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Improving Patient Safety - the Cornerstones

Jeff Convissar and Maxine Power APAC 2014 (1 day lab)


on 12 September 2016

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Transcript of Improving Patient Safety - the Cornerstones

Patient Safety
Teamwork and Communication
Psychological Safety
The Cornerstones
Prof Dorothy Jones
Professor Clinical Safety & Quality
Curtin University ‎
Prof Maxine Power
Director of Innovation and Improvement Science
Salford Royal NHS Foundation Trust
Teamwork and
Have you or someone you've known experienced harm associated with receiving healthcare?
What contributed to the event and what might have prevented it?
Safety Culture
In theory, there is no difference between theory and practice...
In practice there is.
Framing The Discussion
Work in groups of three to five at your table
Discuss the culture ("the way we do things") in your medical center or if you prefer, in the area in which you work
Preventable Harm
Framework for excellence
Safe and reliable care for every patient, every place, every time
Psychological safety
Learning system
Set the stage every morning, every time
Expect it and show it
Voice them daily
Develop know-how
Work in groups of three to five at your table
Pick one of the three areas of respect:
I am treated with dignity and respect by everyone I encounter every day.
I am given the things I need so that I can make a contribution.
I am recognized for my contribution.
Describe how this area can be or is practiced every day in the area in which you work.
Culture Change
So, how is this really, really, really, really going to happen?
Work in groups of three to five at your tables.
Pick one of the top four areas of opportunity from the Learning Journal that most pertain to your work area.
Identify three to four actions that you and your colleagues can take to improve this area.
Discuss these questions:
What can you do?
How are you going to do it?
By when can you do it?
What are the barriers to achieving your action plans
The Challenges of Teamwork
Can you speak up?
Answer this question at your table:
Would you feel safe speaking up if you saw these people performing an unsafe act such as not washing their hands between patients?
If the answer is "no", explain why:
Member of another discipline
Your own stories
Without identifying anyone involved, are any of you willing to share a story of harm when someone knew there was a problem but did not speak up?
We are wired to protect our psychological self
Give Voice
Find Voice
Culture, time,
hierarchy, risk
SBAR, assertion,
critical language
Accountability to Giving Voice
Psychological safety requires inclusive leaders. Inclusive leaders lower the psychological costs of voice and raise the psychological costs of silence.

Model, mentor, coach inclusive leadership.
Don’t tolerate disruptive behavior.
Understand: “I am accountable for my success, my team’s success, and the success of Kaiser Permanente.”

Barriers to Giving Voice
Separate prof education and training
Hierarchical relationships
Time constraints
Beliefs and expectations
Concern nothing will change

Barrier Busting
Find a partner and use your Learning Journal.
Ask your partner to give all the reasons why he or she can’t or doesn’t foster speaking up.
Write your partner’s reasons in the left column on the barrier busting worksheet for Giving Voice in your learning journal.
When the list is finished, read each of the reasons back to your partner, one at a time.
Record your partner’s arguments in the right column. Trade roles.
When your own reasons are read back to you, argue against each:
What’s at risk if you don’t do this?
What’s possible if you do?
Discussion debrief
Did the activity help you "bust" any of your own barriers to giving voice to the others?
Who might you use this activity with?
What do I need to do?
Am I treated with respect by everyone?
For example, an EVS employee must be treated with the same respect as the chief of surgery.
Am I given the tools I need, such as information, education, and training?
Am I recognized for my contribution?
Encourage people to speak up and disavow perfection.
Coach communication skills, provide information and share your thinking.
Take input seriously and always say "thank you".
Give Voice
There are no
stupid questions
Go first
Thank you
Listen as an ally
Act on it
Ask for it
Three questions that must have a "yes" answer
Explicitly ask the team to speak up
Start with "thank you".
Evaluate the concern together.
Decide on next steps.
Speaking up = f (certainty of judgment + role + potential harm to patient + probable effectiveness + cost to self)
From Dwyer, James. Primum Non Tacere:
An Ethics of Speaking Up. The Hastings
Center Report. Jan/Feb94, Vol. 24 Issue 1, p13.
The negative consequences of not speaking up:
Someone may get hurt.
Morale suffers.
Quality of decisions may not be as good.
Organizational learning doesn’t happen.
Individuals learn not to care.

Primum non tacere
(First, be not silent)
Communication skills for
Finding Voice
Teaching assertion
Find a discussion partner and answer the following questions together:

Can you use assertion in your department or unit? If so, how?
Do you need to teach staff how to use assertion?
Would you need to prepare in advance to teach assertion? If so, what would you do to be prepared?
What would you need to do to ensure assertion is successfully used in your unit or department?

Teaching assertion
Can you use assertion in your department or unit? If so, how?
Do you need to teach staff how to use assertion?
Would you need to prepare in advance to teach assertion? If so, what would you do to be prepared?
What would you need to do to ensure assertion is successfully used in your unit or department?

Putting it all together
Culture and communication attributes
Barriers to Giving Voice
Speak up
Speak candidly
Listen effectively
Having the courage to:
Situation, background, assessment, and recommendation
Get the person’s attention, express concern, state the problem, propose action, reach a decision, challenge twice, if needed, and then escalate if no decision is reached
Critical language:
Words and phrases that are understood by all to mean “let’s stop, take a minute and make sure we’re on the same page”

Finish with "thank you", regardless
of what needs to be done
"I don't have any pride
invested here.
If you see me doing
anything wrong,
please let me know."
Creating a psychologically safe workplace
Ask questions
Avoid arguing
Accept feedback
Manage reactions
10 mins
Why are we curious about harm?
How do we use them to learn?
What are the innovations in 2013?
Most estimate 30-50% preventable
Adverse events – what’s the global picture?
International rates generally quoted about 10% of hospitalizations
(including no harm)
What will work if it's not
'Trying Harder'?
10 mins
10 mins
10 mins
10 mins
10 mins
10 mins
The NHS Safety Thermometer
The Vincent Framework
NHS Safety Thermometer
Administrative Data
Point of Care Surveys
Global Trigger Tool - Institute for Healthcare Improvement
Incident Reporting
Special Cause Variation
Chance = 0.5
0.5x.0.5x0.5 =

A Shift
A Trend
Too few or too many
Astronomical Data
One data point wildly different from the others

Run Charts
Statistical Process
Annotation and Goals
Non Random Patterns

Goal = 1%
Full transcript