A Culture of “Surgical” Patient Safety Joseph F. Golob Jr. MD FACS CPHQ Medical Director of Patient Safety Medical Director of SICU and TICU Program Director – Surgical Critical Care Fellowship MetroHealth Medical Center

Objectives What is culture and specifically what is a culture of safety? Describe the key components to a patient safety culture: leadership, psychological safety, accountability, teamwork and negotiation. Google’s model of culture What can you do to foster a culture of safety?

“The equivalent of a jumbo jet crashing everyday with no survivors” 1999 IOM report: 44,000 to 98,000 deaths per year from preventable medical mistakes “The equivalent of a jumbo jet crashing everyday with no survivors”

© 2016 BMJ Publishing Group LTD Makary MA, Michael D. Medical error-the third leading cause of death in the US. BMJ 2016; 353:i2139

a system of clinical excellence which is preoccupied with failure How do we improve? By creating a system of clinical excellence which is preoccupied with failure © 2017 Institute for Healthcare Improvement and Safe & Reliable Healthcare

The way of life, especially the general customs and beliefs, of What is culture? The way of life, especially the general customs and beliefs, of a particular group of people at a particular time The definitions includes a ‘particular group of people’ and a ‘particular time’. This suggests the group can evolve and cultures can change over time. Because of this, I view culture as a verb rather than a noun. I hope that after this talk you will agree that culture is alive and continually evolving “Surgical Dogma” “Because we have done it that way for years”

What is a patient safety culture? “A culture in which healthcare professionals are held accountable for unprofessional conduct, yet not punished for human mistakes; errors are identified and mitigated before harm occurs; and systems are in place to enable staff to learn from errors and near-misses and prevent recurrence” (AHRQ PSNet Safety Culture – 2014)

What is a patient safety culture? No one is hesitant to voice a concern about the patient ---psychological safety Skilled caregivers playing by the rules feel safe to discuss and learn from errors – members of a successful cultures of safety acknowledge both their individual and system VULNURBILITIES and have no fear of discussing them

Why is culture so important? American management consultant, educator and author. “Founder of modern management”

Framework for Clinical Excellence: Leadership

Leaders (Surgeons) and Culture Leaders have 4 main responsibilities: Guard the learning system – transparency, applying improvement and reliability science, and inspiring staff Creating psychological safety – making sure everyone including patients/families can voice concerns Fostering trust – creating environment of non-negotiable trust Ensuring value alignment – applying organization values to every decision

Surgeons and Culture Performance Behaviors Values

Framework for Clinical Excellence: Psychological Safety

It is more than “I can speak up about concerns” Psychological Safety Originated with James Reason’s book, Managing the Risks of Organizational Accidents. Popularized by Amy Edmondson’s book, Teaming It is more than “I can speak up about concerns”

Psychological Safety https://www.youtube.com/watch?v=3r4rS0yzQ1M

Psychological Safety and Retained Surgical Sponges Steelman VM, et al. Retained Surgical Sponges: a descriptive study of occurrences and contributing factors from 2012 to 2017. Patient Surg. 12:20, 2018

Key Components of Psychological Safety Anyone can ask questions without looking stupid Anyone can ask for feedback without looking incompetent Anyone can be respectfully critical without appearing negative Anyone can suggest innovative ideas without being perceived as disruptive Adopted from Amy Edmondson, Teaming

Framework for Clinical Excellence: Accountability

Accountability We are held accountable for our actions, but we are not accountable for system flaws! Comes together with psychological safety You can’t have true psychological safety without accountability

Fair and Just Culture Requires a simple and precise algorithm Fosters an environment in which staff members accept responsibility for their own actions… But know the organization will treat them fairly and not blame them for things out of their control The literature presents a few different accountability algorithms David Marx, Just Culture Algorithm James Reason, Incident Decision Tree

Framework for Clinical Excellence: Teamwork

TeamSTEPPS

Teamwork Huddles, Briefs and Debriefs Backbone of culture Plan forward Reflect back Communicate clearly Manage risk Backbone of culture Must permeate through the entire organization

Teamwork and Communication Complete Communication all relevant information Clear Convey information that is plainly understood Brief Be concise Timely Offer / request information in the appropriate time

Framework for Clinical Excellence: Negotiation

Negotiating Styles

Learning from Google: Building the Perfect Culture Project Aristotle Multimillion-dollar project conducted from 2012-2014 Data gathered and assessed from 180 different Google teams No patterns of types of team members detected why some teams succeeded and others failed

Learning from Google: Building the Perfect Culture “Group Norms” or unwritten and often unspoken rules guiding behavior were identified as the key to success Culture = Group Norms Who is on a team matters less than how the team members interact, structure their work, and view their contributions

Google’s 5 Keys to Success

What Can You Do to Get There? Know thy self Be aware of your patterns and how it affects the team culture Make small adjustments that will increase the quality and productivity of interactions Recognize your vulnerabilities and be open with them in your team Be preoccupied with failure – never settle for average care Support psychological safety in your teams and throughout the hospital

Valuable Culture Lesson Technical expertise alone is inadequate to keep our patients safe, non-technical skills are just as important