AdiósNeumonías:PrevenirlasesPosible

5taSesióndeAprendizaje 23defebrerode2016

“¿Por qué la cultura es clave para mejorar la calidad de atención al paciente en su organización?”

Dr.EzequielGarcíaElorrio

Sobreloserroresysusolución“La gente comete errores , que conducen a accidentes. Accidentes que pueden conducir a la muerte”. La solución estándar es culpar a la personas involucradas . Si descubrimos quien cometió errores y los castigamos, se resuelven los problemas , ¿no? Mal. El problema es rara vez el fallo de un individuo; es el culpa del sistema. Cambiar las personas sin cambiar la sistema y los problemas continuarán" .

2

CulturadeSeguridad

La cultura de la seguridad de una organización es el producto de los valores individuales y grupales, actitudes, percepciones, competencias y patrones de comportamiento que determinan el compromiso, el estilo y dominio de la salud de la organización y la gestión de la seguridad.

Health and Safety Commission (HSC). Organizing for safety: Third report of the human factors study group of ACSNI. Sudbury: HSE Books, 1993.

Cultura y AN 3

CulturadeSeguridad

•  Las organizaciones con una cultura de seguridad positiva se caracterizan por comunicaciones basadas en la confianza mutua, por percepciones compartidas de la importancia de la seguridad y la confianza en la eficacia de la prevención medidas.

Health and Safety Commission (HSC). Organizing for safety: Third report of the human factors study group of ACSNI. Sudbury: HSE Books, 1993.

Cultura y AN 4

ComponentesJames Reason define cuatro componentes básicos relacionados con la voluntad de los empleados en reportar errores como elemento clave de la cultura: 1.  Promoción organizacional del reporte del error. 2.  Habrá reconocomiento por el reporte de error y castigo por

actitudes inseguras voluntarias. 3.  Hay respeto por el conocimiento de los empleados por

aspectos relacionados con la seguridad. 4.  Hay confianza en que los reportes serán analizados y se

implementarán medidas de cambio. La interacción de estos componentes definen un organización segura y altamente confiable.

Cultura y AN 5

Cuandolaculturadeunaorganizaciónesconscientedeloserroresysehabladeellos,entoncesla

seguridadmejora

Cultura y AN 6

7

¿Porquécultura?•  Porserlallaveparacualquierinicia1vademejoraanivelins1tucional.

•  Porrelacionarseconliderazgo.•  Porinvolucraratodoslosallegadosalaatencióndepacientes.•  Esuneventofinaldeinterésennumerososestudiosdeintervencionrelacionadosconlacalidadylaseguridad.

Cultura y AN 8

Evidenciasobreintervencionessobrelaculturaorganizacional •  Recorridas ejecutivas •  Intervenciones para mejorar el trabajo en equipo •  Capacitacion para mejorar la comunicacion entre

profesionales.

•  -La evidencia no da señales consistentes por resultados heterogeneos-.

Cultura y AN 9

Promoting a Culture of Safety as a Patient Safety StrategyA Systematic ReviewSallie J. Weaver, PhD; Lisa H. Lubomksi, PhD; Renee F. Wilson, MS; Elizabeth R. Pfoh, MPH; Kathryn A. Martinez, PhD, MPH;and Sydney M. Dy, MD, MSc

Developing a culture of safety is a core element of many efforts toimprove patient safety and care quality. This systematic reviewidentifies and assesses interventions used to promote safety cultureor climate in acute care settings. The authors searched MEDLINE,CINAHL, PsycINFO, Cochrane, and EMBASE to identify relevantEnglish-language studies published from January 2000 to October2012. They selected studies that targeted health care workers prac-ticing in inpatient settings and included data about change in pa-tient safety culture or climate after a targeted intervention. Tworaters independently screened 3679 abstracts (which yielded 33eligible studies in 35 articles), extracted study data, and rated studyquality and strength of evidence. Eight studies included executive

walk rounds or interdisciplinary rounds; 8 evaluated multicompo-nent, unit-based interventions; and 20 included team training orcommunication initiatives. Twenty-nine studies reported some im-provement in safety culture or patient outcomes, but measuredoutcomes were highly heterogeneous. Strength of evidence waslow, and most studies were pre–post evaluations of low to mod-erate quality. Within these limits, evidence suggests that interven-tions can improve perceptions of safety culture and potentiallyreduce patient harm.

