Selected Podcast
Creating a Culture of Safety
Featuring:
Ginger Wells, NA
Ginger Wells, NA is a Patient Safety Program Manager. Transcription:
Ginger Wells: My name is Ginger Wells. I'm the Patient Safety Program Manager at San Juan Regional Medical Center. And I would like to talk to you today about our ethical dilemma to do no harm in our world.
Everyone that works in healthcare has an ethical oath to do no harm and diligently strives to meet this high calling. However, we are fallible humans working in complex environments with broken systems. In addition, we often lack the tools that are needed to ensure nothing bad happens. That's why the Patient Safety Advocate Program was designed to promote a culture of safety by empowering staff to speak up when they have concerns. Participants in the program are taught to encourage behaviors and practices that could prevent harm. The advantage of the safety tools is that they cross over and can be used in both our professional and personal lives.
One of the safety techniques that is taught is the validate and verified tool. This tool encourages critical thinking to ask questions by listening to our instincts. For example, does this line up with what I know? We need to understand it's okay to ask questions. Asking questions improves communication between the disciplines by using a closed loop technique. This leads to better teamwork and accountability as well as outcomes. It's also important to understand just culture and psychological safety.
Just culture treats errors as failures in the system rather than personal failures. The idea is that some, if not most, errors can be eliminated by designing a better system. This idea is used every day in many areas. Instead of assessing blame, the just culture approach suggests that errors can be treated as inevitable. There is no way to make humans infallible. Instead known failure points can be identified and processes can be engineered to avoid those mistakes in the future.
For example, gas station nozzles and hoses have been ripped off because drivers forget to take them out of the tank after filling their car. To combat this extremely expensive error, modern nozzles have a breakaway coupler that allows them to be pulled off the hose without damaging the nozzle or the pump. We too have fail safe mechanisms built into our electronic medical records, such as alerts and hard stops.
In healthcare, a just culture is intended to reduce adverse patient outcomes by reducing errors. At the same time, intent should be managed immediately. For example, if a staff member was to come to work altered, that needs to be dealt with immediately. Psychological safety is the ability to share one's thoughts and feelings without risk. To understand psychological safety, you need to understand the psychological safety is the ability to share one's thoughts and feelings without risking damage to your reputation or your standing in the organization. In teams, it refers to team members believing that they can take risk without being shamed by other team members. In psychologically safe teams, members can feel accepted and respected.
Other personal benefits of the safety program is learning more about conflict management, giving and receiving feedback and emotional intelligence. It's also important to understand human behaviors that set up opportunities for errors, sometimes catastrophic errors. Many errors can be attributed to a phenomenon called normalization of deviance. Normalization of deviance is a phenomenon by which groups or organizations come to accept lower standards of performance until that lower standard becomes normal for them. This usually occurs when individuals, groups or organizations are under pressure to meet scheduled requirements, conform to budgetary considerations or deliver on a promise while adhering to expected standards or prescribed procedures.
For those in healthcare, many suffer from moral injury or burnout. However, faced with a situation in which relaxing the standards or procedures to get the job done, they decide to utilize lower standards or less robust procedures with the expectations that when things go back to normal, they will go back to utilizing the higher standards or procedures. Sometimes we even give into peer pressure. But without a focused awareness, normal takes much longer to achieve or maybe even never return at all.
Remember the Challenger Space Shuttle crash of 1986? The investigation and root cause analysis revealed that this occurred within NASA during the decision-making and testing surrounding a key flaw that led to the Challenger crash and the deaths of seven people. A simple O-ring was found to be within the bounds of acceptable risk.
Now, I ask you, how normal has it become for you to drive just a touch over the speed limit to avoid a ticket, talk on your cell phone while driving or, even worse, texting and driving? Admit it. We've all done it. Why do we continue? Because we have not experienced a bad outcome. It did not hurt this time. But eventually, it will, just as with the Challenger. They had 24 successful launches using the same simple O-ring, and they continued to use it as an acceptable risk. But eventually, there was a terrible outcome as we all know.
