Culture of Safety and Ethical Framework 9 June 2017

Patcharin Boonyarungsun, Ph.D

Director of Total Quality and Cost Improvement

Bangkok Hospital Head Quarter

Definition of Quality

“ The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”

Institute of Medicine

What is safety culture?

The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management.

Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.

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Organizing for safety; Third Report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations) Study Group on Human Factors. Health and Safety Commission (of Great Britain). Sudbury, England: HSE Books, 1993.

High reliability organizations, organizations that consistently minimize adverse events despite carrying out intrinsically complex and hazardous work. High reliability organizations maintain a commitment to safety at all levels, from frontline providers to managers and executives.

Culture of Safety key features

acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations

a blame-free environment where individuals are able to report errors or near misses without fear of punishment

encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems

organizational commitment of resources to address safety concerns

Safety Culture Patient safety culture can be measured

Hospitals with poor safety culture have more medical errors

Improvements in patient safety culture has been achieved by specific measures such as;

Teamwork training

Executive walk rounds

Unit-based safety teams

RRT, SBAR and other structured communication methods are unproven but being used to improve communication

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A just culture focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability by establishing zero tolerance for reckless behavior. It distinguishes between human error (eg, slips), at-risk behavior (eg, taking shortcuts), and reckless behavior (eg, ignoring required safety steps), in contrast to an overarching "no-blame" approach still favored by some. In a just culture, the response to an error or near miss is predicated on the type of behavior associated with the error, and not the severity of the event.

For example, reckless behavior : “ refusing to perform a "time-out" prior to surgery would merit punitive action, even if patients were not harmed.”

Just Culture Journey

AHRQ defines just culture as one in which frontline staff feel comfortable in disclosing errors including their own while maintaining professional accountability

Definitions and descriptions of just culture vary widely as does hospital execution and implementation practices.

It is important to preserve an appropriate balance of accountability

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Just Culture You want to create a open, fair and just culture

Staff feel comfortable to report and discuss errors

You want to create a learning culture We need to learn from our mistakes and make sure staff are aware of what happens at our facility

You want to create safe systems Time outs, bar coding couples with eMAR, double check of high alert medications, do not work nurse over 60 hours a week to prevent fatigue etc.

You want to manage behavioral choices

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Just Culture and Accountability Once hospitals have a reliable system in place they do need the threat of sanctions to ensure that everyone follows the rules

They propose suspending privileges if physicians fail to practice hand hygiene or refuse to take a time out

This carefully discriminates between system issues and individual violations of safety policies

Strong leadership is needed to ensure this Need to find out if system issue or not so good people don’t make mistakes and want learning environment

Peter Pronovost MD and Robert Wachter MD, Oct 2009 JAMA

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Just Culture Accountability Human errors- slips, lapse or mistakes

Manage through processes, procedures, training and design-CONSOLE

At-Risk Behavior- a choice-risk not recognized or believed justified

Manage through removing incentives for at risk behavior and creating incentives for healthy behaviors and increasing situation awareness-COACH

Reckless Behavior-conscious disregard of unreasonable risk

Manage through remedial action or punitive action-PUNISH

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Just Culture Principles

Responses to human error- willing to discuss this and discipline does not help if one makes a mistake

Responses to reckless behavior- take action if reckless behavior to one who knowingly endangers a patient- need to be fair culture

Severity bias in rejection of no harm no foul, it is not based on only looking at issue if patient was harmed

Equity is about being fair and consistent with every employee group and all are set for the same expectations

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IHI 2016 : six patient safety “resolutions” 1. Focus on what goes right as well as learning from what goes wrong; 2. Move to greater proactivity; 3. Create systems for learning from learning; 4. Be humble — build trust and transparency; 5. Co-produce safety with patients and families; and 6. Recognize that safety is more than the absence of physical harm; it is also the pursuit of dignity and equity. “Ensuring patient safety is about ensuring the right all patients have to a free-from-harm care experience, which includes being treated equitably and with dignity.”

IHI’s National Forum in December 2016

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Framework for Safe, Reliable, and Effective Care 14

IHI’s National Forum in December 2016

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Cultivate Culture of Safety in BHQ is Everyone Responsibility

Develop a Culture of Safety

“An organization can improve upon safety only when leaders are visibly committed to change and when they enable staff to openly share safety information.”