Ann Intern Med. 2013;158:369-374. www.annals.orgFor author affiliations, see end of text.

THE PROBLEM

Developing a culture of safety is a core element ofmany efforts to improve patient safety and care quality inacute care settings (1, 2). Several studies show that safetyculture and the related concept of safety climate are relatedto such clinician behaviors as error reporting (3), reduc-tions in adverse events (4, 5), and reduced mortality (6, 7).Accreditation bodies identify leadership standards forsafety culture measurement and improvement (8), and pro-moting a culture of safety is a designated National PatientSafety Foundation Safe Practice (9). A search of the Agencyfor Healthcare Research and Quality (AHRQ) PatientSafety Net (www.psnet.ahrq.gov) yields more than 5665articles, tips, and fact sheets related to improving safetyculture. Although much work has focused on promoting aculture of safety, understanding which approaches are mosteffective and the implementation factors that may influ-ence effectiveness are critical to achieving meaningful im-provement (10).

Drawing on the social, organizational, and safety sci-ences, patient safety culture can be defined as 1 aspect of anorganization’s culture (11, 12). Specifically, it can be per-sonified by the shared values, beliefs, norms, and proce-dures related to patient safety among members of an orga-nization, unit, or team (13, 14). It influences clinician andstaff behaviors, attitudes, and cognitions on the job byproviding cues about the relative priority of patient safetycompared with other goals (for example, throughput orefficiency) (11). Culture also shapes clinician and staff per-ceptions about “normal” behavior related to patient safetyin their work area. It informs perceptions about what ispraiseworthy and what is punishable (either formally bywork area leaders or informally by colleagues and fellowteam members). In this way, culture influences one’s mo-tivation to engage in safe behaviors and the extent to whichthis motivation translates into daily practice.

Patient safety climate is a related term—often inadver-tently used interchangeably with culture—that refers spe-cifically to shared perceptions or attitudes about the norms,policies, and procedures related to patient safety amongmembers of a group (for example, care team, unit, service,department, or organization) (11). Climate provides asnapshot of clinician and staff perceptions about the ob-servable, surface-level aspects of culture during a particularpoint in time (10, 15). It is measured most often using aquestionnaire or survey. Clinicians and staff are askedabout aspects of their team, work area, or hospital, such ascommunication about safety hazards, transparency, team-work, and leadership. Because climate is defined as a char-acteristic of a team or group, individual responses to surveyitems are usually aggregated to form unit-, department-, orhigher-level scores. The difference between culture and cli-mate is often reduced to a difference in methodology.Studies involving surveys of clinicians and staff are catego-rized as studies of safety climate, and ethnographic studiesinvolving detailed, longitudinal observations are catego-rized as studies of safety culture. The terms are often usedinterchangeably in practice, but it is important to remem-ber that there are conceptually meaningful differences intheir scope and depth. For the purpose of this review, stud-ies of both patient safety culture and climate were in-cluded. We use the term patient safety culture in discussiononly to simplify the reporting of results.

Given that safety culture can influence care processesand outcomes, efforts to evaluate patient safety climate

See also:

Web-OnlyCME quiz (Professional Responsibility Credit)Supplement

Annals of Internal Medicine Supplement

www.annals.org 5 March 2013 Annals of Internal Medicine Volume 158 • Number 5 (Part 2) 369

Downloaded From: http://annals.org/ on 06/26/2013

ClimadeSeguridaddelPaciente

Imagen de los involucrados sobre los aspectos de la cultura: •  Exploración:

•  Encuestas

•  Recorridas ejecutivas

•  Entrevistas

•  Enfoque de mejora: •  Apertura y reporte de incidentes

•  Entrenamiento de los equipos

•  Comunicación y devolución de resultados

•  Capacitación

Cultura y AN 10

Singer SJ, Vogus TJ. Safety climate research: taking stock and looking forward. BMJ Qual & Safety. 2012.

Vigilancia

IniciaRvaspropuestasporIHIparafortalecerlacultura1.  Llevaradelanterecorridasdeseguridad2.  Desarrollarunsistemadereportedeerrores.3.  Designarunencargadodeseguridad(PSO)4.  Actuarenproblemasdeseguridad5.  Involucreapacienteseninicia1vasdeseguridad.6.  Designeauncampeóndeseguridadencadaunidad.7.  Discutaerroresencadapase.8.  Simuleposiblesefectosadversos.9.  Creeunequipoderespuestasanteerrores.10.  Defeedbackalpersonalsobreinicia1vasdeseguridad.

