Concordia News - Patient Safety Culture - July 2009

Published by Hamish Brown


Case Studies - the effect of culture change:
The 1999 US Institute of Medicine (IOM) report, To Err is Human,  initiated a flurry of patient safety initiatives world wide. Subsequently, The Commonwealth Fund wrote 10 Case Studies where improvements have been made. These included:

  • This hospital accelerated patient safety improvement through a multifacited culture change programme. Two of the results included: A 42% increase in ‘expected' communication behaviours; and 50% reduction in events of harm per 10,000 adjusted patient days.
  • The second hospital led organisational change by providing local facilities and front line staff with proven tools, methods, and initiatives for patient safety improvement. They recorded a 30-fold increase in internal safety incident reporting; and 100% increase in perceived preventability of safety events.

Contact us for more details, or a copy of the case studies. info@concordiaworld.com

During NASA's drive to build a culture that would consistently deliver excellence in safety, they identified five guiding principles. These were:

  • 1. Open communication is encouraged and modeled
  • 2. Rigorously informed judgement is the sole basis for decision making
  • 3. Personal responsibility is taken by each individual
  • 4. Integrated technical competence is a shared value
  • 5. Individual accountability is the basis for high reliability

For a description of what each of these means, and why they are so important.. click here...

Oganisations that achieve high levels of (patient) safety find ways to engage staff from all disciplines at all levels.
The following quote is from Taking the Lead in Patient Safety, 2009; Krause, Hindley, Pinakiewicz.

‘Physicians deplore mistakes and inefficient organisational systems that let them down and injure their patients. But few doctors are trained in systems thinking, culture development, or process control methods, and they often feel that these problems are beyond their control, i.e., the responsibility of other people. The attitude is, "My job is to practice good medicine. Nurses should accurately carry out my orders. Administrators should see to it that hospital systems function properly."

The question is, does this doctor think that his or her professional identity encompasses a leadership role in patient safety? What are the implications when trying to garner engagement at all levels, and how does this stance fit with the guiding principles listed above?

To engage staff at all levels first requires an understanding of the culture (or the ‘how we do things around here') at all levels. For more information.. click here...

For those of us only just putting up with the winter, a couple of weather thoughts:
Mark Twain said:  "The coldest winter I ever spent was a summer in San Francisco" 

One of our clients said: "On TV they have a weather channel - 24 hours of weather. We had something like that where I grew up. We called it a window."

A perfect summer day is when the sun is shining, the breeze is blowing, the birds are singing, and the lawn mower is broken.

Concordia - Hamish Brown