SCCM Resource Library-Defining Patient Safety Concepts: Teamwork and Culture

Video Transcription

Good morning. As you've heard before, we will each be speaking about a different component of patient safety. For this first part, we will review the current science and data of  measuring the culture of safety and its impact on teamwork and organizational culture. We will review how simulation education can be used as the quality improvement intervention  in organizations seeking to create safe spaces for strengthening critical care teams. I have  no disclosures. As we talk about patient safety concepts, I'd like you to think about how to define patient safety culture. Think about why we do what we do, what motivates us to  do this job. And as we go through this talk, we're going to come back to this anchor point.  SCCM's mission is to secure the highest quality care for all critically ill and injured patients.  SCCM envisions a world in which all critically ill and injured persons receive care from a present integrated team of dedicated, trained intensivists and critical care specialists.  Multi-professional teams use knowledge, technology, and compassion to provide timely, effective,  safe, efficient, and equitable patient-centered care. Right care right now means that the society maintains this model and that this is best provided by an integrated team of  dedicated experts directed by a trained and present physician credentialed in critical care and intensivist. Right care right now means that the right care is delivered at  exactly the right moment to achieve optimal patient outcomes. Above, I've placed two definitions  for culture and one for teamwork. The difference between societal and organizational culture is subtle, but apparent here and important in their differences when we think about how  individual culture may work with or clash with an organizational culture. When we talk about teamwork, we are looking at how people work together to create a summative whole  that is larger than its part. To talk about the culture of safety, one must also talk about errors and how our culture  handles those errors. One of the greatest errors of our lifetime was the Chernobyl disaster.  After an investigation into this and the uncovering of an horrific and toxic culture, the term safety culture was described. This report details a pervasively unsafe culture, as did  other disaster reports, such as the Landbroke Grove train crash in the UK a few years later. And in 1997, in his seminal work, James Reason described this as a sick system syndrome.  The sick system syndrome was widely applicable to healthcare as well. A sick system is thought  to be hierarchical and deficient in mutual respect, teamwork, and transparency. The mainstay  solutions focus on blame. Mechanisms for ensuring accountability are weak and ambiguous, and  few people in a sick system have the capacity to learn and change, things that are characteristic of a high-reliability industry. In a sick system, most people do not recognize that  safety is a precondition, not a priority. In 2000, the Institute of Medicine, or the IOM, published its seminal report, To Error is Human, and followed this with Crossing  the Quality Chasm in 2001. These highlighted these cultural problems as a priority to address in medicine.  What is the culture of safety? Well, there are many definitions of safety culture. I've chosen this one from the Agency for Healthcare and Research Quality as something that shows  multiple features of a safety culture. These are the acknowledgement that we work in a high-risk environment, that that environment should be blame-free, where individuals may  report errors or near misses without fear of reprimand or punishment, that we encourage or collaborate across ranks, those disciplines to seek solutions to patient safety problems,  and that there is an organizational commitment of resources to address safety concerns. After the Institute of Medicine reports, the concepts of building a safety culture took  off and what followed was several decades of research on the components of a safety culture, both within and outside of medicine.  The NASA Columbia tragedy of 2003 brought into focus that of a systems-level need to improve. Yet it was also noted during this time that despite these advances, many organizations  could not reach a target of zero harm, and that some of the systems-level solutions only worked in certain or particular organizational cultures. We know from motivational theory  that individuals are most often driven by intrinsic motivation, and that by harnessing this motivation, the workforce could drive the safety culture ultimately towards zero harm.  In this 2007 report by Hudson, he described an evolutionary model for advancing a safety culture. This ladder of progression in the energy industry is widely applicable to health  care as well. Importantly in this chart, he defines psychological safety as being at the threshold of an evolving safety culture and a workforce that is intrinsically motivated  to place safety as both a precondition and a priority. So it is culture that can lead us to zero harm. A workforce intrinsically driven to promote safe care will help facilitate  safe culture. Providing psychological safety facilitates an intrinsically driven workforce, and senior leadership is critical to this as they are the ones who drive the culture.  The ultimate goal is either a proactive or a generative culture, and these cultures can integrate into hospital systems through a multidisciplinary approach, partnership with  ongoing safety work, accountability, and follow-up. The IOM and the AHRQ also both emphasize three common elements as critical to a culture of  safety. That is, a belief that although health care processes are high risk, they can be designed to prevent failure. In other words, the system must be resilient. A commitment  at the organizational level to detect and learn from errors, and that leadership behavior  drives both safety culture and safety performance. An environment that is perceived as just because  managers discipline only when an employee knowingly increases risk for patient and peers. And finally, the safety culture must be a common and shared model within an organization.  In 2009, the Lucien Leap Institute was established by the National Patient Safety Foundation  to achieve strategic guidance. The Leap vision for health care is shown above, and this vision  can be measured through the culture of safety questionnaires, such as the AHRQ's Hospital Survey on Patient Safety Culture, the Safety Attitudes Questionnaire, the Patient Safety  Culture and Health Care Organizations Survey, or PSICO, the Modified Stanford Patient Safety  Culture Survey Instrument, or the MSI. These tools are often used by organizations to better understand their strengths and weaknesses within a culture of safety.  So how does simulation factor into all of this, and how can we use simulation to improve our culture of safety? In the next part of my talk, I will review how simulation education  can be used as the QI intervention in organizations seeking to create safe spaces for strengthening  a critical care team. So this is one of my favorite quotes by Captain Scott Kelly, talking about empowerment and how speaking up is key to a culture of safety. The wonderful  thing about simulation is that it's on demand, it's safe, there are controlled variables where people can observe and debrief before an error ever occurs, and allows us to create  a psychologically safe and learning environment for all stakeholders. We know that simulation-based  training improves skills and saves money. Simulation improves the retention of knowledge and teamwork, and by doing all of these things, can improve the quality of care we provide  to our patients. We believe that simulation can improve our culture. It gives us the chance to fail safely, and that is in fact what simulation is known for. And again, safety  here refers to psychological safety as well as patient safety. We all know that what happens  in Vegas stays in Vegas, and in that way Vegas is the ultimate safe space. And this is how  we provide psychological safety in simulations. What happens in Sim stays in Sim. We pre-brief  to establish these ground rules and discuss psychological safety. We perform the simulation for assessment and or formative feedback. We debrief, discussing both Safety 1 and Safety  2 principles, and use each of the components for learning opportunities. And sometimes provide our stakeholders with a chance for deliberate practice, which is the gold standard  for self-directed learning, or deliberate reflection. We understand that people make sense of the world using internal cognitive frames, or internal images of external reality,  or in the QI world we call these mental models. This drives both learning and future actions.  For example, a person who is punished for reporting an error will have a different frame than somebody who is rewarded for reporting an error, and their future actions on error  reporting will be different. Debriefing allows us to change these frames and provide an understanding  of the impact of their perceptions on the world, on their actions, and to craft a new frame and action that may provide us with different solutions or results than initially  thought. Simulation allows us to shift individual perceptions of the world or situation to a shared one, and therefore can create common behaviors and results. This in turn allows  us to strengthen our critical care team by providing a common frame and together discuss how to achieve a desired outcome. We can apply this to many aspects of QI and teamwork.  Where can we utilize simulation? Simulation helps participants anticipate potential patient deterioration events, and we can train teams by anticipating potential clinical declines  in our hospitals. Simulation helps uncover latent safety threats in a psychologically safe manner. Tactical improvements help create a culture that functions in a high-reliability  manner. For example, an error uncovered during a simulated anaphylaxis event may spur discussion  on how to improve the process of epinephrine delivery during anaphylaxis, and ultimately  lead to changes in cognitive aids and processes. We can allow for simulation-based systems-level  errors to be reported using an organization safety event reported system. This allows us to leverage an already existing infrastructure and facilitates hospital-wide tracking and  improvements, including resolution of latent safety threats that are uncovered in a simulation.  We can further strengthen our safety culture using simulation for communication training. This training facilitates the learning of common safety language, such as SBAR or CUS,  and therefore helps to facilitate a common and shared organizational culture. Each of these teams, the Apollo 11 crew, the 61 and 96 Yankees, and AFC Richmond, were legendary  in their teamwork, where truly the whole of the team was greater than a sum of its parts. Something about their training made their performance stand out as superior, and utilizing  principles of excellence, training with deliberate practice, and video feedback and simulation,  we can train our critical care teams to provide superior care. Simulation allows us to investigate  accidents by recreating it using simulation, and also understand why and how things go well. Understanding safety 1 components, or learning from errors, is just the tip of  the iceberg. When things go right, the understanding of safety 2 culture, or why things go well, may truly help us propel our practice to zero harm.  Patient and family engagement is one of the pillars of a high-reliability system and culture. They are the center of our critical care team. We can use simulation to help empower  patients and families by using simulation to teach them. For example, teaching patients and families how to care for tracheostomies and g-tubes, and many other components of  hospital care, allowing for a safe discharge.  Inclusivity is of the utmost priority at SCCM. We believe that this is the best way to provide the best care to our patients.  The mission and visions of SCCM are easily executed with the techniques used in simulation, but we can do better. We've come a long way from single color, single mannequin. There  are now mannequins of all shapes, sizes, and colors. Standardized patients may be from diverse backgrounds, but we still have a long way to go. Studies still show that our  biases affect decision-making in patient care, and there is need for increasing diversity and inclusion, especially in nursing education.  Understanding how simulation can help us create a more diverse, equitable, and inclusive culture  is still a relatively new topic, though in the following talks you'll hear more about  and broader anthropological principles. We are still thinking about how these concepts may be better integrated in emulation.  As you can see, the last 30 years have seen tremendous growth in understanding a culture of safety. The way towards a culture that facilitates a zero-harm environment must be  one that provides psychological safety, and simulation-based interventions provides the psychological safety to allow participations to fail and facilitate patient care improvements  independent of actual patients. This provides a safe space to practice evidence-based communication tools and other QI interventions. Thank you very much.

