1. Culture Trumps….. EVERYTHING!!! Building a Core Belief in Justice in Order to Drive Reliability Kathy Harris, MS, RN, CENP, FACHE Vice President, Clinical Services Banner Health Presented to the Georgia Organization of Nurse Leaders Annual Meeting September 18, 2015 Culture

2. Justice that term which accumulate or reform a society and maintain equality, fairness and morality the quality of being just; righteousness, equitableness, or moral rightness rightfulness or lawfulness the moral principle determining just conduct just conduct, dealing, or treatment

4. My Story

5. Role of the Nurse Implement the treatment plan Provide surveillance Do it perfectly Every time No matter how tired No matter how distracted No matter what else is going on You get the picture

6. Is Perfection The Standard?

8. Imperfect Humans “Under ideal conditions, we— meaning all human beings—fail to perform a check correctly about 5% 1,2 of the time, and we fail to detect an error during the checking process between 5% 2 and 10% 3 of the time. While under moderate stress, our failure to detect an error during an inspection or verification process increases to about 20%. 4,5 ” ISMP Safety Alert August 27, 2009 Volume 14 Issue 17

10. Core Elements of a Just Culture Design of safe systems Management of behavioral choices

11. Our Journey 2008 Team Champions CIPI ESs NPR PPR Planning Implementation More Champions New strategic plan

12. Define Actionable What Support from all levels Data Design Target population(s) Content Toolkit Teachers/Expertise Monitoring Implement Timeline WWDWBW Follow Up Sustainability Implementing Just Culture

13. Just Culture and Alignment to our Mission, Vision, Values, Behaviors High reliability and continuous performance improvement increases the quality of our work and decreases the cost We shift focus from outcome of failures to system designs and behavioral choices where people feel fairly treated Provide guidelines for evaluating employee choices Guides leaders’ decision-making that supports transparency and accountability Behavior alignment: safe & reliable practices, engaged employees treated with respect and compassion, fosters continual learning, performance driven, and accountability for our choices and behaviors 13

14. Framework for Implementation Shared and actionable Vision Support from all levels Define the desired practice Design the program Plan for Implementation Identify expertise Build toolkit Communicate the plan Implement Evaluate progress Monitor

15. Framework for Implementation Shared and actionable Vision Support from all levels Define the desired practice Design the program Plan for Implementation Identify expertise Build toolkit Communicate the plan Implement Evaluate progress Monitor

16. Reliability Human reliability Reliability of engineering (the ability of a system or component to perform its required functions under stated conditions for a specified period of time.) the ability to be relied on or depended on, as for accuracy, relied honesty, or achievement. the extent to which an experiment, test, or measuring procedure yields the same results on repeated trials Reliability is failure-free operation over time--the measurable capability of a process, procedure, or service to perform its intended function. “(F)ailure-free operation over time.” Perfection?

17. Reasons for the Reliability Gap In Healthcare Current Improvement methods in healthcare are highly dependent on vigilance and hard work The focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of security Permissive clinical autonomy creates and allows wide performance margins The use of deliberate designs to achieve articulated reliability goals seldom occurs

18. Reasons for the Reliability Gap In Healthcare Current Improvement methods in healthcare are highly dependent on vigilance and hard work The focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of security Permissive clinical autonomy creates and allows wide performance margins The use of deliberate designs to achieve articulated reliability goals seldom occurs

19. Reasons for the Reliability Gap In Healthcare Current Improvement methods in healthcare are highly dependent on vigilance and hard work The focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of security Permissive clinical autonomy creates and allows wide performance margins The use of deliberate designs to achieve articulated reliability goals seldom occurs

20. Reasons for the Reliability Gap In Healthcare Current Improvement methods in healthcare are highly dependent on vigilance and hard work The focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of security Permissive clinical autonomy creates and allows wide performance margins The use of deliberate designs to achieve articulated reliability goals seldom occurs

21. We Like to be Protected All defects in process do not lead to bad outcomes Healthcare tends to look at outcomes and not the reliability of the process leading to outcomes (hand washing is an example) Benchmark to best practice not aggregate averages

22. Key Learning Points Hard work and vigilance although commendable is not a good design principle

23. Avedis Donabedian’s Legacy 1966 Donabedian article 1 ◦ STRUCTURE and Process -> Outcomes 2006 Pronovost (Hopkins) article 2 : ◦ Other industrial experiences has confirmed the concept of CONTEXT (culture) in safety 1. Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund Quarterly 1966;44:166–206 2. Pronovost, P. et al. How will we know patients are safer? An organization-wide approach to measuring and improving safety. Crit Care Med 2006; 34: 1988-1995

24. Model for Measuring Safety

26. Key Learning Point A single standardized process within the acceptable science is superior to allowing multiple processes while we decide which is the best because it allows testing and training And learning…..

27. Attributes of High Reliability Organizations: Weick 1. Preoccupation with failure 2. Reluctance to simplify interpretations 3. Sensitivity to operations 4. Commitment to resilience 5. Deference to expertise Weick, et al. Research in Organizational Behavior. 1999;21:81-123 Weick, Managing the Unexpected: Assuring High Performance in an Age of Complexity, Jossey Bass 2001

28. Attributes of High Reliability Organizations: Weick 1. Preoccupation with failure 2. Reluctance to simplify interpretations 3. Sensitivity to operations 4. Commitment to resilience 5. Deference to expertise Weick, et al. Research in Organizational Behavior. 1999;21:81-123 Weick, Managing the Unexpected: Assuring High Performance in an Age of Complexity, Jossey Bass 2001

31. Excellent results in a safer environment that you can COUNT ON!

32. Your (Leadership)Role Understand the goal OWN the goal Create the burning platform for something new Articulate the vision and the path Learn, learn, learn Demonstrate discipline and commitment Do what you say you are going to do (Keep trying: even you are not perfect) Become an expert Develop exquisite sensitivity to operations