Jennifer L. Johnson The University of Texas MD Anderson Cancer Center Safety Culture Jennifer L. Johnson The University of Texas MD Anderson Cancer Center

Disclosures I have no financial disclosures to report

Learning Objectives At the completion of this section, the participant will be able to Understand, analyze and create a successful safety culture Apply concepts of a “just culture” Summarize lessons from other industry accidents

Topics to be Covered Safety Culture Definition/Background Assessing Safety Culture Interactions of People, Systems, and Processes Traits of Successful Safety Cultures Concepts of “Just Culture” Lessons from Other Industries

Safety Culture The interaction of shared values and beliefs with the organization’s structures and controls Accidents in high-risk industries (early 20th century) nuclear power, commercial aviation Health care: Institute of Medicine’s report, “To Err is Human” (1999) Generally described as the interaction of shared values and beliefs with the organization’s structures and controls (Uttal 1983; Bate 1992; Thompson et al. 1996). Early 20th century owing to accidents in high-risk industries such as nuclear power plants, commercial aviation Became relevant in health care with the Institute of Medicine’s 1999 report, “To Err is Human” Various theories describe it High Reliability Organization Theory; Donabedian’s Process-Structure-Outcome Model; Organizational Theory; Systems Theory

Safety Culture Various theories describe it High Reliability Organization Theory Donabedian’s Process-Structure-Outcome Model Organizational Theory Systems Theory Generally described as the interaction of shared values and beliefs with the organization’s structures and controls (Uttal 1983; Bate 1992; Thompson et al. 1996). Early 20th century owing to accidents in high-risk industries such as nuclear power plants, commercial aviation Became relevant in health care with the Institute of Medicine’s 1999 report, “To Err is Human” Various theories describe it High Reliability Organization Theory; Donabedian’s Process-Structure-Outcome Model; Organizational Theory; Systems Theory

Assessing Safety Culture Quantitative surveys with various measures, lengths, and reliability levels Culture elements in each survey Identifies areas for improvement Interventions on the work system design Changes may include: organizational controls, structures, work processes, employee attitudes and behaviors Quantitative surveys with various measures, lengths, and reliability levels Culture elements in each survey the Agency for Healthcare Research and Quality’s (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS) the Safety Attitudes Questionnaire the Patient Safety Culture in Healthcare Organizations Survey (PSCHO) the Modified Stanford Patient Safety Culture Survey Instrument (MSI) Identifies areas for improvement interventions on the work system design for a single area of improvement are created, executed, and evaluated for effectiveness may include changes in organizational controls, structures, and work processes, as well as changes in employee attitudes and behaviors. The HSOPS survey focuses on 14 main variables and produces a composite score. The 14 variables of safety culture measured are: communication openness, feedback and communication about error, frequency of events reported, handoffs and transitions, management support for patient safety, nonpunitive response to error, organizational learning and continuous improvement, overall perceptions of patient safety, adequate staffing, management expectations and actions promoting safety, teamwork across units, teamwork within units, patient safety grade given by workers of A or B, and the number of events reported. As a low HSOPS score has been linked to more frequent adverse events (Mardon 2010) among a study of nearly 200 hospitals, it is clear that patient safety culture surveys are able to gauge the impact of safety culture on patient outcome.

Assessing Safety Culture AHRQ HSOPS Safety Attitudes Questionnaire PSCHO MSI Safety Profile self Assessment Tool (SPA) AAPM’s Work Group on the Prevention of Errors in Radiation Oncology (WGPE) See “9. Safety Guidance” for more information Quantitative surveys with various measures, lengths, and reliability levels Culture elements in each survey the Agency for Healthcare Research and Quality’s (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS) the Safety Attitudes Questionnaire the Patient Safety Culture in Healthcare Organizations Survey (PSCHO) the Modified Stanford Patient Safety Culture Survey Instrument (MSI) Identifies areas for improvement interventions on the work system design for a single area of improvement are created, executed, and evaluated for effectiveness may include changes in organizational controls, structures, and work processes, as well as changes in employee attitudes and behaviors. The HSOPS survey focuses on 14 main variables and produces a composite score. The 14 variables of safety culture measured are: communication openness, feedback and communication about error, frequency of events reported, handoffs and transitions, management support for patient safety, nonpunitive response to error, organizational learning and continuous improvement, overall perceptions of patient safety, adequate staffing, management expectations and actions promoting safety, teamwork across units, teamwork within units, patient safety grade given by workers of A or B, and the number of events reported. As a low HSOPS score has been linked to more frequent adverse events (Mardon 2010) among a study of nearly 200 hospitals, it is clear that patient safety culture surveys are able to gauge the impact of safety culture on patient outcome.

