1. PSQH0505_SeptOct08 8/26/08 11:45 AM Page 12
By Stephen W. Harden
TEAMS & C O M M U N I C AT I O N
C r e at i n g a n d S u s t a i n i n g a
C ul t u r e of S af et y
Healthcare consumers are increasingly Step 1. Develop change-initiative tion of culture changing behaviors and
aware of medical error and publicly skills for key leadership positions and tools is primarily a function of effective
reported quality measures. Additionally, an organizational structure that will leadership action.
the Centers for Medicare and Medicaid support the new culture. Realizing no Step 2. Provide training in team-
Services’ (CMS) pending refusal to pay change would occur without partner- work and communication to support
for certain “never events,” the advent of ship with the institution’s physicians, desired culture-changing behaviors.
the Hospital Consumer Assessment of TNMC recruited physician champions, Following a site visit, a thorough patient
Healthcare Providers Survey (HCAHPS), briefed all physicians in perioperative care processes review, and preparation
and the work of the Institute for Health- services through monthly meetings of a teamwork scorecard as part of their
care Improvement (IHI), the National and surgery Grand Rounds, and made needs analysis, LifeWings prepared cus-
Patient Safety Foundation (NPSF), and sure each physician understood the tomized courseware targeting the needs
Joint Commission have combined to methodology, potential results, and of TNMC and presented it to physi-
produce conditions where creating and “what’s in it for you” for supporting the cians and staff. The training was inter-
sustaining a culture of safety is a priority initiative. This was an important step, disciplinary, experiential, and based on
for many healthcare organizations. That as TNMC already had very high levels healthcare case studies. It provided evi-
was the case for The Nebraska Medical of patient safety in other areas. Next, dence-based teamwork skill sets based
Center (TNMC) in Omaha. The aca- key leaders at both the institutional and on team training from the aviation
demic medical center realized in 2004 departmental level were trained on industry—called Crew Resource Man-
that their patient safety efforts needed a leading change initiatives. Skills learned agement (CRM)—and adapted for the
boost to move from very good to great.A included: needs of the OR team. CRM is based on
focus on quality and safety was one of • responding to difficult questions the best science and research on high
four CEO leadership priorities, and the about the initiative, performing teams.
focus on quality and safety was incorpo- • recruiting champions and Step 3. Create and implement site-
rated into the hospital’s strategic plan coaching low performers, and specific safety tools to hardwire the
with full approval of the Board. • conducting rounding for patient teamwork behaviors into daily work
Chief Medical Officer Steve Smith, safety. life. Using a process based on Lean, a
MD, spearheaded the effort to change small work group of physicians and staff
TNMC’s culture:“We want a safer place Organizational development to support met to 1) identify points in their work-
to practice medicine with the confi- the initiative included: flow where improvements in patient
dence that all steps necessary to ensure • a project oversight and steering safety were most needed and 2) create
our patients’ safety to the highest degree committee, safety tools such as checklists, structured
are taken into account for all cases.” • revisions to policy and procedure handoffs, protocols, and communica-
Based on a recommendation from the manuals, tion scripts to facilitate the needed
chief of surgery, Smith elected to join • alignment of leadership assess- improvements. An education and
forces with LifeWings, a consultancy ment systems to support the implementation plan was created for
group that works with clients to create culture, each tool. Tools were implemented over
a culture of safety by adapting the best • a data collection and analysis plan a period of weeks. The first tool com-
practices of aviation and other high for project measurement, and pleted and implemented was a Pre-Pro-
reliability organizations. • making the training and new cedure Briefing (Figure 1) for surgical
TNMC chose to follow a five-point safety tools mandatory for cases that incorporated the elements of
plan for creating and sustaining an all physicians and staff— the Universal Protocol (which is avail-
improved culture of safety. In a 6-month including consequences for able online at www.psqh.com/xxx. It
period of 2005 and 2006, the first four non-compliance. also included checklist items to ensure
steps of the plan were conducted in peri- all staff and needed equipment were
operative services as proof of concept Step 1 was perhaps the most impor- available and operational, and that the
with follow-on implementation planned tant part of the methodology as patient was completely ready for the
for other areas after success in the OR. research shows that “end user” adop- procedure to begin.
12 Patient Safety & Quality Healthcare I September/October 2008 w w w. p s q h . c o m

2. PSQH0505_SeptOct08 8/26/08 11:45 AM Page 13
Figure 1: Safety Climate Survey Results
Culture of Patient Safety Survey Results Cath/EP was hired externally. Once qualified by
Pre-CRM: August 2006 (n=24), Post CRM: July 2007 (n=16) LifeWings, these trainers assumed
■ Pre-CRM ■ Post-CRM
responsibility in 2007 and 2008 for the
93% roll out of Steps 1 through 4 in the
100% 86% emergency department, the cardiac
73% 83%
80% catheterization and electrophysiology
63%
60% labs, and the obstetrics and gynecologi-
29% cal services department. TNMC contin-
40% ues to roll out the system in its critical
20% care areas with plans to implement the
0% culture change in its entire hospital.
We are actively doing Staff will freely speak up Staff feel free to question
things to improve patient if they see anything that the decisions or actions of Results
safety. may negatively affect those with more authority.
The culture of safety has improved at
patient care.
TNMC. Results of the safety-climate sur-
vey administered after the implementa-
Step 4. Collect and analyze data to the culture-changing initiative in-house tion in the areas listed above show dra-
document results. TNMC created a as quickly as possible and avoid an matic improvement in the perception of
measurement plan to analyze results by extended engagement with an outside staff, physicians, and residents on those
examining safety measures including consultant. To develop their internal indicators related to patient safety in their
safety climate surveys, teamwork and capacity, three trainers were chosen in area (Figure 1). Additionally, the culture
communication issues, and process reli- 2006 to learn to provide the teamwork has produced multiple examples of
ability and efficiency. skills training and to create and imple- “good catches” by the staff as they have
Step 5. Conduct training for “mas- ment the safety tools. Two trainers were intercepted potential errors that might
ter trainers.” TNMC wanted to bring from the Six Sigma department and one have affected patient safety. In addition to
September/October 2008 I Patient Safety & Quality Healthcare 13

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improved patient safety, TNMC has seen
an improvement in cases without signifi-
Figure 2: Percentage of Procedures without Delays
cant events, reducing unexpected delays
■ Cath Lab 2007 (Figure 2). As a result of their culture-
changing efforts, TNMC recently won
100% the “Quest for Excellence” award given
each year by the Nebraska Hospital Asso-
90%
ciation. The award represents “the high-
80% est level of professional acknowledge-
ment in Nebraska’s hospital quality
70% improvement arena.” TNMC has proved
63%
that though disciplined leadership
60% action, effective interdisciplinary skills
training, use of site-specific safety tools
50%
that hardwire behaviors, and program-
40% guiding measurement, the safety culture
can be changed and improved. SPSQH
30%
21% Stephen Harden is the co-founder and
president of LifeWings Partners LLC. He is
20%
co-author of CRM: The Flight Plan for
Lasting Change in Patient Safety
10%
(published by HC Pro) and is a nationally
known speaker on creating a culture of
0%
July (N=36) Sept (N=92) patient safety. He can reached at
sharden@SaferPatients.com.
14 Patient Safety & Quality Healthcare I September/October 2008 w w w. p s q h . c o m