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Unit 3: Reliability, Culture of Safety, & HIT This material was developed by Johns Hopkins University, funded by the Department of Health and Human Services,

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Presentation on theme: "Unit 3: Reliability, Culture of Safety, & HIT This material was developed by Johns Hopkins University, funded by the Department of Health and Human Services,"— Presentation transcript:

1 Unit 3: Reliability, Culture of Safety, & HIT This material 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 IU24OC000013.

2 Objectives Discuss reliability as a tool for ensuring safety Examine how ultra-safe organizations operate Identify how teams make wise decisions Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 2

3 Reliability Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 3 Video 1 Image: http://www.pakalertpress.com

4 Reliability EvaluateCalculateImprove Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 4

5 Reliability Prevent Failure Best practice guidelines, tools, techniques Awareness campaigns Memory aids Checklists Making the desired action the default Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 5

6 Reliability Identify and Mitigate Failure Reduce fatigue and distraction Standing orders for best practice treatments Electronic flags Independent double-checks Redesign for Success Understand where the failure is occurring Determine the remedy Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 6

7 High Reliability Organizations Hyper-complexTightly coupledHierarchical differentiationMultiple decision-makers Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 7

8 High Reliability Organizations Complex communicationHigh accountability Need frequent, immediate feedback Compressed time constraints Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 8

9 High Reliability Organizations Mindfulness Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 9 http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm

10 High Reliability Organizations Sensitivity to Operations SCHEDULE TIME ID BAND CLIPBOARD MONITOR IV BAG PILLS/ WATER DOCTOR’S FACE DOCTOR’S HAND Be aware of the context of care. Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 10 http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm

11 High Reliability Organizations Reluctance to Simplify Keep things simple. Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 11 http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm

12 High Reliability Organizations Preoccupation with Failure Be preoccupied with failure. Don’t rely on good brakes to save you every time. Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 12 http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm

13 High Reliability Organizations Deference to Expertise Hear the wisdom of crowds. Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 13 http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm

14 High Reliability Organizations Resilience Be prepared for failure. What can go wrong, will. Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 14 http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm

15 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) Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 15

16 The Blame Game Pointing the finger at people rather than systems Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 16 Image: MS Clipart

17 Blame Stop talking Learn less Improve less Mistakes continue Vicious Cycle Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 17

18 Blame Limits learning Increases likelihood of repeat errors Drives self-reporting underground Culture of Blame Culture of Safety Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 18

19 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 Distinguished 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 Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 19 http://psnet.ahrq.gov/primer.aspx?primerID=5

20 How to Promote a Culture of Safety Accept responsibilityValue learning from mistakesLearn to recognize risky behaviors Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 20

21 How to Promote a Culture of Safety Speak up if something is not right Listen to others & discuss ways to prevent error Take action to reduce risk Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 21

22 How to Promote a Culture of Safety Report errors & near misses Encourage others to report errors & near misses Help change unrealistic policies Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 22

23 Culture of Safety Characteristics Carefully LISTEN to the concern to determine if corrective action is necessary Recognize when a concern is expressed by anyone and STOP Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 23

24 Culture of Safety Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 24 Video 2 http://static.guim.co.uk/sys-images/Environment/Pix/pictures/2008/05/09/honeybee460.jpg

25 References AHRQ Patient Safety Primers. Safety Culture. Available from: http://psnet.ahrq.gov/primer.aspx?primerID=5 Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Rockville, MD. AHRQ Publication No. 08-0022, 2008 April. Agency for Healthcare Research and Quality. Available from: http://www.ahrq.gov/qual/hroadvice/. Riley W, Davis SE, Miller KK, & McCullough M. A model for developing high reliability teams. J Nurs Manag. 2010 Jul18(5):556-563. Reliability. Institute for Healthcare Improvement. Available from: http://www.ihi.org/IHI/Topics/Reliability/ When Good Enough Isn’t…Good Enough: The Case for Reliability. Institute for Healthcare Improvement. Available from: http://www.ihi.org/IHI/Topics/Reliability/ReliabilityGeneral/Improvement Stories/WhenGoodEnoughIsntGoodEnoughTheCaseforReliability.htm Component 12/Unit 3 Health IT Workforce Curriculum Version 2.0/Spring 2011 25

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