the power of culture: where are we at and how can we influence it? march 4, 2011 debbie barnard, ms,...
TRANSCRIPT
The Power of Culture: Where are We at and How Can We
Influence it?
March 4, 2011
Debbie Barnard, MS, CPHQ
Victoria Inn Winnipeg, Manitoba
You may have heard
Culture eats strategy for lunch
Best laid plans often submits to cultural
limitations
An organization cannot sustain results in a
culture that cannot support it
3
First things first
You cannot change::What you do not know
What you don’t understand
How does transformation occur?
To change culture …………….
The organization works through and with the existing culture to transform the organization
Role of Culture
Acts like the “glue”CompassCommon groundSense of OrderContinuity and unity
Collective commitmentSocial system stability
From the Experts
Culture is always local:Micro-system - unit, department, even shiftFacility/HospitalIt will affect your clinical and operational
outcomes
Culture gremlins that will bring “new” issues include:New Manager, New Location, New
Technology
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Knowing & Understanding
We can measure this “animal”Sexton’s workGinsburg at alAccreditation Canada’s recommended toolAHRQ – publicly available tool and database
Areas Measured
AHRQ Dimensions Overall perceptions of safety Frequency of events reported Supervisory Leadership Organizational learning—continuous improvement Teamwork within units Communication openness Feedback & communication about error Nonpunitive response to error Staffing Hospital management support for patient safety
Teamwork across hospital units Hospital handoffs & transitionsPLUS: Patient safety “grade” # of events individuals reported in last 12 months
MSI Dimensions Valuing Safety in the Organization Supervisory Leadership Fear of Repercussions State of Safety
Source: Ginsburg et al
The Economist
Importance of coming to the right conclusion
Why Focus on Culture ………. Improvement for Our Patients
As John Maynard Keynes once noted …….
“ The hardest thing is not to get people to accept the new ideas, it is to get them to
forget the old ones.”And thus …..
When in conflict, Culture will eat Strategy for lunch ---- EVERYTIME
Paraphrased from Mark Bard, MD
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Culture to Support Improvement of Organizational Performance
Motive for Change
Clear Shared Vision
Capacity for Change
Actionable first steps
Let’s Play Bingo
Bingo Rules
You must have all conditions present, before you can give yourself credit
The criteria must match your entire organization not just your individual unit or service
You must laugh and have some fun as we play!
Culture to Support Improvement of Organizational Performance
Motive for Change
Clear Shared Vision
Capacity for Change
Actionable first steps
Motivation for Change
What answer would you most likely get at your organization?Org. Culture #1: “That’s not my job, go away.”
Org. Culture #2: “Sorry, that’s not my job, go see [someone else].”
Org. Culture #3: “That’s not my everyday job, but let me see how I can help you.”
Strategies to ↑ Quality & Safety
Measurement
Reliable, Valid, Cost Effective & Accepted Timely System Tools &
Change Strategies
Improvement, System Thinking, Redesign Processes, Rapid Cycle, Near Miss
Culture
Non-blaming, To err is human, Learning, Leadership
Baker, G.R. & Norton, P. (2002). Patient Safety and Healthcare Error in the Canadian Healthcare System: A systematic review and analysis of leading practices in Canada with reference to key initiatives elsewhere. Ottawa:
Health Canada. p. 158. Retrieved from: http://www.hc-sc.gc.ca/hcs-sss/pubs/care-soins/2001-patient-securit-rev-exam/index_e.html
Culture to Support Improvement of Organizational Performance
Motive for Change
Clear shared vision
Capacity for Change
Actionable first steps
Leadership Commitment
Clearly stated and enacted constancy of purpose—a deep understanding of the vision and mission
Regular review of key indicator dataDecisions made on data rather than hunches
or opinionsLong range view supports search for root
causes and permanent solutions rather than quick fixes
Set Priorities and Communicate Clearly
CASE STUDY Jönköping
24April 25, 2008Le Palais des Congrès – Paris - France -
Anthony Staines
Source: System thinking and spreading knowledge, Bojestig M., Henriks, G., Provost L. IHI European Forum, Prague 2006
25April 25, 2008Le Palais des Congrès – Paris - France -
Anthony Staines
Jönköping – factors that foster improvement
A strong emphasis on improvement cultureQuality seen as holistic – applied to every
department, every activity – quality as a business strategy
Investment in becoming a learning organizationQuality should be exciting, funEmphasis on bottom-upLong-term view - stability
Culture to Support Improvement of Organizational Performance
Motive for Change
Clear Shared Vision
Capacity for Change
Actionable first steps
“The real act of discovery is not in finding new lands, but in
seeing with new eyes”. Marcel Proust (1871-1922)
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What does it mean to buildcapacity for QI?