So, how can we reverse or stop this trend and improve the culture of safety? I have nine tips for that.
Number one. Understand that every job is new and the risk that job contains are unchanged from yesterday. Do it by the book every time.
Number two. Risk has no memory. Risk is not diminished as a function of your success in repeatedly taking a risk. Humans have a difficult time believing that. We think a risk taken is a risk diminished, but the laws of physics does not diminish the probability of something bad happening.
Number three. There is never a one-and-done when it comes to deviance from safety best practice. Just one successful safety shortcut can start a self-sustaining inertia of safety deviance.
Number four. Report near misses. Within our organization. We have the Great Catch Program for this purpose. We know reporting near misses can help guide us as we are looking to improve our processes.
Number five. Leaders need to support and ensure your teams have the resources to safely achieve the assigned goals.
Number six. Procedural compliance should be a religion. The procedures for work in all hazardous environment are figuratively written in blood. They want to make sure that we are dead set on compliance with our procedures.
Number seven. Take each other's back. At any given moment during hazardous operations or delicate procedures, not everyone is bringing their A game to work. Someone can be seriously distracted by personal pressures, family, health, financial, relationships, et cetera. By watching for each other, we can save someone from a serious injury or fatality.
Number eight. There is no rank or seniority when it comes to safety. This is particularly important to understand with the generational changes occurring in many workforces. Newly hired person working with older job veterans may believe they don't count in safety as much as a veteran at their side. We all count. See something, say something, do something. Live out the core values of sacred trust and personal reverence. Don't assume that others will take care of it. You do it.
Number nine. Leaders, make sure you empower your people so they do count. In word and deed convey the message, "I want to see through your eyes. Don't assume I am aware of a problem or hazard, or that somebody will take care of it. Bring it to me." Again, this links to psychological safety.
I want to close today by encouraging staff to consider enrolling in the Safety Advocates Program and expect to walk away with the tools needed that impact safety, both in your work and personal lives.
You will certainly grow as a leader in all areas and maybe even have a few laughs along the way. Thank you and have a wonderful day.
Ginger Wells: My name is Ginger Wells. I'm the Patient Safety Program Manager at San Juan Regional Medical Center. And I would like to talk to you today about our ethical dilemma to do no harm in our world.
Everyone that works in healthcare has an ethical oath to do no harm and diligently strives to meet this high calling. However, we are fallible humans working in complex environments with broken systems. In addition, we often lack the tools that are needed to ensure nothing bad happens. That's why the Patient Safety Advocate Program was designed to promote a culture of safety by empowering staff to speak up when they have concerns. Participants in the program are taught to encourage behaviors and practices that could prevent harm. The advantage of the safety tools is that they cross over and can be used in both our professional and personal lives.
One of the safety techniques that is taught is the validate and verified tool. This tool encourages critical thinking to ask questions by listening to our instincts. For example, does this line up with what I know? We need to understand it's okay to ask questions. Asking questions improves communication between the disciplines by using a closed loop technique. This leads to better teamwork and accountability as well as outcomes. It's also important to understand just culture and psychological safety.
Just culture treats errors as failures in the system rather than personal failures. The idea is that some, if not most, errors can be eliminated by designing a better system. This idea is used every day in many areas. Instead of assessing blame, the just culture approach suggests that errors can be treated as inevitable. There is no way to make humans infallible. Instead known failure points can be identified and processes can be engineered to avoid those mistakes in the future.
For example, gas station nozzles and hoses have been ripped off because drivers forget to take them out of the tank after filling their car. To combat this extremely expensive error, modern nozzles have a breakaway coupler that allows them to be pulled off the hose without damaging the nozzle or the pump. We too have fail safe mechanisms built into our electronic medical records, such as alerts and hard stops.