Senior leaders must drive the culture change by demonstrating their own commitment to safety and providing the resources to achieve results. Their message about safety must be consistent and sustained,

Develop a Culture of Safety

Changes for Improvement

Conduct Patient Safety Leadership WalkRounds™

Create a Reporting System

Designate a Patient Safety Officer

Reenact Real Adverse Events from Your Hospital

Involve Patients in Safety Initiatives

Relay Safety Reports at Shift Changes

Appoint a Safety Champion for Every Unit

Simulate Possible Adverse Events

Conduct Safety Briefings

Create an Adverse Event Response Team http://www.ihi.org/resources/Pages/Changes/DevelopaCultureofSafety.aspx

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Culture of Safety Program

1. Reactive patient safety Risk management program : Peer review , RCA

2. Proactive patient safety Proactive patient safety Policy development and implementation

Compliance monitoring (Tracer )

Culture Safety System Development

Start from 2006

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Staff Alert Response

Conference

Explanation

Occurrence Report

Patient Happy

President of Medical Staff Meet Physician

Quality Culture Cultivated in BHQ by Lead Team : System and Patient Safety Tracer ( 6.30-8.00 am every Tue, Thur)

Emergency Preparedness : Fire Safety Code Drill

Overall Perception of Patient Safety

48%

61% 64% 67% 64% 63% 60%

67% 72%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2008 2009 2010 2011 2012 2013 2014 2015 2016

AHRQ 2016 = 66%

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Patient Safety Culture Result comparing to Benchmarks

Organization

Learning

Teamworkwithinunits

Feedback&commun

ication

Overallperceptio

n ofpateitnsafety

Supv/Mgrexpectation&action

Management

support

Frequencyof eventreported

Communication

openness

TeamworkAcrossunits

StaffingHandoffs&transitio

ns

Nonpunitive

responseto error

BHQ-2015 83% 80% 78% 67% 65% 65% 60% 60% 59% 34% 32% 29%

BHQ-2014 82% 80% 80% 60% 67% 69% 59% 66% 57% 38% 32% 27%

BHQ-2013 81% 78% 82% 63% 63% 67% 56% 67% 53% 33% 29% 23%

AHRQ(Avg)-2014 73% 81% 67% 66% 76% 72% 66% 62% 61% 55% 47% 44%

83% 80% 78% 67% 65% 65% 60% 60% 59% 34% 32% 29% 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

BHQ-2015 BHQ-2014 BHQ-2013 AHRQ(Avg)-2014

Hospital Level Unit Level Outcome

Patient Safety Culture: Unit Level

Composites Patient Safety Culture Items Current BHQ-15 Gap

Feed

back &

Co

mm

un

icati

on

Ab

ou

t E

rro

r

C5: In this unit, we discuss ways to prevent

errors from happening again.

87% 84% 3%

C3: We are informed about errors that

happen in this unit.

79% 80% -1%

C1: We are given feedback about changes

put into place based on event reports.

73% 72% 1%

Su

perv

iso

r/M

an

ag

er

Exp

ecta

tio

ns &

Acti

on

s

Pro

mo

tin

g P

ati

en

t S

afe

ty

B2: My supervisor/manager seriously

considers staff suggestions for improving

patient safety.

81% 79% 2%

B4R: My supervisor/manager overlooks

patient safety problems that happen over

and over.

81% 69% 12%

B1: My supervisor/manager says a good

word when he/she sees a job done

according to established patient safety

procedures.

76% 73% 3%

B3R: Whenever pressure builds up, my

supervisor/manager wants us to work faster,

even if it means taking shortcuts.

54% 42% 12%

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Note: The item’s survey location is shown to the right in parentheses. An “R” indicates a negatively worded item, where the percent positive response is based

on those who responded “Strongly disagree” or “Disagree”, or “Never” or “Rarely”

Patient Safety Culture: Hospital Level

Composites Patient Safety Culture Items Current BHQ-15 Gap

Man

ag

em

en

t

Su

pp

ort

fo

r

Pati

en

t S

afe

ty

F8: The actions of hospital management

show that patient safety is a top priority.

90% 84% 6%

F1: Hospital management provides a work

climate that promotes patient safety.

81% 78% 3%

F9R: Hospital management seems

interested in patient safety only after an

adverse event happens.

37% 33% 4%

Team

wo

rk A

cro

ss U

nit

s F10: Hospital units work well together to

provide the best care for patients.

88% 82% 6%

F4: There is good cooperation among

hospital units that need to work together.

71% 67% 4%

F6R: It is often unpleasant to work with staff

from other hospital units.

62% 53% 9%

F2R: Hospital units do not coordinate well

with each other.

