Mark Graban has a great post about culture and LEAN. http://leanblog.org/2011/04/more-trust-less-fear/
More trust. Less fear. All his points can easily be applied to safety efforts! If staff are afraid of making a mistake or losing their jobs, their attention will be directed as self-preservation rather than organizational goals for safety or anything else.
The 2011 patient safety culture report is out from the AHRQ detailing the results from the survey of patient safety culture in over 1000 hospitals with almost half a million responders. There is some good news and some very concerning news. On the bright side, teamwork and supervisor attention to patient safety received high marks with 75-80% positive responses. Very concerning however are the two lowest scores: handoffs and hospital response to error.
The positive responses to the perception of safe handoffs came in at only 45% and the perception of a non-punitive response to error weighed in at 44%. Of particular concern, as expressed many times on this blog, is the perception of 56% of respondents that response to error is punitive! This perception has not improved AT ALL since the 2007 survey when data was collected from 382 hospitals.
For the New England region only this response to error survey item elicited a positive response in a paltry, scary 38% of respondents. 62% of those working in hospitals in New England perceive that there is a punitive approach to error!
What does this mean?
A culture in which staff perceive that they will be punished for making errors, creates secrecy and a reluctance to report incidents. This can lead to great patient harm. When you blame by the bad apple theory (the error involved a bad clinician) and punish the “bad apples,” the system goes unfixed making the next patient every bit as vulnerable as the one who was harmed by the “bad apple.” Unsafe conditions and near misses go under-reported creating a significant deficit for senior leaders who are trying to improve safety and quality for their organizations. As a senior leader, even if your policy is non-punitive, if the staff believe it is punitive their behavior will be risky.
To move away from a culture of blame, I suggest going to the Just Culture community website linked on this blog or reading “Behind Human Error” (2010) by Woods, Dekker, et al.
Healthcare providers know that the public is invested in the reporting of and the prevention of medical errors. The website Dead by Mistake is run by Hearst newspapers and is a consumer oriented site with scary stories of medical mishaps that would make even the bravest among us afraid to receive hospital care.
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Excerpt from Harvard Business School working Knowledge:
“A Harvard research team recently set out to better understand what managers can do to encourage employees to speak up about problems, and to investigate how managers can encourage employees to offer solutions.
The team’s working paper, “Speaking Up Constructively: Managerial Practices that Elicit Solutions from Front-Line Employees” considers data on nearly 7,500 incidents from a single hospital to determine whether two types of managerial actions increase the frequency with which frontline workers speak up by reporting incidents and do so constructively by including solutions in their incident reports”
Please read their article: View full post
Read Speaking up constructively linked from that post
It is 88 degrees in Tampa as day one kicks off for the SIOP LEC on Developing and Enhancing High Performance Teams.
The amazing speakers: I will list their names and content and the thoughts they have provoked in me from a safety dog perspective.
Gary Latham the co-chair of the LEC gave an inspiring introduction about the purpose of these LECs as not only to hear great speakers but also to compare notes as practitioners. more: Read the rest of this entry »
One of the difficulties in infusing safety into the healthcare environment is getting safety behaviors habitually into bedside practice. The previously referenced degradation of the anesthesia safety policy published in Quality and Safety in Health Care is a perfect illustration of this dilemma. View the full text of this article The natural lifespan of a safety policy: violations and system migration in anaesthesia.
A recent experiment published in the European Journal of Social Psychology contained the results of a study focused on the length of time it took to insinuate a behavior into habit…. Read the rest of this entry »
The future of safety?
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