David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company and TDC Group
Despite more than 20 years of focus on patient safety, many hospitals and healthcare professionals still struggle to create an environment that engenders patient safety and reduces harm. Many medical professionals encounter a confusing array of programs and tools that are touted as necessary, such as team training, simulation, root cause analyses, and efforts to promote a just culture. They struggle with deciding where to focus and whether to recruit support from senior leadership or buy-in from other clinicians. At TDC Group, we believe there are four elements to creating a culture of safety, and everything begins with mutual respect. We then focus on optimizing how people, teams, and systems function, understanding how people think to keep them engaged during training, and finally, being sure that all providers are viewed through a just-culture lens. To help us explore each of these areas, I asked four experts for their stories from the trenches for the TDC Group Leading Voices in Healthcare podcast series. Each of these longtime patient safety leaders has deep experience in organizational change.
Building Mutual Respect in a Culture of Safety
When I interviewed Michael Brodman, MD, Professor and Chair Emeritus in the Raquel and Jaime Gilinski Department of Obstetrics, Gynecology and Reproductive Science at the Icahn School of Medicine and Senior Vice President for Professional Excellence, Mount Sinai Health System, New York, NY, he described some of the wakeup calls that showed him the connection between mutual respect and patient safety. One happened years ago: “We did a survey on the labor floor. And this was shocking: 75 percent of the nurses said that if they saw a doctor doing something wrong, they wouldn’t say something,” because “they were afraid that somebody would yell at them or they’d get fired.” But after five-plus years of work on the institution’s culture, that figure had dropped to between 10 and 15 percent: “Basically, the point was, the nurses felt comfortable working on the floor.” Dr. Brodman says that when the labor floor team “created a just, level playing field, morale went up, and not surprisingly, adverse outcomes went down.”
To hear more of the story behind the creation of the Mount Sinai Code of Professionalism, listen to my conversation with Dr. Brodman.
High-Performance Teams—Crucial for a Culture of Safety
Once upon a time, Michael Leitman, MD, Professor of Surgery and Medical Education and Dean for Graduate Medical Education at the Icahn School of Medicine at Mount Sinai, New York, NY, traveled with his team into the then-unknown world of TeamSTEPPS® training when they decamped from Mount Sinai Beth Israel in New York to Virginia for a week.
Dr. Leitman told me some of what he’s learned about high-performance teams over his years as a surgeon, as an institutional leader, and as a medical educator. His experiences highlight the value of performing a readiness assessment prior to training, the struggle to overcome team member skepticism, and the value of reaching medical professionals early in their careers. He thinks that residents need to understand that "essential to patient safety is teamwork and interprofessional performance. It’s just part of the way we practice caring in hospitals—with the complexity of healthcare being what it is, that is just essential.”
To continue your journey with your own high-performance team, listen to my conversation with Dr. Leitman.
To Build a Culture of Safety, Use Human Factors Engineering
Amish Aghera, MD, emergency medicine physician and the Director for the Center for Clinical Simulation and Safety and the Simulation Fellowship at Maimonides Medical Center in Brooklyn, NY, had what he described as “an existential moment” when testing revealed that medical residents were retaining a lower proportion of his training content than he’d hoped. He thought, “Am I just bad at this thing? Are our residents bad? And you know, the truth was neither. It just has to do with how we think as human beings.” From there, seeking training methods “to keep people engaged,” Dr. Aghera honed his skills in simulation training, and then in human factors engineering, which creates physical workspaces and workflows to support clinical decision making, teamwork, and patient safety. Dr. Aghera describes a variety of potential system interventions that institutions can consider, from the very low-tech to the innovative high-tech.
Dr. Aghera also addressed the necessity of considering large-scale organizational factors to make change: “Who are the people who are going to get things moving at a higher administrative level . . . and who are you going to work with? Who’s that working coalition, so to speak?” To learn more about simulation training, human factors engineering, and organizational change, listen to my interview with Dr. Aghera.
Just Culture Enables a Culture of Safety
Elizabeth Duthie, RN, PhD, told me, “I always like to tell clinicians who are joining us that we expect that despite their best well-intentioned efforts, that errors are going to occur. Because that’s what happens to humans.” Dr. Duthie, Director of Patient Safety at Montefiore Medical Center, Bronx, NY, discusses how important a just culture is to creating a culture of safety. “If something bad happens, we want to learn from it,” she says—and in the absence of a just culture, many risks and near-misses go unreported. Dr. Duthie emphasizes that clinicians and staff need to experience psychological safety to report, and also to see the benefits of reporting risks. This includes knowing they can count on reliable follow-up: “When they put in an event report and it goes into a black hole and they never hear back from it, it says to them, ‘What I have to say doesn’t matter.’”
While just culture has always been critical to safety culture, many are particularly aware of this need today, given the recent criminal conviction of a former nurse for a medical error, which Dr. Duthie and I discussed. To learn more about the journey to a just culture, listen to my interview with Dr. Duthie.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
