National Patient Safety Foundation

PATIENT SAFETY CURRICULUM

Module 5: Increasing Patient Safety Awareness and Practice among
Clinicians and Staff
Julianne Morath, RN, MS
Chief Quality and Patient Safety Officer, Vanderbilt University Medical Center
Director, Center for Clinical Improvement; Associate Professor of Clinical Nursing

Transcript of recorded lecture © National Patient Safety Foundation, Boston, MA

Welcome to Module 5: Increasing Patient Safety Awareness and Practice among Clinicians and Staff. I’m
Julie Morath and I’ll be your guide through Module 5. Topics for this module include teams create safety,
effective communication, measurement and feedback, considerations for goal setting and priorities, and
sustaining awareness and alertness in clinicians and staff in care delivery.

There are leading questions to begin this module and for you as leaders and clinicians to consider in this
work. The first: Is this a safe place to give and receive care? Does our culture allow employees and staff
to tell the truth? And how do you know? This is about psychological safety. And psychological safety is
required for teamwork, awareness, and communication. Paul O’Neill, former CEO of Alcoa and legendary
for his work in bringing safety to new heights in that industry, suggests further questions that are
fundamental to creating safety and achieving habitual excellence. Can your staff answer “yes” to the
following questions? One, am I respected each day regardless of role, pay grade, or other characteristic?
Two, do I have the training, tools, and support to do my job? Three, am I recognized and thanked for my
contribution? It takes respect, support, and recognition inside these questions. And these are
preconditions for trust and teamwork.

Here’s our situation in health care: systems are too complex for extraordinary people to deliver safe care.
The IOM report Crossing the Quality Chasm sent a message that it’s systems not people and that we
need to start seeing gaps. There are some gaps that are large and visible, such as transfer between
facilities, trips to the OR, going home. There are gaps that are more subtle: change of shift, physician sign
outs, provider and family communication. Gaps in communication at transition and transfer of care is
where patients, families, and staff are most vulnerable for harm. We often learn about gaps in hindsight,
after something has happened or a process has failed. Our challenge is to anticipate and bridge gaps
with teamwork and resilience. As we know, our systems today across continuums of care remain faulty.
Creating greater safety requires bridging gaps.

There are lessons from high-hazard industries where error is expected, but does not occur. These include
nuclear energy, aircraft carriers, smoke jumpers, and the airline industry. How do they do this? There are
many lessons around these high-reliability organizations that we’ll cover later in this module. But the most
important is that safety is created in teams. And the work of building teams starts when we stop thinking
about what we need as individuals in our specific specialties and disciplines and start thinking about how
we can contribute and help each other to accomplish the work in a highly reliable way.

And the discipline of high reliability begins with the understanding of a team. A team does not occur by
the proximal distance between people, but rather through very disciplined training and simulation.
Teamwork, or teaming, is critical in today’s health care environment. There are many parallels that have
been drawn between the cockpit of an airplane and the operating or procedural suite, where huddles,
debriefs, briefings, continual mindfulness, clear communication, and a well-articulated and understood
plan is critical.

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A team: there are characteristics of a team. There’s defined roles and responsibilities, expectations
between team members that are understood and mutually validated, training and simulation in the
technologies of teamwork. There are structured protocols by which to communicate and discharge one’s
roles and responsibilities. Reliable communication is a key, often using SBAR, the structured
communication of Situation, Background, Assessment, Recommendation. A team, because they are fairly
stable, can make substitutions and have flexibility in their roles and responsibilities. But consider most
health care environments. Our working conditions in health care have 24/7 demands. And the definition of
a crew may be more applicable. A crew is assembled from a talent pool: unit staff, members of group
practices, float teams, other disciplines such as respiratory therapy, pharmacy, that may come from a
central talent pool. Individual expertise and clinical competence accompany the individuals who
assemble. They form to complete work during a shift or an episode of care. They redistribute following
that shift or episode of care, and they may or may not reassemble in exactly the same way again.
Training and critical communications are essential. They depend on processes and systems of teamwork
in order to reliably perform their responsibilities.

Whether a team or a crew, the risk of failure is inherent in complex systems. Risk is always emerging. Not
all risk is foreseeable. People are fallible, no matter how hard they try not to be. Systems are fallible. And
alert, well-trained clinicians are crucial to deliver care. In teams or crews that perform with high reliability,
there are everyday terms and operating conditions. They are alert and obsessed with failure, always
searching to see gaps. They react to very weak signals that change or danger is coming. There are
symptoms when weak signals are not picked up. They include clinical surprises, breakdowns, or conflict
in communication, and more errors occurring. They expect the unexpected. They commit to resilience, the
ability to anticipate and recover when things go wrong. There’s exquisite attention to operations and the
experience of the front line. They do not accept shortcuts that compromise care. They refuse to simplify
explanations, but continually seek to understand and ask why. And there is constant communication and
collaboration.

