehensive Patient Safety Program

STAFF SAFETY SURVEY

Thank you for helping improve safety in your workplace!

Please describe how the next patient in your work area will be harmed. Please describe how we can prevent this harm. Please describe how we can make the potential harm visible before it happens. If the patient were to suffer this harm, how could we reduce the harm?

Name: Role Date: Unit:

Please describe how you prevented a patient from being harmed.

ISSUES IDENTIFIED ACROSS ICU’S

• Patient transport

• Medication errors

• Communication

• Central line infections

Percent Understanding Patient Care Goals

00.10.20.30.40.50.60.70.80.9

1

1 2 3 4 5 6

Residents

Nurses

Implemented patientgoals sheet

Impact on ICU Length of Stay

0

0.5

1

1.5

2

2.5A

vg. L

OS

(day

s)

ICU LOS

654 New Admissions: 7 Million Additional Revenue

Daily Goals

ICU catheter-related blood stream infections

NNIS Mean

Education

Line Cart

Checklist

0

10

20

30

Jan

Feb

Mar

Ap

rM

ay Jun

Jul

Au

gS

epO

ctN

ovD

ecJa

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ebM

arA

pri

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ayJu

ne

July

A

ugu

st

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e/1,

000

Cat

hete

r da

ys

Figure 1: Percent of Charts with Medication Errors Identified per Week through Medication Reconcillation Process*

0%

10%

20%30%

40%

50%

60%

70%80%

90%

100%

Week

Series1 94% 94% 50% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 50% 0% 0% 13% 0% 0% 0% 0% 0% 0% 0%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Culture

Safety Climate Across Orgs

0

10

20

30

40

50

60

70

80

90

100

4 3 6 5 1 2 8

% o

f res

pond

ents

with

in a

clin

ical

are

a re

port

ing

good

saf

ety

clim

ate

What can you do:

The safety program provides a practical, goal directed tool to improve safety culture and lead to measurable improvements in safety

NEXT STEPS

• Communication

– Safety Tales

– Sharing Lessons Learned

• Additional Training

• Nursing units and Departments

• Medical/nursing students

Is Safety your Hedgehog Concept

What can you be great at

What are you passionate about

What is importantJim Collins

Who is willing to shave their Head

Who is willing to commit to improving patient safety