Organizational Culture and Patient Safety Julie Kennedy Oehlert DNP RN Vice President of

1. Organizational Culture and Patient Safety Julie Kennedy Oehlert DNP RN Vice President of Patient Experience University of Arizona Health Network

2. We Made the front cover

3. Learning Objectives: • Understand why healthcare culture has such an effect on safety, quality and the patient experience • Learn how to assess where your organization's culture and use that knowledge to impact efforts for a successful healthcare culture • Learn how to strategically move your culture toward actualization and partnership

4. Our Reality • Of 17 high-income countries studied by the National Institutes of Health in 2013, the U.S. had the highest prevalence of: • Infant mortality • Heart and lung disease • Sexually transmitted infections • Adolescent pregnancies • Injuries • Disabilities • Homicides • Such issues place the U.S. at the bottom of the list for life expectancy. On average, a U.S. male can expect to live almost four fewer years than those in other high-income countries

5. Our Reality According to the World Health Organization (WHO), the U.S. spent more on health care per capita ($8,608), and more on health care as percentage of its GDP (17.9%), than any other nation.

6. Our Reality • 99,000 Americans die each year in hospitals from hospital-acquired infections • 40% is the average rate of hand hygiene compliance in American hospitals

7. Our Unspoken Reality • Data cannot change your opinion if your belief is ZERO • We fit evidence into our beliefs and filter out evidence that does not fit our beliefs • It is rarely about evidence or about the facts

8. Health Care Culture Your Mission Here: __________________ Your Vision Here:____________________ “How We Do Things Around Here” “How Relationships are Structured”

9. Health Care is complicated ( Source: Life Magazine, 1993

10. Health Care Strategies for Safety • TeamSTEPPS • Just Culture • Culture of High Reliability • Human Factors Adaptive versus Technical Change Technical change involves people putting in place solutions to problems for which they know the answers. Adaptive change involves changing more than routine behaviors or preferences; it involves changes in people’s hearts and minds. Culture

11. Training (again and again) vs Culture Training is Appropriate TRAINING IS INAPPROPRIATE • Need to become familiar with new technology, tools or devices • Need to develop and test new techniques, or practice in low risk environment • Practice or test procedures for emergency situations • Stop staff from using technologies, tools or devices in the wrong way • Attempt to change innate human characteristics “be more vigilant” • Previous training has been done and problem persists The Science of Human Factors: Separating Fact From Fiction Russ, Fairbanks, Karsh, Militello,Saleem & Wears, 2012

13. Fear Hierarchy The Lens of Domination Power

14. Disrespectful Behaviors Most Often Encountered During the Past Year: NurseAdvise-ERR. (2013). Unresolved disrespectful behavior in healthcare. ISMP Medication Safety Alert, 11 (10),

15. Disrespectful Behaviors Least Frequently Encountered at Least Once During the Past Year: NurseAdvise-ERR. (2013). Unresolved disrespectful behavior in healthcare. ISMP Medication Safety Alert, 11 (10),

16. Study of nurses, pharmacists, others: • 50% reported experiences with intimidation changed how they handle questions about medication orders • 40% who had concerns about safety of medication said at least once in past year they assumed it correct instead of interacting with an intimidating prescriber “Fear Obscures Facts and Limits Innovations” Eisler, R. & Potter, T., 2014 Transforming Interprofessional Partnerships

17. Domination / Partnership Continuum “Power Over” “Power With”

18. What is Interprofessionality? • Interprofessionality is defined as the process by which professionals reflect on and develop ways of practicing that provides an integrated and cohesive answer to the needs of the client/family/population • It involves continuous interaction and knowledge sharing between professionals, organized to solve or explore a variety of education and care issues all while seeking to optimize the patient’s participation. D’Amour and Oandasan (as cited in Institute of Medicine, 2011)

19. History of Interprofessionality • 1972 • IOM conference “Educating for the Health Care Team” leaders from medicine, dentistry, nursing, pharmacy and allied health gathered to reflect how to use the existing work force optimally and cost-effectively • 2006 • ACGME published 6 Core competencies that included professionalism and interprofessional skills and communication • Essentials of Doctoral Education for Advanced Nursing Practice describes interprofessional collaboration as the path to improve patient and population health outcomes • 2010 • IOM report “The Future of Nursing Leading Change and Advancing Health” identifies interprofessionality as one of its four key messages

20. Interprofessionality The Domination/Partnership Continuum • “Power Over” • Hierarchies of control • Superior/Inferior relations • Dominate or be dominated (only two relationships) • Maintain ranking • Not all roles are equal in value • “Power With” • Hierarchies of actualization • Relations of mutual respect and mutual benefit • Shared focus on nurturing and values • Partnership • All roles are valuable Eisler, R. & Potter, T., 2014 Transforming Interprofessional Partnerships

21. Cooper “I stressed the importance of working well between disciplines. Two terms were used throughout the day: “Power Over” and “Power With” “Power Over” is when there is a hierarchy between the departments. If one doctor thinks his discipline is more important than another, overall care is thwarted and the patient suffers  “However, if all disciplines work together in a “Power With” approach, care is enhanced and the patient benefits greatly. As the saying goes, “None of us is as smart as all of us!” 

22. What “Power Over” CostsBecause…Who is at the Bottom of Your Hierarchy? • Turn Over costs • Legal costs • Access costs • Compliance costs

23. Health Care Culture “How We Do Things Around Here”

24. Assess: Surveys • Many engagement surveys and culture surveys have questions that help interpret or understand the continuum of domination / partnership culture.

25. Assess: Ask Staff and Physicians Accountability Collaboration Cohesion Teamwork Respect Focus on Patient Alignment Decision-making Communication Agreement Empowerment Them/Us Disruptive Behaviors Insincere Reactive Controlling Trust Win/Lose Pressure Culture Clash There is None Independent Mean-spirited Dictating to Others Silos Fear Competitive Inauthentic Out or Self Hierarchical Fragmented Learning Insecurity Confused Hostile Formal Resentment Blame Inconsistent Protective Chaotic Disdainful Arrogant

26. Assess: Ask the patients

27. Assess: Root Cause Analysis

28. Assess: Where on the continuum? In the organization or workplace where you are employed, how are relationships structured? “Power Over” Domination “Power With” Partnership 1 2 3 4 5

29. Change: Strategic Goal Setting • Who is at the table? • Ask the question… • Do goals reflect mission, vision, and values? • Ask the question…

31. Change: Leadership and Development • Leadership Goals • Do leaders carry interprofessional goals? • Are leaders held accountable for engagement? • Turnover • Recruitment • Incidents of lateral violence • Leadership Development • Who is included? • Is it interprofessional? • Is partnership valued? • What communication training/coaching training do leaders have?

32. Change: Policy and Procedures

33. Change: Behavioral Based Interviewing Add a section to behavioral based interview questions on interprofessionality: • “Tell me about a time when you saw a colleague bullying another colleague” • “What did you feel/ what did you doand what was the outcome?” • “Tell me about an incident when someone who reported to you complained about another discipline in a disparaging way” • “What did you do and what was the outcome?” • “Describe a time when you had to engage another profession / specialty in a issue that impacted safety and quality” • “What were your strategies to engage them and what was the outcome?”

35. Julie KennedyOehlert DNP RN Vice President of Patient Experience University of Arizona Health Network Julie.kennedyoehlert@uahealth.com Office: 520 694 6099 Thank you!