Cultura y AN 11

IHI White Paper on safety culture www.ihi.org

La evolución ante temas de calidad de atención

Cultura y AN 12

Así estamos Bien

¿Quién tiene La culpa?

Pensamiento en procesos

Mejora de procesos

Seguridad del Paciente

Org Alta confiabilidad

No hay acción QA CQI TQM

Reactiva

Proactiva

Elaboraciónpropiadelexpositor

Reacciones ante el cambio •  Losdatosestánmal.•  Losdatosestánbienperonohayunproblema•  Ladatossoncorrectos,esunproblemaperonoesmiproblema.

• Mejoremos…

DonaldBerwick,IHI

www.ihi.org

Cultura y AN 13

Una visión compartida

•  ¿Por qué cuesta tanto?

•  1. Foco en sobreuso y desperdicio •  2. Promocion de herramientas de mejoras de proceso

adaptadas a salud •  3. Intervenir en la cultura organizacional

Cultura y AN 14

By Mark R. Chassin

VIEWPOINT

Improving The Quality Of HealthCare: What’s Taking So Long?

ABSTRACT Nearly fourteen years ago the Institute of Medicine’s report, ToErr Is Human: Building a Safer Health System, triggered a nationalmovement to improve patient safety. Despite the substantial andconcentrated efforts that followed, quality and safety problems in healthcare continue to routinely result in harm to patients. Desired progresswill not be achieved unless substantial changes are made to the way inwhich quality improvement is conducted. Alongside important efforts toeliminate preventable complications of care, there must also be an effortto seriously address the widespread overuse of health services. Thatoveruse, which places patients at risk of harm and wastes resources at thesame time, has been almost entirely left out of recent qualityimprovement endeavors. Newer and much more effective strategies andtools are needed to address the complex quality challenges confrontinghealth care. Tools such as Lean, Six Sigma, and change management areproving highly effective in tackling problems as difficult as hand-offcommunication failures and patient falls. Finally, the organizationalculture of most American hospitals and other health care organizationsmust change. To create a culture of safety, leaders must eliminateintimidating behaviors that suppress the reporting of errors and unsafeconditions. Leaders must also hold everyone accountable for adherence tosafe practices.

Asense of mounting frustration atthe slow pace of improvement inhealth care quality is evident inconversations with many stake-holders lately. Their comments of-

ten go something like this: What’s wrong withour hospitals? They can’t get doctors and nursesto wash their hands despite an epidemic ofhealth care–associated infections. They can’tprevent fires from breaking out in their operat-ing rooms and severely burning patients. Theycan’t stop operating on thewrong patients or thewrongparts of theirbodies.Don’t theyget it?Thepublic is fed upwith all thesemistakes.Hospitalsknow what they have to do.Why can’t they get it

right? It’s not rocket science.The evidence supporting this frustration is

substantial. Hand hygiene in hospitals failsabout 60 percent of the time.1 Communicationacross various transitions of care fails 40 percentof the time or more.2,3 Operating-room fires mayoccur about 600 times every year,4 and theremaybe asmany as fifty wrong-site surgeries per weekin the United States.5 A steady stream of mediastories puts names and faces to individual casesof these failures.6,7

Quality problems such as these have plaguedhealth care for a long time, and in the past alitany of reasons emerged to explain their exis-tence:Health care leaderswere in denial. Quality

doi: 10.1377/hlthaff.2013.0809HEALTH AFFAIRS 32,NO. 10 (2013): 1761–1765©2013 Project HOPE—The People-to-People HealthFoundation, Inc.

Mark R. Chassin (mchassin@jointcommission.org) ispresident and CEO of theJoint Commission, in OakbrookTerrace, Illinois.