Understanding what we know and don’t know about QI
• Determining how to close the gap between where we
are and where we want to be• Building how good by when goals• Deciding who needs what (dosing)• Developing curriculum content• Creating a plan for execution and spread• Allocating resources to work on building capacity
S + P = O
Culture to Support Improvement of Organizational Performance
Motive for Change
Clear Shared Vision
Capacity for Change
Actionable first steps
Sexton Tools
Safety Culture Debriefing & Action
OBJECTIVE: Use the Debriefing Guide to conduct a 30-60min structured discussion & produce a specific data-driven next step to improve the local environment in this unit.
Debriefing Guide:Review SAQ results with particular attention to items
with less than 60% agreement. • Which item(s) seem most relevant (items/why)?• Which item is of particular concern to this unit
right now due to recent events or activities (item/score/why)?
• Share examples of how this item reflects your events or experiences in this unit?
• Envision an ideal unit: what would it look like if 100% of the caregivers in this unit agreed strongly with the SAQ item (provide specific behaviors, processes, norms, policies)?
• Agree on one actionable step toward the ideal unit (agree on the task; the person responsible; the follow-up date; the external committee or leader to whom this plan is disclosed)?
Safety Culture Debriefing & Action Tool
Adapted from:Sexton, Paine, et al. A Checkup for Safety Culture in “My Patient Care Area,” Jt Comm J Qual Patient Saf. 2007 Nov;33(11)
Root Cause Lite for ICU:Learning from Defects
OBJECTIVE: Conduct a 30-60min discussion of the defect in the context of the systems in which it occurred, to facilitate mutual interpretation and agreement upon actions to reduce the likelihood of it recurring in this ICU. Briefly describe the defect. What contributed this occurrence?: □ ICU environment (staffing levels, workload, equipment, mgt support, physical environment [space or noise], failure to follow policy/procedure) □ Institutional time pressures, acuity□ Departmental pharmacy, lab, etc.□ Training & Education: caregiver knowledge, skills or competence; failure to follow established protocol; supervision□ Patient condition: complexity, agitation, language □ Caregiver fatigue/attitude/motivation□ Task: availability of protocols and accurate test results□ Verbal or written team communication: during handoffs, routine care, crises□ IT: CPOE/EMR How will you prevent recurrence?
Learning From Defects
The purpose of this tool is to provide a structured approach to help care givers and administrators identify the factors and systems that contributed to the defect, and follow-up to ensure safety improvements are achieved.Defects are any clinical or operational events or situations that you would not want to happen again. These could include incidents that you believe caused patient harm or put patients at risk for significant harm.
Investigation ProcessI. Provide a clear, thorough, and objective explanationof what happened.II. What factors contributed (negatively or positively).III. How did these factors, in combination, contribute to the defect in a way that could happen again with different caregivers. IV. How will you prevent this defect from happening again to other caregivers in this ICU? List what you will do, who will lead the intervention, when you will follow up on the intervention’s progress, and how you will know risk reduction has been achieved.
Adapted from:Pronovost et al. Jt Comm J Qual Patient Saf. 2006 Feb;32(2):102-8.-and-Pronovost et al. Crit Care Med. 2006 Jul;34(7):1988-95.
Senior Leader & Unit Partnerships
OBJECTIVE: remove barriers, enhance trust so their issues are surfaced and addressed, allow learning and improvement with a local ownership of this process (i.e., “not here to blame or audit”).
STRATEGIES (to surface barriers): Review recent incident reports: SAQ results: were Culture Checkup Tool actions taken? Learning from Defects using Root Cause Lite: (What happened, Why did it happen, what have you done to reduce the likelihood of it happening again, and with whom did you share the lessons learned?), Follow up on actions to address issues from previous visits
SAMPLE QUESTIONS: “How will the next pt in this clinical area be harmed?” “Was a pt recently harmed because of less-than-safe care?” “What can this unit do on a regular basis to improve safety?”