Video Summary

The video discusses the importance of patient safety culture and its impact on teamwork and organizational culture. It explains that patient safety culture acknowledges the high-risk environment of healthcare and encourages reporting errors without fear of punishment. The video also highlights the role of simulation education in improving patient safety culture by creating safe spaces for critical care teams to strengthen their skills. Simulation allows for learning and improvement without the risk of harming real patients. It helps teams anticipate potential patient deterioration events, uncover latent safety threats, and practice communication skills. The video emphasizes the importance of psychological safety in simulations and debriefing sessions to shift individual perceptions to a shared understanding and improve teamwork. It also mentions the potential for simulation to empower patients and families by teaching them how to participate in their own care. The ultimate goal is to create a culture of safety that achieves zero harm and promotes equitable and inclusive care.

Asset Subtitle

Quality and Patient Safety, 2022

Asset Caption

The importance of generating a culture of patient safety is well known at individual, team, hospital, and healthcare system levels to reduce errors and improve interprofessional team dynamics, thereby improving patient outcomes. We can translate this attention to safety into creating environments for cultural competence, cultural safety, and environments supportive of diversity.

Meta Tag

Content Type Presentation

Knowledge Area Quality and Patient Safety

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Quality and Patient Safety

Tag Diversity Equity and Inclusion DEI

Year 2022

Keywords

patient safety culture

teamwork

organizational culture

simulation education

psychological safety

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