Human factors is an important concept when considering teams and the ability to delivery effective care.
Human factors is an interaction of humans, technologies, and environments. It involves the study of all
aspects of the way humans relate to the world around them, with the aim of improving operational
performance or safety. If you’re interested in human factors, I highly recommend Donald Norman’s
seminal work on The Psychology of Everyday Things. Note the teapot and its construction.

Our environments are replete with mixed messages and ambiguities. I have a collection of signs such as
Keep Right, Entrance Only, Do Not Enter. We navigate these in subtle ways on an ongoing basis. To help
guard against human fallibility, tools such as Atul Gawande’s checklist hardwires the wisdom of the team
into operations. It’s now in international use and has demonstrated error reduction. The checklist helps
navigate the ambiguities, mixed messages, and distractions that constantly surround the clinicians in our
busy health care environments.

Other tools are critical and crucial conversations. Learning how to communicate effectively in the milieu of
opposing opinions, strong emotions, and high stakes, because lives are at stake. There are many
resources available to help train and guide teams through conducting crucial conversations. This visual
may be helpful to look at reliable communication. There are routine communications that happen all the
time, such as universal protocol, time outs, debriefs, huddles before surgery and procedures. And I would
add before a shift starts. There’s the elimination of prohibited abbreviations, the reduced reliance on
verbal orders, and always having critical results and readbacks, informed consent teachbacks, medication
reconciliation, total transparency, and structured communication like SBAR, as discussed before.

There are also rescue communications, stop the line, the ability of any patient, family member, staff
member to stop any procedure or activity if they perceive it is incorrect or would place the patient in harm;
escalating the chain of command using rapid response teams; and the use of disclosure when things go
wrong, especially when things go wrong.

We tend to create understanding by use of data that confirms what we already know. And in doing so, we
miss learning from what we don’t know. I highly recommend The Black Swan: The Impact of the Highly
Improbable, as you pursue greater understanding in patient safety. The Black Swan suggests that what

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you do not know is more relevant, often, than what you do know. Confirmation bias surrounds us. We
preselect segments of what is seen and generalize to the unseen. As human beings, we always seek
certainty. Unexpected or unpredicted rare events are often understood in the context of what we already
know. And we miss and distort the facts in front of us to confirm what we already do know. And in the
retelling of events, we often fall victim to narrative fallacy, which explains the world in ways that are
comfortable for us. In the work of patient safety, these biases consistently need to be challenged. And
that is where your team comes in. Safety requires engagement and partnership among clinicians, staff
and patients.

Safety action teams or frontline CUSP teams are technologies that help mobilize and engage the front
line, their local interdisciplinary staff and clinicians, and they use tools such as local survey results,
reporting and learning, good catch logs, which are simply notebooks kept on the units or the work
environments where anyone can jot down a concern or a good idea. They follow simple rules, exercise
local problem solving. Simple rules are used in complexity. And front line safety teams exercise these
simple rules: fix what you can, tell what you fixed so others can learn from it, and find someone who can
fix what you cannot. This is often the case when issues of safety cross geographic boundaries or
boundaries in the different disciplines. This is when managers, quality consultants, or other resources
may join the team to help problem-solve.

The goals of these local teams are to create situational awareness, which guards against the
normalization of deviance. People living in unmitigated risk begin to see as normal those situations that
are hazardous. By discussing these and bringing them forward through candid conversations, greater
situational awareness of risks are developed and kept alive. It’s also a place where we make sense.
Sense making about how we are operating. It engenders trust and teamwork. Escape Fire is a resource
that you might choose to look at here, authored by Don Berwick, it recounts the tragedy of Mann Gulch
and explores the role of the leader of knowledge, of a team, and of the ability to trust in order to innovate
and create safety. Local teams also take on projects. And so staff are empowered and directly involved in
making things better for patients and for themselves as they work.

Teams create an environment of learning and safety requires a learning culture. This culture is
characterized by transparency of errors. People talk about what went wrong, what almost went wrong,
what they worry about. They ask and they tell. There’s robust reporting. Debriefs, simulations, and mental
rehearsals are commonplace. Stories are told -- stories that convey the culture and lessons learned. They
engage in complex conversations. They go beyond the superficial to really expose what they’re
concerned about. And they see gaps. They anticipate, predict, and close gaps before patients are put in
harm’s way.

