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Slide 2 Unit 3 Reliability, Culture of Safety, & HIT Component 12 Unit 31CIDG Health Care Curriculum Slide 3 Objectives Discuss reliability science as a tool for ensuring safety Examine how ultra safe organizations operate Identify how teams make wise decisions Component 12 Unit 32CIDG Health Care Curriculum Slide 4 Reliability Component 12 Unit 33CIDG Health Care Curriculum Slide 5 Reliability EvaluateCalculateImprove Component 12 Unit 34CIDG Health Care Curriculum Slide 6 Reliability Prevent Failure Best practice guidelines, tools, techniques Awareness campaigns Memory aids Checklists Making the desired action the default Component 12 Unit 35CIDG Health Care Curriculum Slide 7 Reliability Identify and Mitigate Failure Reduce fatigue and distraction Standing orders for best practice treatments Electronic flags Independent double-checks Redesign for Success Understand where the failure is occurring Determine the remedy Component 12 Unit 36CIDG Health Care Curriculum Slide 8 High Reliability Organizations Hyper-complexTightly coupledHierarchical differentiationMultiple decision-makers Component 12 Unit 37CIDG Health Care Curriculum Slide 9 High Reliability Organizations Complex communicationHigh accountability Need frequent, immediate feedback Compressed time constraints Component 12 Unit 38CIDG Health Care Curriculum Slide 10 High Reliability Organizations Mindfulness Component 12 Unit 39CIDG Health Care Curriculum Slide 11 High Reliability Organizations Sensitivity to Operations Component 12 Unit 310CIDG Health Care Curriculum Slide 12 High Reliability Organizations Reluctance to Simplify Component 12 Unit 311CIDG Health Care Curriculum Slide 13 High Reliability Organizations Preoccupation with Failure Component 12 Unit 312CIDG Health Care Curriculum Slide 14 High Reliability Organizations Preoccupation with Failure Component 12 Unit 313CIDG Health Care Curriculum Slide 15 High Reliability Organizations Resilience Component 12 Unit 314CIDG Health Care Curriculum Slide 16 Culture the shared perceptions of the individuals within the team or an organization about what is good, right, important, valued, supported, or expected at any given time. Component 12 Unit 315CIDG Health Care Curriculum Slide 17 The Blame Game Pointing the finger at people rather than systems Component 12 Unit 316CIDG Health Care Curriculum Slide 18 Blame Stop talking Learn less Improve less Mistakes continue Vicious Cycle Component 12 Unit 317CIDG Health Care Curriculum Slide 19 Blame Limits learning Increases likelihood of repeat errors Drives self-reporting underground Culture of Blame Culture of Safety Component 12 Unit 318CIDG Health Care Curriculum Slide 20 Just Culture Focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors Maintains individual accountability by establishing zero tolerance for reckless behavior Distinguished between human error, at-risk behavior, and reckless behavior Response to error or near miss is predicated on the type of behavior associated with the error, not the severity of the event Component 12 Unit 319CIDG Health Care Curriculum Slide 21 How to Promote a Culture of Safety Accept responsibility Value learning from mistakes Learn to recognize risky behaviors Component 12 Unit 320CIDG Health Care Curriculum Slide 22 How to Promote a Culture of Safety Speak up if something is not right Listen to others & discuss ways to prevent error Take action to reduce risk Component 12 Unit 321CIDG Health Care Curriculum Slide 23 How to Promote a Culture of Safety Report errors & near misses Encourage others to report errors & near misses Help change unrealistic policies Component 12 Unit 322CIDG Health Care Curriculum Slide 24 Culture of Safety Characteristics Carefully LISTEN to the concern to determine if corrective action is necessary Recognize when a concern is expressed by anyone and STOP Component 12 Unit 323CIDG Health Care Curriculum Slide 25 Culture of Safety Component 12 Unit 324CIDG Health Care Curriculum