In healthcare, a just culture is intended to reduce adverse patient outcomes by reducing errors. At the same time, intent should be managed immediately. For example, if a staff member was to come to work altered, that needs to be dealt with immediately. Psychological safety is the ability to share one's thoughts and feelings without risk. To understand psychological safety, you need to understand the psychological safety is the ability to share one's thoughts and feelings without risking damage to your reputation or your standing in the organization. In teams, it refers to team members believing that they can take risk without being shamed by other team members. In psychologically safe teams, members can feel accepted and respected.
Other personal benefits of the safety program is learning more about conflict management, giving and receiving feedback and emotional intelligence. It's also important to understand human behaviors that set up opportunities for errors, sometimes catastrophic errors. Many errors can be attributed to a phenomenon called normalization of deviance. Normalization of deviance is a phenomenon by which groups or organizations come to accept lower standards of performance until that lower standard becomes normal for them. This usually occurs when individuals, groups or organizations are under pressure to meet scheduled requirements, conform to budgetary considerations or deliver on a promise while adhering to expected standards or prescribed procedures.
For those in healthcare, many suffer from moral injury or burnout. However, faced with a situation in which relaxing the standards or procedures to get the job done, they decide to utilize lower standards or less robust procedures with the expectations that when things go back to normal, they will go back to utilizing the higher standards or procedures. Sometimes we even give into peer pressure. But without a focused awareness, normal takes much longer to achieve or maybe even never return at all.
Remember the Challenger Space Shuttle crash of 1986? The investigation and root cause analysis revealed that this occurred within NASA during the decision-making and testing surrounding a key flaw that led to the Challenger crash and the deaths of seven people. A simple O-ring was found to be within the bounds of acceptable risk.
Now, I ask you, how normal has it become for you to drive just a touch over the speed limit to avoid a ticket, talk on your cell phone while driving or, even worse, texting and driving? Admit it. We've all done it. Why do we continue? Because we have not experienced a bad outcome. It did not hurt this time. But eventually, it will, just as with the Challenger. They had 24 successful launches using the same simple O-ring, and they continued to use it as an acceptable risk. But eventually, there was a terrible outcome as we all know.
So, how can we reverse or stop this trend and improve the culture of safety? I have nine tips for that.
Number one. Understand that every job is new and the risk that job contains are unchanged from yesterday. Do it by the book every time.
Number two. Risk has no memory. Risk is not diminished as a function of your success in repeatedly taking a risk. Humans have a difficult time believing that. We think a risk taken is a risk diminished, but the laws of physics does not diminish the probability of something bad happening.
Number three. There is never a one-and-done when it comes to deviance from safety best practice. Just one successful safety shortcut can start a self-sustaining inertia of safety deviance.
Number four. Report near misses. Within our organization. We have the Great Catch Program for this purpose. We know reporting near misses can help guide us as we are looking to improve our processes.
Number five. Leaders need to support and ensure your teams have the resources to safely achieve the assigned goals.
Number six. Procedural compliance should be a religion. The procedures for work in all hazardous environment are figuratively written in blood. They want to make sure that we are dead set on compliance with our procedures.
Number seven. Take each other's back. At any given moment during hazardous operations or delicate procedures, not everyone is bringing their A game to work. Someone can be seriously distracted by personal pressures, family, health, financial, relationships, et cetera. By watching for each other, we can save someone from a serious injury or fatality.
Number eight. There is no rank or seniority when it comes to safety. This is particularly important to understand with the generational changes occurring in many workforces. Newly hired person working with older job veterans may believe they don't count in safety as much as a veteran at their side. We all count. See something, say something, do something. Live out the core values of sacred trust and personal reverence. Don't assume that others will take care of it. You do it.
Number nine. Leaders, make sure you empower your people so they do count. In word and deed convey the message, "I want to see through your eyes. Don't assume I am aware of a problem or hazard, or that somebody will take care of it. Bring it to me." Again, this links to psychological safety.
I want to close today by encouraging staff to consider enrolling in the Safety Advocates Program and expect to walk away with the tools needed that impact safety, both in your work and personal lives.
You will certainly grow as a leader in all areas and maybe even have a few laughs along the way. Thank you and have a wonderful day.