October 2013 32:10 Health Affairs 1761

Quality Of Care

by guest on May 27, 2014Health Affairs by content.healthaffairs.orgDownloaded from

Cultura de Seguridad del Paciente-AHRQ-

15

Ingredientes para un cambio exitoso • Apoyo de los líderes – Administración y Ejecutivos

• Compromiso del personal de primera línea • Comités multi disciplinarios • Prueba piloto • Sistemas de información tecnológica • Cambio de actitudes prevalentes • Educación y entrenamiento para apoyar al personal de primera línea

Herram Seg Pac CMIC Nov 15 16

Aquí está la acción

Accountability Teamwork

Leadership

Continuous Learning

Improvement and Measurement

Pat

ient

and

Fam

ily C

ente

red

Car

e

Cul

ture

Lear

ning

Sys

tem

Another Framework

Allan Frankel, USA

Marco conceptual para lograr un cuidado centrado en el paciente

17

Un Marco para la Seguridad: 9 Componentes •  Liderazgo - facilitar y orientar el trabajo en equipo, la mejora, el respeto y

la seguridad psicológica

•  Equipos - ponerse de acuerdo sobre comportamientos específicos

•  Comunicación - transmisión y recepción de información son la misma cosa

•  Responsabilidad - apoyar la seguridad psicológica ya que los empleados

creen que van a ser tratados de manera justa.

•  Seguridad Psicológica

•  Aprendizaje Continuo - proporcionar un cuidado fiable, mediante la aplicación de la mejor evidencia y la minimización de la variación

•  Cuidado Fiable - cuidado continuo y es la responsabilidad de los que

trabajan directamente con pacientes

•  Mejora y Medición - generar calidad, mitigar y eliminar defectos

•  Transparencia

18

Cui

dado

Cen

trad

o en

Pac

ient

es y

Fa

mili

as

Sis

tem

a de

A

pren

diza

je

Cul

tura

Componentes Culturales •  Liderazgo - facilitar y orientar el trabajo en equipo, la mejora,

el respeto y la seguridad psicológica •  Equipos - ponerse de acuerdo sobre comportamientos

Específicos •  Comunicación - transmisión y recepción de información son

la misma cosa •  Responsabilidad - apoyar la seguridad psicológica ya que los

empleados creen que van a ser tratados de manera justa •  Seguridad Psicológica

19

Cui

dado

Cen

trad

o en

Pac

ient

es

y Fa

mili

as

Cul

tura

Componentes del Sistema de Aprendizaje •  El Aprendizaje Continuo - proporcionar un cuidado fiable,

mediante la aplicación de la mejor evidencia y la minimización de la variación

•  Cuidado Fiable - cuidado continuo y es la responsabilidad de los que trabajan directamente con pacientes

•  Mejora y Medición - generar calidad, mitigar y eliminar defectos

•  Transparencia

20

Cui

dado

Cen

trad

o en

Pac

ient

es

y Fa

mili

as

Sis

tem

a de

A

pren

diza

je

¿Elmodelodelaculturajusta?•  Crearunaculturaabiertayequita1va.•  Crearunaculturadeaprendizaje• Diseñarsistemasseguros• Manejardecisionesdeconducta

Cultura y AN 21

Eventos adversos

Errores Humanos

Decisiones Del staff

Diseños De sistemas

Cutura de aprendizaje/Cultura Justa

El problema

Cultura y AN 22

Soporte de la seguridad del

sistema

Cultura sin castigos

Cultura de castigo

Aplicada a: • Proveedores • Gestores • Instituciones • Regulaciones

Que sistema de responsabilidad

puede aplicarse?

Respuestadelaculturajusta

Seguridaddelpacienteyculturajusta•  Losestudiosmuestranquelaculpaindividualestodavíadominantepesealaliteratura

•  “Sinculpa”eslaposturaadecuadaparaerroresrelacionadosconelsistema.Pero¿quépasaconlaconductaimprudenteoactosintencionalesqueconducenaldaño?

•  Algunoserroresdemandanderendicióndecuentasylateoríaculturajustaesqueelequilibrio

•  Establecerlatoleranciaceroparaelcomportamientoimprudente,comoignorartodaslasmedidasdeseguridadpuestasenmarcha,parecenserpartedelcamino

23

CulturaJusta• Laculturajustareconoceladiferenciaentreelerrorhumano(comolosresbalones),lasconductasderiesgo(porejemplo,tomaratajos),yelcomportamientoimprudente(comoignorarlasmedidasdeseguridadnecesarias,comolacodificacióndebarrasytenerdrogasdobleverificacióndealtoriesgoporsegundapersona),encontrasteconalenfoque"sinculpa”

• Esimportanteseñalarquelarespuestanosebasaenlaseveridaddelevento–Sihuboonodaño-

24

Culturajusta•  ¿Quieres crear una cultura abierta , justa y equitativa?

