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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 on theme: "Quality Improvement Reliability, Culture of Safety, & HIT This material (Comp12_Unit4) was developed by Johns Hopkins University, funded by the Department."— Presentation transcript:

1 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 IU24OC000013.

2 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

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

4 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

5 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

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

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

8 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

9 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

10 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.

11 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

12 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

13 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

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

15 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

16 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

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

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

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

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

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

22 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

23 Reliability, Culture of Safety, & HIT References References AHRQ Patient Safety Primers. Safety Culture. Available from: http://psnet.ahrq.gov/primer.aspx?primerID=5http://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/ http://www.ahrq.gov/qual/hroadvice/ Riley, W., Davis, S.E., Miller, K.K., & McCullough, M. A model for developing high reliability teams. J Nurs Manag. 2010 Jul18(5):556-563. 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: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htmhttp://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm Images Slide 3: Aircraft Carrier USS Enterprise. Courtesy U.S. Navy, photo by Photographer's Mate Airman Rob Gaston. Available from: http://www.navy.mil/view_single.asp?id=15089http://www.navy.mil/view_single.asp?id=15089 Slide 6: High Reliability Organizations: Mindfulness. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1- 6.htm)http://www.ahrq.gov/qual/hroadvice/hroadvicefig1- 6.htm Slide 7. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm) http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm Slide 8: Preoccupation with Failure. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htmhttp://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm 23 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT

24 Images Slide 9: Reluctance to Simplify. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htmhttp://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm Slide 10: Deference to Expertise. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htmhttp://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm Slide 11: Resilience. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htmhttp://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm 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: http://www.flickr.com/photos/wwarby/http://www.flickr.com/photos/wwarby/ 24 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Reliability, Culture of Safety, & HIT Reliability, Culture of Safety, & HIT References

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