1. Faculty Disclosure: As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) must insure balance, independence, objectivity, and scientific rigor in all its individually sponsored or jointly sponsored educational activities. All faculty participating in a sponsored activity are expected to disclose to the audience any significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in an educational presentation. (Significant financial interest or other relationship can include such things as grants or research support, employee, consultant, major stockholder, member of speaker’s bureau, etc.) Tom Garcia has indicated he is President and Senior Consultant of Culture Dynamics, Inc.

2. Tom Garcia Navy Fighter Pilot -22 yrs Navy Fighter Pilot -22 yrs Commercial Airline Pilot -14 yrs Commercial Airline Pilot -14 yrs Naval Safety Center Consultant & Analyst Naval Safety Center Consultant & Analyst

4. MD80 757 767 F100 777

5. High Reliability Organization (HRO) Organizations which perform complex tasks in demanding environments with very low rates of error. Every study done of HRO’s has concluded that culture is the key element.

6. Culture The learned and shared assumptions, beliefs, values, and behavior of an organization.

7. Keys to Understanding Culture Stable – The deepest, most driving forces of your culture are the most stable. If you want to manage them, you must understand them. Stable – The deepest, most driving forces of your culture are the most stable. If you want to manage them, you must understand them. Hidden – Based on assumptions. Hidden – Based on assumptions.

8. 0 10 20 30 40 50 60 50607080900001 03 Angled decks Aviation Safety Center Naval Aviation Maintenance Program (NAMP), 1959 RAG concept initiated NATOPS Program, 1961 Squadron Safety program System Safety Designated Aircraft ACT ORM Naval Aviation Mishap Trend FY50-03 Rate 776 aircraft destroyed in 1954 28 aircraft destroyed in 2003 Culture Workshop

9. Patient Safety? HRO Lessons Learned HRO Lessons Learned Learn from HRO’s instead of the hard way and become an HRO quicker.

10. Patient Safety and Developing a Culture of Safety HRO key to success is Culture HRO key to success is Culture HRO’s have great safety records HRO’s have great safety records Healthcare  HRO = Culture of Safety

11. Healthcare Transition to High Reliability Develop the cultural traits of a HRO. Develop the cultural traits of a HRO. How? How? Maintain HRO status. Maintain HRO status. How? How?

12. Naval Aviation 1996 4 Serious and costly mishaps 4 Serious and costly mishaps All preventable All preventable Underlying problems were dysfunctional cultures Underlying problems were dysfunctional cultures

13. Naval Aviation Already has the cultural traits of a HRO. Already has the cultural traits of a HRO. In order to maintain HRO status. In order to maintain HRO status. Prevent dysfunctional cultures from developing. Prevent dysfunctional cultures from developing. Eliminate dysfunctional cultures that do develop. Eliminate dysfunctional cultures that do develop.

14. Dysfunctional Cultures Kotter and Heskett, Harvard Business School professors, spent 4 years studying over 200 large U.S. companies. Kotter and Heskett, Harvard Business School professors, spent 4 years studying over 200 large U.S. companies. dysfunctional cultures “…are not rare; they develop easily, even in firms full of reasonable and intelligent people.” dysfunctional cultures “…are not rare; they develop easily, even in firms full of reasonable and intelligent people.”

15. Dysfunctional Cultures NASA - Columbia Accident Investigation Board Report NASA - Columbia Accident Investigation Board Report “Cultural traits and organizational practices detrimental to safety were allowed to develop.”

16. Dysfunctional Cultures No one is immune. No one is immune. The best safety program in the world can be undermined by a dysfunctional culture. The best safety program in the world can be undermined by a dysfunctional culture. Great safety programs do not guarantee a culture of safety!

17. Naval Aviation 1996 Implements culture assessment program Implements culture assessment program Two parts: Two parts: Climate survey Climate survey Culture assessment Culture assessment

18. March 2002 – March 2004 93% of Class A (serious) Mishaps occurred in squadrons not participating in the Safety Culture Assessment Program. The program is now mandatory. Source: Naval Safety Center Approach magazine Mar-Apr 2004

19. Naval Aviation $1.1 billion saved over 5 years by assessing and improving culture LtCol(Ret) Rick ‘Spike’ Boyer, former Director of Aviation Safety, U. S. Naval Safety Center

20. Naval Aviation A HRO found that by managing culture A HRO found that by managing culture Reduced error even further Reduced error even further More lives saved More lives saved More money saved More money saved Improved operational efficiency, not just safety Improved operational efficiency, not just safety Eliminated unnecessary training! Eliminated unnecessary training!