•  Haz que el personal se sientan cómodos de informar y tratar errores

•  ¿Quieres crear una cultura de aprendizaje ? •  Tenemos que aprender de nuestros errores y asegurarse de que el

personal esté consciente de lo que sucede en nuestras instalaciones

•  ¿Quieres crear sistemas seguros? •  Los tiempos fuera , codificación de barras con eMAR , doble

control de los medicamentos de alerta elevados , limitar el trabajo de enfermería a 60 horas a la semana para evitar la fatiga , etc.

25

PrincipiosdelaCulturaJusta•  ValoresyExpecta1vasdeloqueesimportanteparalaorganización

•  Sistemadediseño-con1nuoyrediseñodelsistemaydelosprocesos

•  Coachingyentornoabierto•  Intercambiodeinformacióndeentrenamientoparaayudarseunosaotrosamantenerlaseguridadyhacerquelascosasseestánhaciendocorrectamente

26

27

Errareshumano…

28 The Just Culture Community

Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.Copyright 2007, Outcome Engineering, LLC. All rights reserved.Copyright 2007, Outcome Engineering, LLC. All rights reserved.

To Err is Human

Desviarseeshumano

29

The Just Culture Community

Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

To Drift is Human

Errorhumanoeinteracciónconeldesvío•  Lasconductasderiesgoqueelegimosnoshacenmáspropensosaerroreshumanos•  Porejemplo:manejarhablandoporteléfono.

•  Elrendimientotambiénnoshacemáspropensoaunerrorhumano•  -Porejemplo:fa1ga

Cultura y AN 30 The Just Culture Community

Copyright 2009 Outcome Engineering. Strictly for the purpose of presentation. Do not reproduce, distribute or transmit electronically without written permission.

Human Error and Drift Interaction• At risk behaviors we choose make us

more prone to human error– e.g. driving in a residential neighborhood

• Performance shaping factors also make us more prone to human error– e.g. fatigue

Actitudes dentro de la cultura justa •  ErroresHumanos-resbalones,caducidad,etc.Ges1onaratravésdeprocesos,procedimientos,formaciónydiseño-CONSUELA

•  Comportamientoderiesgo-unaopciónderiesgoquenosereconoceonosecreejus1ficado.Ges1onaratravésdelaeliminacióndelosincen1vosparaelcomportamientoderiesgoylacreacióndeincen1vosparaloscomportamientossaludablesyelaumentodelaconcienciasituacional-ACONSEJA

•  Comportamientoimprudente-Comportamientoconscientededespreciodelriesgoirrazonable.Ges1onaratravésdemedidascorrec1vasopuni1vasacciónSANCIONAR

31

ManejandoRiesgo:Tresconductas

Cultura y AN 32

Conducta de riesgo

Búsqueda de riesgo no-intencional

Conducta descuidada

Búsqueda de riesgo intencional

Gestionar con

•  Cambios disciplinarios

Gestionar con :

• Entender riesgos

• Evitar incentivos

• Crear incentivos para reducir riesgos

• Aumentar monitoreo situacional

Error Humano

Producto del error de diseño

Gestionar con :

• Procedimientos

• Procesos

• Entrenamiento

• Diseño

• Ambiente

DefinicióndeconductadisrupRvaComportamiento que interfiere con el trabajo o crea un ambiente hostil, por ejemplo : abuso verbal, acoso sexual, gritos, groserías , vulgaridades, amenazantes palabras/acciones; contacto físico no desead; amenazas de daño ; comportamiento razonablemente interpretado como intimidante conductas agresivas pasivas: mal comportamiento que crea ambientes estresantes e interfiere con el funcionamiento eficaz de los demás

Cultura y AN 33

Vanderbilt University and Medical Center Policy #HR-027

33

Categorias del comportamiento disruptivo

34

Agresivo(MásVisible)

Episodiodeenojo,Amenazas,InsultarContactoFísico,TirarCosasAcosoSexual

PasivoAgresivo

Comentariossobreelhospital,grupo,etc.Rechazartareas

Pasivo(Máscomún)

LlegartardeUsoinadecuadousodeHC.“Brazoscaídos”

SamenowCP.SwiggartW.SpickardAJr.ACMEcourseaimedataddressingdisrupRvephysicianbehavior.PhysicianExecuRve.34(1):32-40,2008.

¿Por qué preocuparse por esto?

