A reporting culture must interact with just, flexible, and learning cultures. Safety culture emerges gradually from sustained attention to engineering the interactions between the practices associated with these four components. In CAHs, directors of nursing and quality improvement must engineer these interactions while often continuing to provide care at the bedside. Consequently, these front-line managers require support from their senior leaders and education and tools from network hospitals, Quality Improvement Organizations, and other organizations that advocate for rural hospitals.
The
sustained attention necessary to engineer interactions between practices
that support the four components of culture can be illustrated in the
execution of the various tools.
Engineering
Interaction Between the Components of Culture with
Root Cause Analysis (RCA)
A thorough,
credible root cause analysis begins with the reporting of a specific
event in the context of a
Reporting Culture, which requires a systematic approach to error
reporting, data collection, and analysis. Next, senior leaders determine
whether an individual is culpable for the event in the context of a
Just Culture—over 90% of the
time events and errors result from the breach of defenses in our systems
and not due to the risky behavior of individuals. The execution of the
RCA requires teamwork skills—particularly effective communication in the
context of a
Flexible
Culture. During the RCA, the team determines how the causes of the
specific event that was reported reveal latent risks and hazards present
in organizational processes and systems. The products of the RCA are a
set of causal statements and an action plan to minimize the likelihood
of similar errors occurring in the future. This action plan is executed
and evaluated in the context of a
Learning Culture, which
allows all front-line staff to evaluate whether “mistakes have led to
positive changes.”
Engineering
Interaction Between the Components of Culture with
Aggregate Root Cause
Analysis (RCA)
Aggregate
RCA is a process for identifying trends and system sources of error
across groupings of similar events, such as medication errors or falls.
An aggregate RCA begins with the reporting and aggregation of multiple
non-harmful events in the context of a
Reporting Culture, which
requires a systematic approach to error reporting, data collection, and
analysis. In the context of a
Just Culture, front-line managers
recognize that the ‘blame and retrain’ response to multiple individual
events results in the perception that, “When an event is reported, it
feels like the person is being written up and not the problem.” Instead,
individual events are reviewed for their actual and potential severity
using the
Severity Assessment Code. Events that were not catastrophic or major in their severity or do not
have the potential to be this severe are aggregated and analyzed for
similarities on a regular basis. The execution of the aggregate RCA
requires teamwork skills—particularly effective communication in the
context of a
Flexible
Culture. The products of the aggregate RCA
are a set of causal statements and action plans to minimize the future
occurrence of similar types of errors. These action plans are executed
and evaluated in the context of a
Learning Culture, which allows
all front-line staff to evaluate whether “mistakes have led to
positive changes.”
Engineering
Interaction Between the Components of Culture by
Reporting and Managing Disruptive Behavior
Disruptive behavior is any inappropriate behavior, confrontation, or conflict, ranging from verbal abuse to physical or sexual harassment. Disruptive behavior causes strong psychological and emotional feelings, which can adversely affect patient care (Rosenstein & O’Daniel, 2008). On July 9, 2008, The Joint Commission issued a Sentinel Event Alert regarding disruptive behavior: and stated that, “Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.”
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm
To function as part of a team, individuals must feel valued and be treated with respect.
Alan Rosenstein, M.D., M.B.A., is Vice President and Medical Director, VHA West Coast. He is a nationally-recognized expert in the prevalence and management of disruptive behavior in healthcare. Michelle O’Daniel, M.H.A., M.S.G., is Director of Member Services at VHA. Dr. Rosenstein and Ms. O’Daniel have published extensively on the topic of disruptive behavior. Rosenstein and O’Daniel advocate a strategy to address disruptive behavior that includes: raising awareness through surveys, developing policies and procedures for reporting, and education. This education links disruptive behavior to adverse events and identifies structured teamwork and communication skills such as those in the TeamSTEPPS™ curriculum essential to managing disruptive behavior.
