Residency Insight -- A PRESENT Podiatry eZine

Creating an Environment of Honesty
and Integrity in your Hospitial

Jay Lieberman, DPM, FACFAS

Genie Lieberman,
MS, MBA,OTR/L

It took sixteen years between "2001 A space Odyssey" and its sequel 2010; Odyssey II for us to learn why the "mistake proof" computer, Hal 9000, failed. In the sequel, astronauts and computer engineers discovered that the Hal 9000 was given conflicting information and ordered to conceal salient information about the true purpose of the mission. Hal was designed for "the accurate processing of information without distortion or concealment." When Hal was forced to deal with a contradiction and keep a secret, his personality "degraded to paranoia" and he failed. The human crew's decision to abort the mission contributed to HAL's failure, because he had been programmed to guarantee the success of the mission.

Joe Orman's HAL 9000: A Logical Progression to Breakdown. Read more

Most nurses, physicians, residents, and technical staff have a desire to do their best work in helping patients.

Similar dilemmas can occur with hospital employees. Most nurses, physicians, residents, and technical staff have a desire to do their best work in helping patients. Unfortunately, the harsh realities of our health care environment can influence staff members in a negative way. If not communicated well, initiatives related to productivity goals, cutbacks and layoffs could result in situations where staff becomes misdirected from safe and effective patient care.

Can a residency director expect an accurate interpretation of the facts by his/her residents, even if it means two more on call hours in the hospital? Is the environment conducive to the resident feeling comfortable reporting his or her mistakes? Can the resident come to the director with mental health issues, substance abuse or family issues, which may be affecting their ability to carry out their job effectively?

Or let's say a cephalosporin was inadvertently prescribed in the face of a Penicillin allergy. Will the resident stop, admit his mistake and immediately rectify the problem?

If a patient is surprised to find a cast on his foot after surgery, will the resident be able to comfortably report to the patient that a minor complication occurred in surgery which necessitated a cast be put on the foot?

A recent article in the Annals of Internal Medicine¹ points out that the culture of an organization has an enormous impact on patient outcomes. The senior author and facility director of the Yale Global Health Leadership Institute at Yale University, Elizabeth Bradley, states "It's how people communicate, the level of support and organizational culture that trump any single intervention or any strategy that hospitals frequently adopt." This study also pointed to the fact that the approach to challenging patient care issues seemed to set hospitals apart.

An error at a low-performing hospital might result in clinicians blaming each other and the administrators trying every way to stay uninvolved. In contrast, the clinicians and administrators at high-performing hospitals would be eager to address the error and acknowledge it without disparaging each other. Then they would work together to reexamine and, if necessary, reconfigure the process in question.

It was the approach to challenging patient care issues that seemed to set institutions apart. A hospital might discover, for example, that a heart attack patient that returned to the hospital with severe edema, or swelling, might have been discharged without her prescribed diuretic.

"The difference is very powerful," Dr. Bradley noted. "Even top hospitals had problems that would make your hair stand on end; but then it is like choreography when they all get together to figure out what went wrong."²

A CULTURE OF SAFETY

Residents in attendance at one of a variety of Podiatric Workshops.

An environment in which individuals feel comfortable drawing attention to potential hazards or actual failures without fear of censure from management creates a CULTURE OF SAFETY. How do you address this at your hospital?

The Agency for Healthcare Research and Quality has several great Safety Primers and one in particular on building a culture of safety. One can apply the ideas to a department, a division, or most ideally, an entire organization. The authors of the primer emphasize the concept of buy-in at all levels. They point out that organizations that consistently minimize adverse events have a commitment to safety from frontline providers to the top administrators.

This commitment establishes a "culture of safety" encompassing these key features:

acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations
a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
organizational commitment of resources to address safety concerns³

JUST CULTURE

What steps can you take to develop a culture of safety? Possibly help create a Just Culture. The term Just Culture has its origins in aviation and health care, where accidents caused by human and system errors can have tragic results, A Just Culture is marked by an awareness that it is safe to report and learn from mistakes. It promotes safety by facilitating open communication within an organization and setting up a system of accountability that encourages safe behavior.

Building a culture of trust is a very complex and important undertaking. As a leader, it is important to encourage the free exchange of ideas, reporting of errors and collaborative problem solving. For this effort, you may want to look at the work of David Marx, one of the leading authorities on the topic. He describes it this way:

On one side of the coin, it is about creating a reporting environment where staff can raise their hand when they have seen a risk or made a mistake. It is a culture that rewards reporting and puts a high value on open communication—where risks are openly discussed between managers and staff. It is a culture hungry for knowledge.

On the other side of the coin, it is about having a well-established system of accountability. A Just Culture must recognize that while we as humans are fallible, we do generally have control of our behavioral choices, whether we are an executive, a manager, or a staff member. Just Culture flourishes in an organization that understands the concept of shared accountability—that good system design and good behavioral choices of staff together produce good results. It has to be both.⁴

If your hospital or institution has already embarked on this course, take the opportunity to participate and contribute to improved patient safety. If your hospital is not there yet, you may have a chance to bring a significant initiative to the leadership.

Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum.

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REFERENCES:

Bradley EH. et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Ann Intern Med. 2011 Mar 15;154(6):384-90

Chen, P., MD (March 17, 2011) What Makes a Hospital Great. The New York Times Doctor and Patient: What Makes a Hospital Great - NYTimes.com

AHRQ Patient Safety Network - Safety Culture High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work. Such organizations establish a culture of safety by maintaining a commitment to safety at all levels, from frontline providers to managers and executives.