Evidence shows that the % of caregivers exposed to rounds over time should be maximized (via # rounds & connecting with different caregivers each visit)
Senior Leader Partnerships & Patient Safety Leadership
WalkRounds™
Senior Leader Partnerships with a specific clinical area are related to and also known as methodologically rigorous Patient Safety Leadership WalkRounds™
–Target care areas in which less than 60% of caregivers report good safety climate–Build trust and rapport between frontline and a senior leader through regular (monthly or more frequent) rounds, speaking with different caregivers each visit–Who makes a good “senior leader” for this?: Select a leader, typically VP or higher, that is approachable, comfortable walking through clinical areas and discussing complicated problems, and able to bring both operational perspective and resources to the unit in order to remove barriers and facilitate needed changes identified by caregivers.–Ask about culture, staff safety assessment, event reporting, last month’s defect analysis, other outcomes–The percent of caregivers exposed to rounds over time should be maximized
Adapted from:Thomas et al. BMC Health Serv Res. 2005; Jun 8;5(1)-and-Frankel et al. Jt Comm J Qual Patient Saf. 2005 Aug;31(8)
Senior Leader Partnerships & Patient Safety Leadership
WalkRounds™
Senior Leader Partnerships with a specific clinical area are related to and also known as methodologically rigorous Patient Safety Leadership WalkRounds™
–Target care areas in which less than 60% of caregivers report good safety climate–Build trust and rapport between frontline and a senior leader through regular (monthly or more frequent) rounds, speaking with different caregivers each visit–Who makes a good “senior leader” for this?: Select a leader, typically VP or higher, that is approachable, comfortable walking through clinical areas and discussing complicated problems, and able to bring both operational perspective and resources to the unit in order to remove barriers and facilitate needed changes identified by caregivers.–Ask about culture, staff safety assessment, event reporting, last month’s defect analysis, other outcomes–The percent of caregivers exposed to rounds over time should be maximized
Adapted from:Thomas et al. BMC Health Serv Res. 2005; Jun 8;5(1)-and-Frankel et al. Jt Comm J Qual Patient Saf. 2005 Aug;31(8)
“What did we do that harmed a patient?”“How will we harm the next patient?”“What doesn’t work well?”“Do some Ethnic groups get better care here than others?”“Do we disclose information to patients?”“How well does teamwork occur on this unit?”
QUESTIONS:
Optimal Profile
Alignment of strategy, performance measurement and improvement work
Capability & Capacity DevelopmentIntentional Use of QI/Process Improvement Tools
Defined improvement model e.g. PDSACommunication of the organization play bookCollaborative Care Model/ Teamwork
Bingo Results
Culture to Support Improvement of Organizational Performance
Motive for Change Very Slow Start
Clear Shared Vision
Capacity for Change
Actionable first steps
Culture to Support Improvement of Organizational Performance
Motive for Change
Clear shared vision False Starts, Fade Out
Capacity for Change
Actionable first steps
Culture to Support Improvement of Organizational Performance
Motive for Change
Clear Shared Vision
Capacity for Change
Anxiety frustration
Actionable first steps
Culture to Support Improvement of Organizational Performance
Motive for Change
Clear Shared Vision
Capacity for Change
Actionable first steps
Uncoordinated efforts
Take Home PointsImproving Quality: You should know your culture
to be effective stewards of limited quality resources
Culture is local – work unit culture trumps hospital culture, and is related to clinical and operational outcomes
Culture Critters that introduce new Chaos:New Manager, New Location, New Technology
Patient safety and quality with methodological rigor is a pioneering effort – the science of safety is racing to keep pace
Be ready to answer the question: “Are We Safer?”
Sexton et al
If Disney Ran Your Hospital: 91/2 Things You Would Do Differently
Employees say, “I love to work here.”Managers say, “I love the people I work with.”Caregivers say, “I love our patients.”Patients and families say, “We love this hospital.”
Our outcomes - Best in class!
The Power of Culture: Where are We at and How Can We Influence it?
March 4, 2011Debbie Barnard, MS, CPHQ
Victoria Inn Winnipeg, ManitobaE-mail: [email protected]
Questions