The Continued Quest for a True Culture of Safety

The continued learnings that have come from the Asiana crash in San Francisco have reinforced one of the most important safety and quality issues affecting healthcare today–an existing culture that inhibits caregivers and support staff from holding each of us accountable and speaking up when we perceive a problem with patient care.

In a recent ETY post, Lessons Healthcare Can Learn From Asiana Flight 214, I shared the thoughts of Steve Harden as he applied the learnings from the Asiana crash to common weaknesses in patient safety. In a recent follow-up to his original piece, Harden reports on the interviews and investigations that have taken place since the crash last fall. He writes:

Though Captain Lee was an experienced pilot with the Korea-based airline, he was a trainee captain in the 777, with less than 45 hours in the jet. Captain Lee’s co-pilot on that fatal flight was an experienced instructor pilot who was responsible to mentor and monitor Captain Lee’s performance…(Lee) told investigators he had been “very concerned” about attempting a visual approach without the instrument landing aids, which were turned off. A visual approach involves lining the jet up for landing by looking through the windshield and using numerous other visual cues, rather than relying on a radio-based system called a glide-slope that guides aircraft to the runway.

…he did not speak up because other airplanes had been safely landing at San Francisco under the same conditions. As a result, he told investigators, “(he) could not say to his instructor pilot (that) he could not do the visual approach.”

What does this story have to do with healthcare? Harder emphatically shares that:

…after working with over 140 healthcare organizations, reviewing scores of root cause analyses, and conducting hundreds of real time observations in hospitals, clinics, ASCs, and labs – many of my experiences with healthcare staff sound just like Captain Lee’s interview. The culture in many of our healthcare organizations might as well have been created at Asiana.

Screen Shot 2014-01-16 at 12.23.16 PMThis past weekend, I was an invited participant on the Culture of Safety Panel at the Patient Safety Summit held in Laguna Niguel, CA. The Summit was founded by Joe Kiani, the CEO of Masimo, and was keynoted by President Bill Clinton. It also included a number of thought leaders from across the country who came together with one common goal…Zero Preventable Hospital Deaths by 2020. During our panel, I posed the question, “If we as caregivers struggle to take collective professional accountability for safety concerns happening around us, who will?  When we don’t stand up and share safety concerns about our patients with one another, we lose the most important element of any caregiver-patient relationship, which is trust.”

In his article, Harden asks the question, “How would (your healthcare teams) answer this question?

In 100 out of 100 cases where it is needed, am I absolutely sure that my most junior and inexperienced staff member, when they perceive a problem with patient care, can and will have a stop-the-line conversation with my most senior and experienced physician?

At the Patient Safety Summit this weekend, Dr. Mark Chassin the CEO of the Joint Commission, asked the audience almost the same question Harden posed:

How many in the audience can answer yes to the following question (paraphrasing): If one of your junior staff members saw a potentially unsafe condition, how many of you are confident the staff member would “stop the line” and report that potential unsafe condition?

About 2-3% of the audience raised their hands. Dr Chassin confirmed that when he has asked the same question at other meetings, the responses are consistently between 0-5%, with no raised hands being the most frequent observation.

Screen Shot 2013-09-01 at 8.33.40 AMHarden’s article and the panel discussions on accountability this past weekend at the Patient Safety Summit took me back to the words of Dr. Sidney Dekker, a Professor of Humanities at Griffith University in Brisbane, Australia. Dr. Dekker has a PhD in Cognitive Systems Engineering and is the author of Just Culture: Balancing Safety and Accountability:

Calls for accountability themselves are, in essence, about trust.  Accountability is fundamental to human relationships…Being able to offer an account for our actions (or lack of action) is the basis for a decent, open, functioning society.

The vast majority of caregivers want to do the right thing but the long-standing incentives and pressures to “look the other way” are powerful. To achieve a true safety culture, leaders need to be held accountable to removing these barriers and celebrating caregivers who raise their hand when safety concerns arise. Collective accountability can restore honesty and trust in our healthcare work place, and is essential to any healthy patient-caregiver relationship.

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