A word about measurement. Measurement and feedback, when hardwired into the organization help
maintain safety. It helps us understand where our boundaries of safety are and how we are progressing
and creating greater safety. Aims and measures that are clear, understood, and aligned throughout the
organization, regular reporting to the board of directors, having internal risk on patient safety databases
so that we understand and learn from things that have gone wrong and can identify leverage points for
change. Focus groups and qualitative data are important. There’s a saying that data convinces and
stories compel. External reporting is another mechanism of accountability and also helps us gauge how
we do internally as well as compare to others in the field. CMS core measures, adverse event reporting,
CDC reporting are all part of our external reporting matrices. Some states have reporting requirements.
While they differ, they align and are important to attend to.

There are surveys out there that can help you keep your finger on the pulse of your organization:
Leapfrog, the Survey on Patient Safety Culture, the AHRQ Culture of Safety Survey, the Customer
Assessment of Healthcare Provider and Services, Hospital Assessment of Healthcare Provider and
Systems. With any survey, completing it is not sufficient. It’s getting the feedback to the front lines so that
they understand where their opportunities are and where they can celebrate their accomplishments.
Surveys, as with other reporting, can serve as a drumbeat to keep priorities in front of people and
continually let us know how we’re doing against what we aspire to achieve.

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There are collaboratives. Doing this work alone can be pretty lonely and often limiting. There are
collaboratives that exist in the Joint Commission Innovation Center with the Institute for Health
Improvement, with the CHCA and NICHQ collaboration, as well as opportunities through NPSF and other
organizations. Measuring best practice implementation is also a mechanism to make sure that your
organization is staying on top of what the evidence suggests is the best practice for creating safety.

I find this slide helpful to think about how different organizational cultures handle safety information. In the
previous slide we’ve just seen many sources of safety information, including that which is internal where
people who work within the organization report. In a pathological culture, you don’t want to know, the
messengers are shot, failure is concealed, or worse, punished, and new ideas are actively discouraged.
In a bureaucratic culture, you might not find out. Messengers are listened to, if they arrive and navigate
the bureaucracy to get to an ear. Failure leads to local repairs, and new ideas often present problems. In
a generative culture, which is a safety culture, information about safety is actively sought, messengers
are trained and rewarded, failures lead not only to local repairs but to far-reaching reforms, and new ideas
are not only accepted but they are welcomed and encouraged. A safety culture is generative, constantly
uneasy, seeking, learning, and changing. This is the culture that we aspire to when we create safety.

Just a word on reporting. We report accidents because everyone knows about them. But reporting is very
much like an iceberg and accidents are only the tip. Near misses and learning from near misses has the
same kind of richness and opportunity that learning from accidents does. One does not have to harm a
patient in order to learn. Near-miss reporting is one of our largest opportunities. There’s also the reporting
of dangerous situations and deviations and variances. As one goes deeper, one has a more robust and
reliable reporting system.

Safety learning feedback is important to keep people engaged. Increased reporting is a proxy for trust.
The reporters trust that management will act on the information that is sent, and management
encourages reporting so that they can better learn where the opportunities and the resources need to be
applied. So when one reports, it should receive a thank you. The reports are accumulated and analysis is
performed so that patterns and themes for leverage points of change are sent back to the organization.
And analysis leads to lessons learned in which alerts and stories are broadcast. In such a way, one
establishes a learning architecture so that safety and improvement become alive within the organization.

Safety requires accountability. The quote from Churchill, “however beautiful the strategy, you should
occasionally look at the results,” could not be more true. But a word of caution about measurement,
Einstein was famous for saying that “not all that can be measured matters and not all that matters can be
measured.” It’s important to measure because that’s where people put their attention. But intuition,
uneasiness, hunches are also important in this work to further pursue information that exists within the
organization.

Measurement is not new. The earliest key performance measures for a hospital that I could locate was in
1754. This was at the Pennsylvania Hospital. The number of patients was 117. There were four
diagnostic categories: cancer, lunacy, dropsy, consumption. And the metrics they used on an ongoing
basis were outcomes: cured, relieved of symptoms, irregular behavior, discharged incurable, taken away
by friends, dead, or left in the hospital.

We haven’t changed all that dramatically, but are getting much more specific around the kinds of things
that make a difference to our patients. The following are a number of slides that demonstrate different
ways to visualize information from measurements. This is an example of looking at central line-associated
blood stream infection over time. This looks at progress with eliminating hospital acquired pressure
ulcers, to look at the trend line and the confidence intervals.

