Quality Improvement Reliability, Culture of Safety, & HIT This material (Comp12_Unit4) was developed...

Quality Improvement

Reliability, Culture of Safety, & HIT

This material (Comp12_Unit4) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.


Learning Objectives

• Discuss reliability as a tool for ensuring safety.

• Examine how ultra-safe organizations operate.

• Identify how teams make wise decisions.

2Health IT Workforce Curriculum Version 3.0/Spring 2012

Quality Improvement Reliability, Culture of Safety, &

HIT

Reliability

Video 1



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High-Reliability Organizations

• Hyper-Complex

• Tightly Coupled

• Hierarchical Differentiation

• Multiple Decision Makers



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High-Reliability Organizations

• Complex Communication

• High Accountability

• Need Frequent Immediate Feedback

• Compressed Time Constraints



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High-Reliability OrganizationsMindfulness



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High-Reliability OrganizationsSensitivity to Operations



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High-Reliability OrganizationsPreoccupation with Failure

• Be preoccupied with failure. Don’t rely on good brakes to save you every time.



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High-Reliability OrganizationsReluctance to Simplify

• Keep things simple.



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High-Reliability OrganizationsDeference to Expertise



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Hear the wisdom of crowds.

Hear the wisdom of crowds.

High-Reliability OrganizationsResilience

• Be prepared for failure. What can go wrong, will.



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Culture

“The shared perceptions of the individuals within the team or an organization about

what is good, right, important, valued, supported, or expected at any given time.”

Riley, W., et al (2010)



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http://www.clker.com/clipart-24007.html



The Blame Game

Pointing the finger at people rather than systems.



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Blame



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Blame

• Limits learning

• Increases likelihood of repeat errors

• Drives self-reporting underground



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Just Culture• Focuses on identifying and addressing systems

issues that lead individuals to engage in unsafe behaviors

• Maintains individual accountability by establishing zero tolerance for reckless behavior

• Distinguishes between human error, at-risk behavior, and reckless behavior

• Response to error or near miss is predicated on the type of behavior associated with the error, not the severity of the event



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How to Promote a Culture of Safety



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Culture of Safety Characteristics



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Culture of Safety



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Video 2


Summary

In this unit we explored the characteristics of high reliability organizations and learned more about establishing an organizational culture of safety.



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Reliability, Culture of Safety, & HITReferences

References• AHRQ Patient Safety Primers. Safety Culture. Available from: http://psnet.ahrq.gov/primer.aspx?primerID=5• Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Rockville, MD. AHRQ

Publication No. 08-0022, 2008 April. Agency for Healthcare Research and Quality. Available from: http://www.ahrq.gov/qual/hroadvice/

• Riley, W., Davis, S.E., Miller, K.K., & McCullough, M. A model for developing high reliability teams. J Nurs Manag. 2010 Jul18(5):556-563.

Charts, Tables, Figures

Table 4_1. The five specific concepts that help create the state of mindfulness that is needed for reliability, which in turn is a prerequisite for safety. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm

Images

Slide 3: Aircraft Carrier USS Enterprise. Courtesy U.S. Navy, photo by Photographer's Mate Airman Rob Gaston. Available from: http://www.navy.mil/view_single.asp?id=15089

Slide 6: High Reliability Organizations: Mindfulness. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm)

Slide 7. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm)

Slide 8: Preoccupation with Failure. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm



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Images

Slide 9: Reluctance to Simplify. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm

Slide 10: Deference to Expertise. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm

Slide 11: Resilience. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm

Slide 14: Blame. Created by Dr. Stephanie Poe.

Slide 15: Blame Arrows. Created by Dr. Stephanie Poe.

Slide 17: How to Promote a Culture of Learning 1. Courtesy: Dr. Anna Maria Izquierdo-Porrera

Slide 18: How to Promote a Culture of Learning 2 Courtesy: Dr. Anna Maria Izquierdo-Porrera

Slide 19:How to Promote a Culture of Learning 3 Courtesy: Dr. Anna Maria Izquierdo-Porrera

Slide 20: Culture of Safety Characteristics. Courtesy: Dr. Anna Maria Izquierdo-Porrera

Slide 21: Honey Bee. Creative Commons by William Warby. Available from: http://www.flickr.com/photos/wwarby/



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Reliability, Culture of Safety, & HITReferences

Quality Improvement Reliability, Culture of Safety, & HIT This material (Comp12_Unit4) was developed...

Documents

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