Ann Scott Blouin, RN, PhD, FACHEExecutive Vice President

Customer Relations

Michigan Hospital AssociationMarch 7, 2017

Psychological Safety:A Hallmark of Effective Teams

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3 Waves of Innovation in Patient Safety

Technical and procedural improvements have made surgery safer, but future innovations will focus on reliably organizing the work of patient care.

Ghaferi AA, et al. The Next Wave of Hospital Innovation to Make Patients Safer. Harvard Business Review. Aug. 8, 2016

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Leadership RPI

Commitment to Zero Patient

Harm

Safety Culture

Empowering staff to speak up

about patient risks

Systematic data-driven approach to solving complex problems

High Reliability in Health Care Requires:

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ECRI InstituteNew Safety Concern 2016

Failure to Embrace aCulture of Safety

Healthcare organizations must have a culture of safety that both spans the entire organization and permeates each department.

Source: Top 10 Patient Safety Concerns for Healthcare Organizations 2016. ECRI Institute Executive Brief. April 2016.

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Essential Elements: Culture of “Mindfulness” for

Psychological SafetyAn atmosphere of trust in which errors and “near �misses” are valuable lessonsA “just” response to human errors, differentiating �intentional from unintentional A system that provides for easy, de-identified �reporting of unexpected events and errors, and that gives feedback and learning to those who reportA learning system that not only shares feedback, �but uses the learning to redesign the operations and challenge the assumptions that underlie the system itself

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Getting to Zero Harm

“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”

- Lucian Leape MD, member of the Quality of Health Care in America Committee at the Institute of Medicine and adjunct professor of the Harvard School of Public Health

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Safety CulturePrinciples and Traits

Principle TraitEveryone is personally - Personal Accountabilityresponsible for safety

Leaders demonstrate a - Leadership safety valuescommitment to safety

Trust permeates the - Effective safety communicationsorganization - Respectful work environment

- Environment for raising concerns

Decision-making reflects - Decision-makingsafety first

Adapted from: Traits of a Healthy Nuclear Safety Culture. INPO 12–012, April 2013. Copyright © 2012, 2013 by the Institute of Nuclear Power Operations

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Safety CulturePrinciples and Traits

(continued)

Principle TraitHealth care technology is - Work processes automatedrecognized as special andunique

A questioning attitude is - Questioning attitude applaudedcultivated

Organizational learning is - Continuous learningembraced - Problem identification & resolution

Patient Safety undergoes - Continuous learning and fixesconstant evaluation - Problem identification

Adapted from: Traits of a Healthy Nuclear Safety Culture. INPO 12–012, April 2013. Copyright © 2012, 2013 by the Institute of Nuclear Power Operations

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A Psychologically Safe Culture:Interlocking Elements

Learningculture

Just culture

Reportingculture

Source: James Reason

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Safety Culture Maturation

Trust and intimidating behavior are not assessed

Emphasis is on blame; inequitable application of discipline

Root cause analysis is limited to adverse events

Limited or no efforts to assess system defenses against quality failures and remedy weaknesses

No measures of safety culture exist

Beginning ApproachingHigh levels of (measured) trust exist in all clinical areas

All staff recognize/act on personal accountability; equitable disciplinary procedures

System defenses proactively assessed; weaknesses proactively repaired

Close calls/unsafe conditions routinely reported with early problem resolution

Safety culture measures results routinely reported to the board; system improvement initiatives under way

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Culture Change is Difficult

AHRQ Safety Culture Survey 1. Staff feel mistakes are held

against them (% YES) 2. When event is reported, it feels

like the person is being written up, not the problem (% YES)

3. Staff worry mistakes are kept in their personnel files (% YES)

2007 (n=382)

2012 (n=1128)

2007 2012

50

54

65

50

57

65

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What Behaviors Are Intimidating?

Wide range: from hanging up the phone �instead of answering a question to verbal abuse (cursing, yelling) or physical abuseMost common?�

Refusal to answer questions or to return phone calls –or pages; condescending tone or language; impatience with questions2003: about ¼ of nurses and pharmacists –personally experienced these from MDs more than 10 times in past year

Have we improved?

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Sometimesthe silence getsso loud, the onlything left to dois hope yourheart is strongenough to beatit outAuthor: Rachel Wolchin

Culture of Silence

14https://www.jointcommission.org/issues/article.aspx?Article=rFhOFvmOhideyaeaXWHwdF7iIsdGP%2bTcEobEhA7d2RU%3d accessed via internet June 24, 2016

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Drive out fear and create trust- W. Edward Deming

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Trust

ReportImprove

Adapted from Reason J., and Hobbs A. 2003. Managing Maintenance Error: A Practical Guide. Burlington, VT: Ashgate.

Safety Culture

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TrustCredibility Reliability Authenticity

Self-Interest

“The Trust Equation”

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What Do Healthcare Staff Need for Psychological Safety?

Respect and engagement�Freedom from harm�

physical–psychological–

Meaningful work�Opportunities to learn �and develop

Source: Lucian Leape Institute Roundtable, National Patient Safety Foundation 2013. http://www.patientcarelink.org/uploadDocs/1/Through-Eyes-of-the-Workforce_online.pdf

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Elements of Psychological Safety in Teams

Trust teammates to support and help each other�Respectful communications�Assume good intentions – no “hidden agendas”�Believe everyone’s goals are aligned�Able to challenge others’ ideas in positive �mannerHold each individual accountable for own actions�Open to learning from mistakes�Fear is absent�

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The Joint CommissionCustomer Relations Department

Operating PrinciplesClearly communicate expectations; if instructions are not clear, receiver should �clarify with senderRespect others in word and actions�Treat others as you’d like to be treated�Be honest in all interactions; respectfully approach the individual with any �concerns privatelyBe transparent in all communications�Watch each others “back” � be a good team player�If uncertainty, difference of opinion, meet internally and problem solve�We live and thrive as a team�“No gossip” � confront (politely and privately) the person directly; be constructive�Assume good intentions, respond professionally to any constructive feedback�Everyone steps up to help when department workloads begin to increase as �needed (one team, one goal)Exchange ideas that are creative, innovative and useful that can increase the �efficiency and effectiveness of Customer RelationsBuild and maintain a culture that incorporates trust�

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Where to Start: A Simple Test

Can your staff answer yes to the following three questions?

Am I treated with dignity and respect everyday by 1.everyone I work with?

Do I have the knowledge, skills, and tools to do my 2.job?

Am I recognized and thanked for my contributions?3.

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Role of Hospital Leadersin Building a Culture of Psychological Safety

Motivate care teams to uphold a fair and �just safety cultureProvide a transparent environment in which �patient safety events are honestly reportedModel professional behavior�Remove intimidating behavior that might �inhibit a culture of safetyProvide the resources and training �necessary to take on improvement initiatives

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What gets rewarded gets repeated

“Recognition”It’s not a natural skill . . .

It must be taught!

“65% of Americans reported that they received no recognition for good work in the past year …”

Source: Rath T, Clifton D. How Full Is Your Bucket, 2004.

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Eight Recommendations for Achieving Total Systems Safety

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Eight Recommendations for Achieving Total Systems Safety