DANA M' LANGNESS, RN, BSN, MA

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CREATING A SAFE CULTURE
By DANA M. LANGNESS, RN, BSN, MA SENIOR DIRECTOR
PERIOPERATIVE SERVICES REGIONS HOSPITAL
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• All I could see from where I stood
• Was three long mountains and a wood
• I turned and looked the other way,
• And saw three islands in a bay./So with my eyes I
  traced the line
• Of the horizon, thin and fine,/Straight around
  till I was come
• Back to where Id started from/And all I saw
  from where I stood/ Was three long mountains and
  a wood. 
• Over these things I could not see
• These were the things that bounded me
• 
  - Edna St. Vincent Millay

                              






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What will a major patient safety transformation
look like?

• Make patient safety the 1 priority.
• Embrace a new mindset.
• Take a bold and brave leadership approach.
• Collaborate rather than compete.
• Create a culture of safety.

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Make patient safety the 1 priority

• Sentinel events reported in 2005
• 3,548
• Most-frequently reported sentinel event
• Wrong-site surgery
• (12.8 of events)
• A root cause in 80 of reported wrong-surgery
  events
• Communication

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How hazardous is healthcare?
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Embrace a new mindset

• Acknowledging our vulnerability to make mistakes.
• Unlearn what we learned in school. Reliance on
  professional/individual responsibility.
• Human factors such as environment, stress, noise,
  etc. influence our work.
• Flatten the hierarchy.
• Communicate, communicate, communicate.

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Transformational Leadership

• Adding wings to caterpillars does not create
  butterfliesit creates awkward and dysfunctional
  caterpillars. Butterflies are created through
  transformation.
• Stephanie Pace Marshal

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Transformational Leadership

• Transformational change requires effective
  leadership Its about us!
• Create an environment where the right
  questions/inner passion are allowed to emerge
• We set the vision they create the how
• New partnerships
• Baseball Team vs. Basketball Team

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Transformational Leadership

• Just and Accountable
• Minimize the chaos and unpredictability in the
  environment
• Partnership with patients, vendors and community
• New Puppies as well as Old Dogs

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A Jedi must have the deepest commitment, the
most serious mind.
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Try not. Do or do not, there is no try (Yoda)
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Collaborate rather than compete

• Definition of
• collaboration
• To labor together.
• To work jointly with
• others or together.
• 3. To learn from one another.
• 4. To trust, support, value one another.

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Collaborate rather than compete
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Create a culture of safety

• Definition
• All team members place the safety of the patient
  first by their shared values, attitudes, degree
  of effort,
• and pattern of behaviors.

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Culture is critical

• 25-40 of RNs told us they would be hesitant to
  speak up if they saw a physician making a
  mistake.
• The chance of an orthopedic surgeon performing a
  wrong-site procedure during their career is 25.
• How we set the tone in the first 10 seconds in
  that room has a profound impact on whether people
  will comfortably voice concerns.

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Correct-Site SurgeryThe old way of doing
thingsRelying on human vigilance
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The Old Way of Doing Things
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Safe Site Surgery Collaborative
Aim Eliminate surgical procedures involving
the wrong patient, wrong site, and the wrong
procedure across the community. (Later our aim
was expanded to include procedural and bedside
invasive procedures.) Measure Wrong events
per million procedures aggregated from 19
hospitals. Strategy Develop a standardized
protocol.
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Next steps

• Focus on culture
• 2007 Reliability-Centered Collaborative
• Processes to improve teamwork, communication, and
  to address human factors research
• Implementation of new surgical protocol regarding
  retained foreign objects
• 2. Spread of safe-site protocol in MN
• Partnership with Minnesota Hospital Association
  and MN Dept of Health

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High reliability principles

• Pre-occupation with failure
• Reluctance to simplify
• Commitment to resilience
• Deference to expertise
• Sensitivity to operations

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High-reliability collaborative objectives

• To build a culture of safety in the surgical
  environment.
• To improve communication and team practices
  resulting in high reliability teams.
• To advance efficient surgical process flow by
  implementing standardized surgical protocols.
• To create safe and reliable practices and reduce
  the number of adverse events in surgery.

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Why communication?

• The overwhelming majority of untoward events
  involve communication failure.
• Wrong site surgery somebody knows theres a
  problem but cant get everyone in the same movie
  often its hard to speak up.
• The clinical environment has evolved beyond the
  limitations of individual human performance.

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Effective communication requires

• Structured communication SBAR
• (Situation, Background, Assessment,
  Recommendation)
• Assertiveness/critical language Stop-the-Line
  (the ability to speak up and stop the show)
• Psychological safety
• Effective leadership an environment of respect

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Assertion What is it?

• Individuals speak up, and state their
  information with appropriate persistence until
  there is a clear resolution.

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Why is Assertion / Critical Language Important?

• Because we know 25-40 of nurses tell us on the
  Safety Attitude Questionnaire they would be
  hesitant to speak up if they saw an MD making a
  mistake
• Often people dont speak up or do so quite
  indirectly
• Knowing the plan using SBAR makes it much
  easier to speak up
• How we set the tone in the first 10 seconds in a
  room has a profound impact on whether people will
  comfortably voice concerns

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Where do Things Fall Through the Cracks?

• Systems information, tests, diagnoses
• Communication hand-offs
• Failure to plan
• Failure to recognize
• Failure to rescue

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Error is Inevitable Because of Human Limitations

• Limited memory capacity 5-7 pieces of
  information in short term memory
• Negative effects of stress error rates
• tunnel vision
• Negative influence of fatigue and other
  physiological factors
• Limited ability to multitask
• cell phones and driving

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Risk Factors of Surgical Error

• 2 or more physicians involved
• Lack of expertise
• Communication failures
• Fatigue
• Emergencies
• Interruptions
• Reliance of memory

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Situational Awareness

• How do we keep everyone in the same movie as the
  case progresses?
• Its hard to speak up if you dont know whats
  supposed to happen
• This requires initially sharing the plan and
  actively updating the team active callouts

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Red Flags Loss of Situational Awareness

• Ambiguity
• Reduced/poor communication
• Confusion
• Trying something new under pressure
• Deviating from established norms
• Verbal violence
• Doesnt feel right
• Fixation / boredom / task saturation
• Being rushed / behind schedule

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Active Call-Outs

• Were closing
• Im going to need X-ray in
• about 20 minutes
• Well be done in 30 minutes
• Were bleeding more than I like we may need to
  open well decide within 5 minutes

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Our vision
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QUESTIONS?