43% 33% 10%

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Note: The item’s survey location is shown to the right in parentheses. An “R” indicates a negatively worded item, where the percent positive response is based

on those who responded “Strongly disagree” or “Disagree”, or “Never” or “Rarely”

STOP THE LINE for Patient Safety “Stop the Line for Patient Safety” supports the VA’s Blueprint for Excellence by encouraging proactive, personalized, patient-driven care in an environment that makes hospital and employee safety and well-being a priority.

Part of Risk Management Program,

employees are introduced to a tool called “the 3Ws©”:

Say what you see;

Say what you are concerned about;

Say what you want to happen to keep things safe.

To reinforce the importance of using this tool, VHA employees—from clinical staff such as nurses and doctors to administrative staff such as food service workers and environmental management --explain how it’s everyone’s responsibility to ensure patient safety.

http://www.qualityandsafety.va.gov/StoptheLine/StoptheLine.asp#sthash.tlT9LkIw.dpuf

Direction 1. Involve all the senior executives in the organization, not just the chief

executive officer(CEO) member of the senior executive team can rotate for

easier scheduling, but ideally every senior leader should perform WalkRoundsTM every week.

2. Get a commitment from senior executives for an hour every week, at a minimum of once per week. The WalkRounds™ may be rescheduled but never canceled. (Circumstances may demand postponement from an originally scheduled date, but the WalkRoundTM should still occur within the original week.)

3. Organizations should decide whether or not to announce the time and place of WalkRoundTM in advance, and the decision should be agreed to by all parties (senior leaders, managers, physicians, and front-line staff).

4. Organizations should reassure employees that all information discussed in WalkRoundsTM is strictly confidential

5. Organization may conducted WalkRoudsTM in conjunction with Safety Briefing.

Patient Safety Leadership WalkRounds™ Institute for Healthcare Improvement Idealized Design Group and Allan Frankel, MD

Cambridge, Massachusetts, USA

1. Patient Identification 2. Investigation Result 3. Medication Explanation 4. Safe Surgery 5. Reduce HAI 6. Fall prevention 7. Pain Control

Patient Involvement : Get Patient on Board

Safety Culture : Concept to Implementation

Safety Culture VS Just Culture

Safety Culture : Culture is Critical – Safety Culture Implementation ( 2006)

Leader : Leading for Change - Execution is Everything

Making Patients Our Partners : Ask the Patient from Patient Experience (2013)

Better Communication - Team Training : Physician Involvement is Vital (2012-2016)

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Code of Conduct 1. Respect laws

2. Avoid political involvement

3. Protect company’s property

4. Protect confidential information and internal information

5. Avoid conflicts of interest

6. Participate in giving and receiving gifts ethically.

7. Conduct all individual and interpersonal interactions ethically and responsibly

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Reference for Ethical

Framework Healthcare

• Laws & Regulations

• Medical and Professional Ethics

• Human Rights (WHO)

• Professional Standards

• Religious / Beliefs

• Social Norms

Organization (Hospital /BDMS)

• Vision/Mission

• BDMS Values

(B/ D/ M/S)

Moral Commitment

• Code of Conduct

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Ethics program to promote

• the rights of patients;

• shared decision making between patients (or their surrogates if decisionally incapacitated) and their clinicians;

• fair policies and procedures that maximize the likelihood of achieving good, patient-centered outcomes; and

• to enhance the ethical environment for health care professionals in health care institutions.

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• ตวแทนฝายแพทย พยาบาล

• ผมสวนไดสวนเสยอน

• นกสงคมสงเคราะห

• ตวแทนศาสนา

• ตวแทนชมชน

• ตวแทนฝายคณภาพ

• ทรพยากรบคคล

• นกกฏหมาย

Ethics members

Ethics in the Workplace

• The application of moral principles, standards of

behavior, or set of values regarding proper conduct in

the workplace as individuals and in a group setting

• Ethics allow you to distinguish(ความเหนตาง) the

difference between right and wrong

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Fairness เสมอภาค

Autonomy การเคารพความเปนอสระ ตวตนบคคล

Integrity ซอสตย ตรงไปตรงมา

ท าสงดเปนประโยชน Common good

Beneficial

F

A

I

R Law, culture, belief, social norm, religion, professional ethics, patient rights 39

How to Encourage Good Ethics in the Workplace

How to Encourage Good Ethics in the Workplace

• Fair consequences

• Fair treatment

• Recognition

• Communication (be clear

and consistent)

• Have office policies

• Transparency

• Trainings

• Have plans of action

• Constructive feedback

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What are some examples of good ethics in the workplace?

