2. Obtaining Results Desire Vessel Execute Culture is a vessel to cross the quality chasm

3. Aviation Accidents per million departures

4. Primary accident causes (%)

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

6. 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

7. Johns Hopkins Comprehensive Patient Safety Program

8. 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

9. 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

10. 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

11. 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

12. % of respondents within a clinic reporting good teamwork climate

13. % of respondents reporting above adequate teamwork

14. 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

16. ISSUES IDENTIFIED ACROSS ICU’S Patient transport Medication errors Communication Central line infections

17. Percent Understanding Patient Care Goals

18. Impact on ICU Length of Stay 654 New Admissions: 7 Million Additional Revenue Daily Goals

19. ICU catheter-related blood stream infections NNIS Mean Education Line Cart Checklist 0 10 20 30 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar April May June July August Rate/1,000 Catheter days

21. Culture

22. % of respondents within a clinical area reporting good safety climate

23. What can you do: The safety program provides a practical, goal directed tool to improve safety culture and lead to measurable improvements in safety

24. NEXT STEPS Communication –Safety Tales –Sharing Lessons Learned Additional Training Nursing units and Departments Medical/nursing students

25. Is Safety your Hedgehog Concept What can you be great at What are you passionate about What is important Jim Collins

26. Who is willing to shave their Head Who is willing to commit to improving patient safety