Quality Improvement Reliability, Culture of Safety, & HIT This material (Comp12_Unit4) was developed by Johns Hopkins University, funded by the Department.

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Presentation transcript:

Quality Improvement Reliability, Culture of Safety, & HIT This material (Comp12_Unit4) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC

Reliability, Culture of Safety, & HIT Learning Objectives Discuss reliability as a tool for ensuring safety. Examine how ultra-safe organizations operate. Identify how teams make wise decisions. 2 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

Reliability Video 1 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

High-Reliability Organizations Hyper-Complex Tightly Coupled Hierarchical Differentiation Multiple Decision Makers 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

High-Reliability Organizations Complex Communication High Accountability Need Frequent Immediate Feedback Compressed Time Constraints 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

High-Reliability Organizations Mindfulness 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

High-Reliability Organizations Sensitivity to Operations 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

High-Reliability Organizations Preoccupation with Failure Be preoccupied with failure. Don’t rely on good brakes to save you every time. 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

High-Reliability Organizations Reluctance to Simplify Keep things simple. 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

High-Reliability Organizations Deference to Expertise 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT Hear the wisdom of crowds.

High-Reliability Organizations Resilience Be prepared for failure. What can go wrong, will. 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

Culture “The shared perceptions of the individuals within the team or an organization about what is good, right, important, valued, supported, or expected at any given time.” Riley, W., et al (2010) 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

The Blame Game Pointing the finger at people rather than systems. 13 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

Blame 14 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

Blame Limits learning Increases likelihood of repeat errors Drives self-reporting underground 15 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

Just Culture Focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors Maintains individual accountability by establishing zero tolerance for reckless behavior Distinguishes between human error, at-risk behavior, and reckless behavior Response to error or near miss is predicated on the type of behavior associated with the error, not the severity of the event 16 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

How to Promote a Culture of Safety 17 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

How to Promote a Culture of Safety 18 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

How to Promote a Culture of Safety 19 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

Culture of Safety Characteristics 20 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

Culture of Safety 21 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT Video 2

Reliability, Culture of Safety, & HIT Summary In this unit we explored the characteristics of high reliability organizations and learned more about establishing an organizational culture of safety. 22 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

Reliability, Culture of Safety, & HIT References References AHRQ Patient Safety Primers. Safety Culture. Available from: Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Rockville, MD. AHRQ Publication No , 2008 April. Agency for Healthcare Research and Quality. Available from: Riley, W., Davis, S.E., Miller, K.K., & McCullough, M. A model for developing high reliability teams. J Nurs Manag Jul18(5): Charts, Tables, Figures Table 4_1. The five specific concepts that help create the state of mindfulness that is needed for reliability, which in turn is a prerequisite for safety. Available from: Images Slide 3: Aircraft Carrier USS Enterprise. Courtesy U.S. Navy, photo by Photographer's Mate Airman Rob Gaston. Available from: Slide 6: High Reliability Organizations: Mindfulness. Available from: 6.htm) 6.htm Slide 7. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Available from: Slide 8: Preoccupation with Failure. Available from: 23 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

Images Slide 9: Reluctance to Simplify. Available from: Slide 10: Deference to Expertise. Available from: Slide 11: Resilience. Available from: Slide 14: Blame. Created by Dr. Stephanie Poe. Slide 15: Blame Arrows. Created by Dr. Stephanie Poe. Slide 17: How to Promote a Culture of Learning 1. Courtesy: Dr. Anna Maria Izquierdo-Porrera Slide 18: How to Promote a Culture of Learning 2 Courtesy: Dr. Anna Maria Izquierdo-Porrera Slide 19:How to Promote a Culture of Learning 3 Courtesy: Dr. Anna Maria Izquierdo-Porrera Slide 20: Culture of Safety Characteristics. Courtesy: Dr. Anna Maria Izquierdo-Porrera Slide 21: Honey Bee. Creative Commons by William Warby. Available from: 24 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT Reliability, Culture of Safety, & HIT References