Good Workplace Ethics • Staying productive

• Be accountable for your actions

• Take initiative

• Think critically to be able to solve problems

• Blowing the whistle

• Be punctual

• Stay positive

• Stay professional

• Take pride in your work

• Immediately attempting to correct an issue

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Poor ethic

• Conducting Personal Business on Company Time

• Taking Credit for Others' Work

• Harassing Behavior

• Disregard of Company Policy

• Failure to Honor Commitments

• Sexual Harassment

• Poor customer services

• Gossiping

• Abusing computer privileges

• Ignoring problems

• Blackmail

• Lying

• Taking on roles that are not under your job title

• Being unpunctual; poor attendance

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Rationalization by the Wrongdoer

• Attempt by wrongdoer to justifying why they

acted a certain way:

– Everybody does it

– It’s not part of my job description

– Nobody is going to notice

– I don’t get paid enough

– Unrealistic expectations of what the job entails

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Consequences of Poor Ethics in the Workplace

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Consequences of Poor Ethics in the Workplace

• Stricter rules

• Fewer privileges

• An undesirable work environment

• Stunts growth and productivity

• Causes a domino affect among other colleagues

• Potential job loss

• Potential closing of the organization

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What is ethical

dilemmas?

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• Ethical dilemmas are situations involving conflicting morals claims, and give rise in such questions as :

• What ought I to do?

• What harm and benefit result from this decision or actions?

• What is good (virtue) or what is duty (right)? Aroskar et al

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Ethical Dilemma Examples Personal Friendships

Tom Rose

Tony

Jack

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No matter who he tells,…he is going to end up “hurting one", if not both friends. Does he remain silent and hope his knowledge is never discovered?

What do you make ethical decisions?

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Information access and privacy.

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Tony knows he should report this but would have to admit to violating the company’s information technology regulations by logging into Robert’s computer. If he warns Robert to stop his betting, he would also have to reveal the source of his information.

What

does

Tony do

in this

situation?

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PHYSICIAN' DILEMMA ON PARTNER

NOTIFICATION FOR HIV

If the patients decide not to tell

HIV result to partner

“what can we do?"

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END-OF-LIFE ISSUES

Would you ever

consider halting life-

sustaining therapy

because of family

demands, even if you

felt that it was

premature?

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PRIVACY CONFIDENTIALITY

Would you ever discuss patient information in

situations that did not fully protect their privacy,

e.g., socially or while subjects not related to the

patient?

Yes

No

It depends

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PATIENT’S RIGHT

PERSONAL BELIEF

How does a nurse care for a

patient who has had an

abortion, when the nurse

considers abortion murder? Can

that nurse with very opposing

values support that patient’s

right to choose her autonomy?

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FREEDOM VERSUS CONTROL

A patient wants to stop

eating, but the nurse

knows the consequences

will harm the patient.

Does the nurse have the

“right” to force the patient

to eat?

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TRUTH TELLING VERSUS DECEPTION

Families want to deny

telling the patient the truth

about the medical

condition.

Family insists telling the

patient the prognosis

will cause harm?

Patient have the right to

know?

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EMPIRICAL KNOWLEDGE VERSUS

PERSONAL BELIEF

What should a nurse do when a patient is

admitted to the hospital that desperately

needs a transfusion to live but has the

belief that transfusions are unacceptable?

• The nurse knows this patient will die

without the transfusion.

• How does that nurse empathize with the

patient’s family who supports the family

member’s choice and still be supportive

of the patient’s and family’s right to this

decision?

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How to report

dilemmas?

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OCR

Sup HOD

?!! CEO

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The Ethical Dilemmas Decision-Making Process

RULES=

ISSUES

6

65

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Identify issues

Inform HOD manager

Fact finding

Call meeting

Decision making

Evaluate/ sustain

S E U S S I

The Ethical Decision-Making Process

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Reference

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1) World Medical Association International Code of Ethics, 2006 2) Declaration of Geneva, 2006 3) Universal Declaration of Human Rights, 2006 4) Physician Ethics, Thai Medical Council, 2006 5) Nurse Ethics, Thai Nursing Council, 2007 6) Pharmacist Ethics, Thai Pharmacist Council, 1995& 2003 7) Physiotherapist Ethics, Thai Physiotherapist Council, 2008 8) Radiology Technician Ethics, Health Ministry Regulation, 2004 9) Medical Technician Ethics, Thai Medical Technician Council, 2010 10) BDMS Code of Conduct, 2014 11) Patient Rights, Thai Medical Council, 2015

Safety Culture :Leader Leading for Change - Execution is Everything

Learn from Best Practice

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