21. Unnecessary Training Because culture assessments find the true underlying problems, they highlight the effectiveness of current programs and the potential of new programs. Some existing programs had no real benefit. Some existing programs had no real benefit. New programs that initially looked good, now no longer did. New programs that initially looked good, now no longer did.

22. Naval Aviation Lessons Learned 50 years of trial and error. Some programs worked, many didn’t. But now with culture assessments they find the underlying problems and safety program trial and error is a thing of the past. 50 years of trial and error. Some programs worked, many didn’t. But now with culture assessments they find the underlying problems and safety program trial and error is a thing of the past. Great safety programs don’t guarantee a culture of safety. Culture must actively be managed. Great safety programs don’t guarantee a culture of safety. Culture must actively be managed.

23. Naval Aviation Lessons Learned Technology improvements must be accompanied by cultural improvements to maximize the benefits. Technology improvements must be accompanied by cultural improvements to maximize the benefits. It is easier to manage culture to improve it than to fight it to change it. It is easier to manage culture to improve it than to fight it to change it. Working with and improving culture pays! Working with and improving culture pays!

24. Naval Aviation Culture Assessment Two parts: Two parts: Climate survey Climate survey Culture assessment Culture assessment

25. Culture vs. Climate? Climate = organizational conditions Observable Observable What we see and hear What we see and hear Can change from day to day Can change from day to day

27. Purpose of a Survey A survey is a benchmarking tool used to indicate potential problems. What it gives you are symptoms. You still need to find the problems.

28. Healthcare Climate Survey Safety climate surveys were conducted at 15 hospitals and from naval aviators from 226 squadrons. & Differences in Safety Climate Between Hospital Personnel and Naval Aviators, Human Factors, Volume 45, 2, Summer 2003 Stanford University &VA Palo Alto

29. Survey Results Question#QuestionNavy All Hospital Personnel High Hazard Domain 2 Loss of experienced personnel has negatively affected my ability to provide high quality patient care 18.555.159.4 17 Staff are provided with the necessary training to safely provide patient care 2.211.312.9 Differences in Safety Climate Between Hospital Personnel and Naval Aviators, Human Factors, Volume 45, 2, Summer 2003

30. Survey Results Question#QuestionNavy All Hospital Personnel High Hazard Domain 20 Senior management has a clear picture of the risks associated with patient care 1.921.930.6 4 Senior management does not hesitate to temporarily restrict clinicians who are under high personal stress 7.837.145.4 Differences in Safety Climate Between Hospital Personnel and Naval Aviators, Human Factors, Volume 45, 2, Summer 2003

31. Survey Results Where do the most significant problematic responses point? Staffing  Policy  Management 

32. Theseus Equation ™ for Error  Error Rate = Climate + Culture Error rate drops/increases with the sum of improvement/dysfunction of climate & culture Structure Staffing  Policy  Management  AssumptionsBeliefsValuesPerceptionsTeamworkMoral

33. Survey Results Will new safety programs and training improve?: Will new safety programs and training improve?: Staffing Staffing Policy Policy Management Management Are there actual staffing, policy and management problems or only misperceptions of them? And what sort of additional symptoms are these issues causing? Are there actual staffing, policy and management problems or only misperceptions of them? And what sort of additional symptoms are these issues causing? Diagnosis of these symptoms is needed.

34. Culture Assessment? Develop the cultural traits of a HRO. Develop the cultural traits of a HRO. Yes Yes Maintain HRO status. Maintain HRO status. Yes Yes

35. Culture Assessment and its Role in Developing High Reliability The Key Element in HRO is Culture. The Key Element in HRO is Culture. Why? Why? “Complex tasks in a demanding environment.” “Complex tasks in a demanding environment.” In the case of aircraft carrier ops, the observed conditions and environment initially confused researchers as to why the error rate was not higher. In the case of aircraft carrier ops, the observed conditions and environment initially confused researchers as to why the error rate was not higher. Aircraft carrier staffing example. Aircraft carrier staffing example.