Developmental measures are often helpful in starting new programs relating to safety. They’re descriptive
and look at projects and implementation as opposed to specific process and outcome metrics. This is a
chronogram, which is an interesting way to look at data. This particular one shows smart pump guardrails.
And you note that the chronogram is built around the hours of the clock. And you note that at 1800, the
guardrails were hit much more frequently than any other time. It turns out that this, when investigated, this
was a time when residents handed over their cases, shifts changed, meals were sent to a unit and

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pharmacy delivered medications. The opportunity here was load leveling all this activity so that more
attention was paid to the patients rather than the logistics of the care setting.

Focus groups also provide insight into safety. This is often used in follow-up to culture of safety surveys.
This is one organization where focus groups were used to look at the story of safety within the
organization. Initially, it was all about not having enough staff, and interpersonal conflicts, and lack of
leadership clarity. Two years later, after intense work in patient safety, staffing was not an issue, the
number of staff, but rather staff training, communication, and teamwork. So it was not so much numbers
of people, but how people effectively worked together. The other issue was that through a very
aggressive patient safety initiative and high visibility of leaders, the question about leadership clarity
engagement came off the list of the things that most staff were concerned about.

Accounting or reporting for data points that loses the story is a waste. Stories create safety. This is very
important. The data point gives us direction and convinces and provides a rigor, but the story, the human
face of what happens, is also important to keep people engaged and compelled toward action. This next
slide is a complex one, and I hesitated about including it. But I think it’s important, and it’s an introduction
only. But hope you will pursue the information.

This is a dynamic safety model. There’s a black line, a blue line and a red line. They represent the
boundaries in which organizations operate. The vertical axis is benefit to individual persons and
organizations. And the horizontal axis, production and performance. Now this relates to measures and
priorities. So we know our financial boundaries. We know production. We know our financial reports. We
continuously get feedback and can engage. The blue line representing our quality of work life is also well
informed through staff satisfaction surveys, focus groups, and other human resource and management
interventions. What is not well understood is the safety boundary. We’re beginning to understand that as
we have more measures, more standards, and greater clarity about what it takes to require a safety
environment.

But what can happen is that as financial pressures and quality of work life issues, work in tension to one
another, it’s like putting a water balloon in a vice. And the safety boundary gets pushed out into borderline
tolerated conditions of use where the probability of an accident is much higher and that exceeding that
boundary, the probability of an accident is high. Hospitals and health care organizations typically operate
within that illegal normal. One of the things that I believe is essential for our work and safety is to begin to
understand and define that safety boundary and respond to it in the same way that we do our financial
and our quality of work life boundaries.

So borderline tolerated conditions of use is a transparent system of production and recovery. It involves
anticipation and, again, teamwork is essential. One may move into this zone, but must do so in a
thoughtful intentional way with plan for pull-back and recovery and a team surrounding. How do we define
this boundary of safety? Well, errors help us define the boundary. If we are systematically tracking error,
we begin to develop an understanding of when errors increase and when they decrease. Safety cultures
know their boundaries. They know when they’re moving into exceedency for safety and into intolerable
risk. This is one of the lessons from the high-reliability organizations that we referred to earlier. Huddles,
course corrections, pull-backs are all part of knowing when we’re reaching boundaries of exceedency.

Red rules put a hard stop on boundaries. For example, hospital-wide two patient identifiers, hand hygiene
each time, every time. Requirements of Time out/Universal Protocol and site verification within operative
and procedural environments. Telemetry: monitoring alarms audible at all times. And environmental
services: never ever mix chemicals. They’re a few but powerful, and they begin to set the minimum
requirements of a safety boundary.

Executive WalkRounds reinforce safety boundaries and are another way to learn about the environment
and answer questions about whether it’s a safe environment to give and receive care. Leadership is
important. Teams will not develop and work effectively without the support of leaders and a shared
commitment to safety.

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This is also an opportunity to identify resilience and sources of success. The ability of teams to recover is
as important to patient safety as prevention. In complexity, there will always be new and novel
experiences and conditions. And the team that is able to communicate, constantly aware of their situation
and able to anticipate where gaps of care will be, are those that will be able to be resilient and intervene
to deflect an error from reaching a patient.

Back to questions for leaders. As you consider the information covered in this module, take this back to
your environments and ask the questions: Is this a safe place to give and receive care? Does your culture
allow employees to tell the truth? How do you know? What are you measuring? What are you monitoring?
What’s your feedback circle? And what’s your learning architecture? And further, can everyone in your
organization answer “yes” to the questions: Am I recognized, respected regardless of my pay grade, my
role, or any other characteristic? Do I have the knowledge, tools and support to do my job? And am I
acknowledged for the job that I do and thanked for my contribution?

Thank you for participating in Module 5.

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