Learning from the IFC IQ-Healthcare webinars

I am glad to share some key takeaways from our previous webinar on Healthy Culture: How to Balance Blame-free with Accountability.

HEALTHY HOSPITALS: FROM SHAME AND BLAME TO FAIR BLAME

Changing Culture to Ensure Patient Safety

Imagine a doctor convicted of manslaughter for a mistake that resulted in his patient’s death. Imagine the fallout, cost, and reputational damage. Who was blamed? Usually, the doctor.

In the 1990s, things changed. The healthcare industry and medical professionals recognized that mistakes were caused by a lack of safety protocols. Finger pointing and blame stopped. Staff were encouraged to report incidents. Hospitals put in risk management structures and training. A fair blame culture emerged.

Below, are a few things to consider when working to change culture: What should leaders do? What are the best practices to report incidents? How should mistakes be analyzed?

First: Leaders do not produce organizational excellence by themselves, but they can destroy

a safety culture alone, thus leadership commitment is critical. What is the senior leader’s role:

·      Encourage staff to report errors and reward them for speaking up.

·      Be patient: creating a safety culture takes time and communication.

·      Do not blame staff; instead look for system errors and train them.

·      Establish model behavior, rules and clear policies.

Second: Team efforts aimed at improvement help create an atmosphere of “no fear,” thus it is essential to:

·      Empower staff: Give them the right to report an incident. Encourage, educate, and define clear directions. Report not just “what happened” but also “what could have happened,” i.e. near misses and close calls.

·      Differentiate between human and systemic errors. Human mistakes are often caused by staff fatigue and work overload. Systemic mistakes are often caused by poorly designed, imperfect protocols and inadequate communication.

·      Learn from failures. Share lessons learned and the results of root cause analysis with all teams.

·      Use tools: “Lesson of the Month,” or “Reporter of the Month.”

Third: Every mistake has two sides: individual and system level. There are more system level factors because protocols and procedures are usually inadequate, thus staff must:

·      Use root cause analysis when staff make mistakes. This will help identify the real cause of the mistake, and not point to the person.

·      Use a multidisciplinary team to perform the root cause analysis. Include key stakeholders and subject matter experts.

·      Use the fishbone method: look at process, technology, environment and people. Ask the “5 Whys” and – be open and not confrontational. Keep asking “why” until it points to the problem in the system or a lack of protocols.

·      Blame the system, not the person.

This publication is based on the IFC IQ-Healthcare webinar “Healthy Culture: How to Balance Blame-free with Accountability.” To learn more, please watch this webinar on our YouTube channel: https://www.youtube.com/watch?v=uPyshxj4RTw

In this webinar:

Gunnar Németh, PhD, Co-Founder and Chairman of the Board at Stockholm Center for Spine Surgery:

00:8:20 – A Culture for Quality in Healthcare

 Eric Woo, ECRI’s Regional Director, Asia Pacific Region

 00:28:29 – Introducing ECRI’s Learning Model to Patient Safety

Dr. Olujimi Coker, CEO of Lagoon Hospitals, Lagos, Nigeria

1:07:52 – Healthy Culture: Balancing Blame-Free with Accountability

#IFC #patientsafety #patientcare #hospitalsafety #justculture #protocols #training #noblameculture