Interactions of People, Systems, and Processes People have inherent attitudes, beliefs, and values about safety People interact with organizational systems of controls, structures, practices and policies as they complete their work Changing systems and processes can help create a safety culture Ongoing changes require continuous process People have inherent attitudes, beliefs, and values about safety Difficult to change

Successful Safety Cultures Full understanding and fear of the operational risks Provide appropriate front-line support Training, communication, procedure design Provide adequate maintenance, quality assurance, appropriate resources

Traits of Successful Safety Cultures Informed of their accidents Events and near misses As soon as it occurred Examine to determine causes Accidents are primarily due to active failures of both organizational and local workplace factors, combined with unsafe acts committed by individuals, and to failures along latent condition pathways (Reason 2004)

Traits of Successful Safety Cultures Have an effective reporting structure Reporter confidentiality or de-identification Report filing ease A reporting analysis group that is separated from disciplinary authority Rapid and useful feedback Trust Have a “just culture”

Concepts of “Just Culture” Between a “no blame” and highly punitive culture Acceptable and unacceptable behaviors are clearly identified Unacceptable behaviors result in appropriate disciplinary action Focus on underlying behavior at the time of the error Substitution test: “Would a new individual behave any differently or a peer commit a similar unsafe act?” (Johnston 1995) Between a “no blame” and highly punitive culture Acceptable and unacceptable behaviors are clearly identified Unacceptable behaviors result in appropriate disciplinary action Focus on underlying behavior at the time of the error Less forgivable: reckless conduct, negligent conduct, or intentional rule violations Substitution test: “Would a new individual behave any differently or a peer commit a similar unsafe act?” (Johnston 1995)

Lessons from Other Industries Nuclear power industry, aircraft industry, oil exploration industry, production industry Recurrent errors have three elements universals, or obvious, ever-present hazards local traps, or workplace or task characteristics which lead to unsafe acts when combined with human error or violations drivers, or motivating forces that drive individuals into erroneous behavior National Aeronautics and Space Administration’s Challenger and Columbia shuttle incidents Chernobyl explosion in 1986

Lessons from Other Industries Common driver: the constant conflict between safety and productivity Potential balancing act problems (Reason 2004) Trading off improved [safety] defenses for increased production Keeping your eye on the wrong ball Attempting too much with too little: the ‘can-do’ syndrome Believing that past non-events predict future non-events (forgetting to be afraid) National Aeronautics and Space Administration’s Challenger and Columbia shuttle incidents Chernobyl explosion in 1986

conduct a standard safety survey ask the hospital medical director The best way for a hospital to assess its safety culture and to identify an area for improvement is to: conduct a standard safety survey ask the hospital medical director count the number of reported adverse events conduct leadership walkarounds increase team training 10

conduct a standard safety survey ask the hospital medical director The best way for a hospital to assess its safety culture and to identify an area for improvement is to: conduct a standard safety survey ask the hospital medical director count the number of reported adverse events conduct leadership walkarounds increase team training Ref: Halligan, M. and A. Zecevic. (2011). “Safety culture in healthcare: a review of concepts, dimensions, measures and progress.” BMJ Qual Saf 20:338–343. 10

A therapist is taking call for the third week in a row to earn some extra money. However, the therapist has been involved lately in a couple of near-miss events on the treatment machine. The department makes a change to the on-call policy by limiting the amount of call in a row that can be taken. This is an example of: punishing the therapist for the near-miss events taking responsibility for the therapist’s actions keeping the department’s financials in balance covering the department’s liability for future events changing systems and processes for safety culture 10

punishing the therapist for the near-miss events A therapist is taking call for the third week in a row to earn some extra money. However, the therapist has been involved lately in a couple of near-miss events on the treatment machine. The department makes a change to the on-call policy by limiting the amount of call in a row that can be taken. This is an example of: punishing the therapist for the near-miss events taking responsibility for the therapist’s actions keeping the department’s financials in balance covering the department’s liability for future events changing systems and processes for safety culture Ref: Reason, J. (1998). “Achieving a safe culture: theory and practice.” Work and Stress 12:293–306. 10

Successful ______ cultures have similar traits: they are informed of the accidents, have an effective reporting structure, and have a “______ culture” reporting; safety safety; just just; no blame no blame; reliable reliable; reporting Ref: Reason, J. (1998). “Achieving a safe culture: theory and practice.” Work and Stress 12:293–306. 10

Successful ______ cultures have similar traits: they are informed of the accidents, have an effective reporting structure, and have a “______ culture” reporting; safety safety; just just; no blame no blame; reliable reliable; reporting Ref: Reason, J. (1998). “Achieving a safe culture: theory and practice.” Work and Stress 12:293–306. 10