Developing a Safety Culture The Challenges in Medicine

Developing a Safety Culture: The Challenges in Medicine J. Bryan Sexton, Ph.D. Department of Anesthesiology and Critical Care Medicine The Johns Hopkins Quality and Safety Research Group Euroanesthesia 2004 17S1 Lisbon, Portugal 6/06/2004 Aviation Accidents per million departures Primary accident causes (%) Other FAA Weather Maintenance Airplane Flight Crew 0 10 20 30 40 50 60 70 80 Aviation background • NASA research found that 70%+ of air transport accidents involved human error • Sources of Errors – – – – – leadership communication monitoring and challenging teamwork decision making • Industry welcomed research Teamwork by Edict: Today, pilots can fail their certification based on poor human factors, or “non technical” aspects of their performance. Teams and Technology… In both aviation and medicine, people must cope with technology in an imperfect environment “ Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects….. Their part is that of adding the final garnish to a lethal brew that has been long in the cooking.” James Reason, Human Error, 1990 Millions of Dollars Spent Annual US Health Research Funding 30,000 25,000 20,000 15,000 10,000 Federal Pharma 5,000 0 Basic Clinical Health Services Type of Research Sources: ACP-ASIM Observer, 2001, http://www.acponline.org/journals/news/feb01/clinresearch.htm Federal Funding and Priorities for Health Services Research, AcademyHealth, March 10, 2003. We have a long way to go in understanding the delivery and context of care… Why look at Attitudes? • Aggregate-level attitudes indicate the climate of a clinical area/organization – 1 attitude = opinion, everyone’s attitude = climate • Reliably assessed through research instruments – Cheaply and easily • Predict performance and outcomes – attitudes help to explain variability in safety and performance measures • Malleable to interventions – Interventions that target attitudes improves subsequent performance Culture is Context: • There is a growing consensus that quality of care must be investigated within the context of teams and their work environments • Complimentary to other forms of data, i.e, serves an explanatory function for problems with: – absenteeism, Turnover, incident reporting, case delays, LOS, readmission rates What is Culture*?: “The way we do things around here” *aka Climate Factor: Definition Job satisfaction: positivity about the work experience Teamwork climate: perceived quality of collaboration between personnel Example items –I like my job –This hospital is a good place to work –Disagreements in the ICU are appropriately resolved (i.e., what is best for the patient) –Our doctors and nurses work together as a well coordinated team –I would feel perfectly safe being treated in this ICU –ICU personnel frequently disregard rules or guidelines developed for our ICU –Hospital management supports my daily efforts in the ICU –Hospital management is doing a good job –I am less effective at work when fatigued –When my workload becomes excessive, my performance is impaired –Our levels of staffing are sufficient to handle the number of patients –The ICU equipment in our hospital is adequate Safety climate: perceptions of a strong and proactive organizational commitment to safety Perceptions of management: approval of managerial action Stress recognition: acknowledgement of how performance is influenced by stressors Working conditions: perceived quality of the work environment and logistical support (staffing, equipment etc.) Teamwork Climate : Perceived quality of collaboration between personnel % of respondents within a clinical area reporting good teamwork climate 100 90 80 70 60 50 40 30 20 10 0 Teamwork Climate Across 29 Clinical Areas: Same Organizataion Culture is Local… % of respondents within an ICU reporting good teamwork climate 100 10 20 30 40 50 60 70 80 90 0 Teamwork Climate Across ICUs Teamwork Climate is perceived differently by MDs and RNs 100 % Rating Teamwork Climate Positively 90 80 70 60 50 40 30 20 10 0 36 19 Nurse Physician % of respondents reporting above adequate teamwork 100 90 80 70 60 50 40 30 20 10 0 ICU Physicians and ICU RN Collaboration 90% 54% KP L &D RN rates ICU Physician ICU Physician rates RN Bridging the disconnect: A focus of collaboration is sharing one’s mental model common understanding of the situation Teamwork Items Most Predictive of RN Turnover – Our physicians and nurses work together as a wellcoordinated team. – In this clinical area, it is difficult to speak up if I perceive a problem with patient care – Disagreements in this clinical area are appropriately resolved (i.e., not who is right, but what is best for the patient). OR MD/RN Collaboration Ratings 100 % Collaboration rated positively 90 80 70 60 50 40 30 20 10 0 CRNAs & Anesth Attndgs Surg Nurses & Surg Nurses and Anesth Attndgs Surg Attndgs CRNAs & Surg Attndgs RN rates M D M D rates RN nurses rated physicians less positively (particularly surgical attendings) Communication breakdowns which lead to delays in starting surgical procedures 100 are common: 90 80 70 60 50 40 30 20 10 0 % of respondents who agree 79 79 80 54 54 Anesthesiologist Staff Surgeon Surg Tech OR Nurse CRNA Conflict Resolution in the OR • Conflict was observed in 10% of flights and 10% of surgeries •Resolved in 80% of instances in cockpit •Resolved in 20% of instances in operating room In the news… Doctors Fined for Fight in Operating Room Worcester, Mass. Nov. 27 (AP) --- A state medical board has fined a surgeon and an anesthesiologist $10,000 each for brawling in an operating room while their patient slept under general anesthesia. After their fight, the anesthesiologist, Dr. Kwok Wei Chan, and the surgeon, Dr. Mohan Korgaonkar, successfully operated on the elderly female patient. In addition to imposing the fines, the state board of Registration in Medicine last week ordered the doctors to undergo joint psychotherapy. It also directed officials at the Medical Center of Central Massachusetts, who had already put the doctors on five years' probation, to monitor Drs. Chan and Korgaonkar for five years. The medical board said that on Oct. 24, 1991, Dr. Korgaonkar was about to begin surgery when he and Dr. Chan began to argue. Hospital officials would not provide the nature of their disagreement. Dr. Chan swore at Dr. Korgaonkar, who threw a cotton-tipped prep stick at Dr. Chan, the board said. The two then raised their fists and scuffled briefly, at one point wrestling on the floor. A nurse monitored the anesthetized patient as the doctors fought. Surgeon Shoots Anesthetist Dead During Operation -- Patient Faints Rio de Janeiro. Reuters. A Brazilian surgeon shot a colleague, who was responsible for the anaesthesia of the patient, during abdominal surgery. While this was happening on Monday. The patient awoke from anaesthesia and, on seeing the bloodbath, fainted. The Resident who was present attempted to save the life of the anaesthetist then ended the abdominal operation. The surgeon was long gone over the mountains. There was disagreement regarding the surgery between the two doctors, members of a private clinic at Macae, near Rio de Janeiro, where the operation took place. During the dispute, the 60 year old surgeon, Marcelino Pereira da Silva took out a revolver and put three shots into the head of Elimson Ribeiro Elias, age 40. Search is on for the surgeon. Transparency & Familiarity Percent Understanding Patient Care Goals 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 Implemented patient goals sheet Residents Nurses 1 2 3 4 5 6 Familiarity with others is a critical component of effective teamwork: •74% of all commercial aviation accidents happen on the first day of a crew flying together •Highlights the importance of predictable patterns of behavior Lessons Learned: • Culture is local • Focus on communication: share your mental model • Teamwork related to turnover • Familiarity improves predictable patterns of behavior (improves performance) • Safety interventions must be goal directed – Need practical tools and senior-level commitment • Culture changes incrementally and the change is local • Respect the wisdom of the front line workers Questions? Hey… what’s a mountain goat doing way up here in a cloud bank?