36. Culture Assessment and Developing High Reliability Researchers discovered that it was the culture of the organization that overcame the “organizational climate” limitations and barriers. Researchers discovered that it was the culture of the organization that overcame the “organizational climate” limitations and barriers. “We have been struck by the degree to which a set of highly unusual formal and informal rules and relationships are taken for granted, implicitly and almost unconsciously incorporated into the organizational structure of the operational Navy.” The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea Gene I. Rochlin, Todd R. La Porte, and Karlene H. Roberts Gene I. RochlinTodd R. La PorteKarlene H. RobertsGene I. RochlinTodd R. La PorteKarlene H. Roberts

37. Culture Assessment and Developing High Reliability So, a process of accurately assessing, managing and improving culture will greatly improve any organization’s transition to high reliability. So, a process of accurately assessing, managing and improving culture will greatly improve any organization’s transition to high reliability. Because – Culture is so important to that transition.

38. Culture Assessment - Developing and Maintaining a High Reliability Culture Think of culture as a patient. How do we improve and maintain the health of our patient?

39. Culture as Our Patient First step is to Diagnose. We define the current state of health. First step is to Diagnose. We define the current state of health. Second step is to treat as necessary. Second step is to treat as necessary. You can’t improve or treat an unknown therefore a thorough and accurate diagnosis leads to accurate treatment.

40. Keys Elements That Exist and Must be Developed in a HRO Vision/Mission Vision/Mission Decision Making Process Decision Making Process Learning Organization Learning Organization Redundancy Redundancy

41. Culture Assessment & HRO Keys Vision/Mission Vision/Mission Are they understood, shared and realistic? Decision Making Process Decision Making Process What Barriers exist? Standardization? Learning Organization Learning Organization Is error reporting working? Redundancy Redundancy Is it being utilized properly?

42. Culture of Safety What are the keys? What are the keys? Can CA help? Can CA help?

43. Culture of Safety Key Characteristics Standardization Standardization Leadership Commitment Leadership Commitment Open Communication Open Communication Absence of Fear Absence of Fear Best Practices Best Practices

44. Culture Assessment & Culture of Safety Standardization Standardization Define and solicit for improvement Leadership Commitment Leadership Commitment Must be real and in touch with org Open Communication Open Communication CA is an open communication process

45. Culture Assessment & Culture of Safety Absence of Fear Absence of Fear CA defines the level of confidence and is an excellent forum for anonymous real time feedback. Best Practices Best Practices Lessons learned and Feedback

46. Keys to Assessing Culture Culture is a group phenomenon. You won’t get it from surveys, observation, or individuals. It is hidden. Culture is a group phenomenon. You won’t get it from surveys, observation, or individuals. It is hidden. Self diagnosis is flawed. Self diagnosis is flawed.

47. How Do We Assess/Diagnose? Logical Peer Group Logical Peer Group Brings assumptions to the conscious level Brings assumptions to the conscious level Exposes and defines the current culture of safety. Exposes and defines the current culture of safety. Exposes the underlying problems to observed symptoms. Exposes the underlying problems to observed symptoms.

48. How Do We Then Manage and Improve Culture? Beauty of CA is that it greatly simplifies this process. Beauty of CA is that it greatly simplifies this process. CA fixes ½ your problems CA fixes ½ your problems As much as 50% of problems are related to miscommunication and misperceptions. Clearly define your cultural strengths. Clearly define your cultural strengths. It is easier to build upon cultural strengths than to fight the constraints of your weaknesses.

49. How Do We Then Manage and Improve Culture? Clearly defined weaknesses Clearly defined weaknesses When you understand the true underlying causes of your weakness, solutions are much easier. Example – your car is running poorly.

50. Culture of Safety Too many historical examples of great safety programs that did not create a culture of safety. Relying on safety programs alone to shift culture is trial and error. Too many historical examples of great safety programs that did not create a culture of safety. Relying on safety programs alone to shift culture is trial and error. Treat culture like a patient – work directly with that culture to thoroughly define the current state and then manage it to improve it. You will get better results. Treat culture like a patient – work directly with that culture to thoroughly define the current state and then manage it to improve it. You will get better results.

51. Culture of Safety Diagnose, then Treat!