Losmiembrosdelequipoadoptanunestadodeánimonega4vo/ira(DimbergyOhman,1996)Laconfianzadisminuyeentrelosmiembrosdelequipoquepuedenconduciralaejecucióndetareasdisminuida...Afectaalacalidadyseguridaddelpaciente(LewickiyBunker,1995;Wageman,2000)

Cultura y AN 35

35

Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175-222.

La falla en identificar y atenuar este fenomeno lleva a:

Patrón aparente

¿Incidente aislado?

”Informal: Tomarse un

café”

Nivel 1: “Accion de advertencia”

Nivel 2 “Accion de autoridad”

Nivel 3 “acción disciplinaria”

Persiste

Patrón

No ∆

Gran mayoría sin problemas

Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007

PirámidedelaconductadisrupRva

Cultura y AN 36

ABSTRACT Medical errors continue to occur despite multiple strategies devised for their prevention. Although many safety initiatives lead to improvement, they are often short lived and unsustainable. Our goal was to build a culture of patient safety within a structure that optimised teamwork and ongoing engagement of the healthcare team. Teamwork impacts the effectiveness of care, patient safety and clinical outcomes, and team training has been identified as a strategy for enhancing teamwork, reducing medical errors and building a culture of safety in healthcare. Therefore, we implemented Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), an evidence-based framework which was used for team training to create transformational and/or incremental changes; facilitating transformation of organisational culture, or solving specific problems. To date, TeamSTEPPS (TS) has been implemented in 14 hospitals, two Long Term Care Facilities, and outpatient areas across the North Shore LIJ Health System. 32 150 members of the healthcare team have been trained. TeamSTEPPS was piloted at a community hospital within the framework of the health system’s organisational care delivery model, the Collaborative Care Model to facilitate sustainment. AHRQ’s Hospital Survey on Patient Safety Culture, (HSOPSC), was administered before and after implementation of TeamSTEPPS, comparing the perception of patient safety by the heathcare team. Pilot hospital results of HSOPSC show significant improvement from 2007 ( pre-TeamSTEPPS) to 2010. System-wide results of HSOPSC show similar trends to those seen in the pilot hospital. Valuable lessons for organisational success from the pilot hospital enabled rapid spread of TeamSTEPPS across the rest of the health system.

Building a culture of safety throughteam training and engagement

Lily Thomas, Catherine Galla

▸ Additional supplementary filesare published online only. Toview these files please visit thejournal online (http://dx.doi.org/10.1136/bmjqs-2012-001011).

North Shore LIJ Health System,Institute for Nursing, New HydePark, New York, USA

Correspondence toDr Lily Thomas, North Shore LIJHealth System, Institute forNursing, 400 Lakeville Road,Suite 170, New Hyde Park,NY 11042, USA;lthomas@nshs.edu

Received 20 March 2012Revised 20 August 2012Accepted 2 November 2012Published Online First4 December 2012

To cite: Thomas L, Galla C.BMJ Qual Saf2013;22:425–434.

ABSTRACTMedical errors continue to occur despite multiplestrategies devised for their prevention. Althoughmany safety initiatives lead to improvement, theyare often short lived and unsustainable. Our goalwas to build a culture of patient safety within astructure that optimised teamwork and ongoingengagement of the healthcare team. Teamworkimpacts the effectiveness of care, patient safetyand clinical outcomes, and team training hasbeen identified as a strategy for enhancingteamwork, reducing medical errors and buildinga culture of safety in healthcare. Therefore, weimplemented Team Strategies and Tools toEnhance Performance and Patient Safety(TeamSTEPPS), an evidence-based frameworkwhich was used for team training to createtransformational and/or incremental changes;facilitating transformation of organisationalculture, or solving specific problems. To date,TeamSTEPPS (TS) has been implemented in 14hospitals, two Long Term Care Facilities, andoutpatient areas across the North Shore LIJHealth System. 32 150 members of thehealthcare team have been trained. TeamSTEPPSwas piloted at a community hospital within theframework of the health system’s organisationalcare delivery model, the Collaborative CareModel to facilitate sustainment. AHRQ’s HospitalSurvey on Patient Safety Culture, (HSOPSC), wasadministered before and after implementationof TeamSTEPPS, comparing the perception ofpatient safety by the heathcare team. Pilothospital results of HSOPSC show significantimprovement from 2007 (pre-TeamSTEPPS) to2010. System-wide results of HSOPSC showsimilar trends to those seen in the pilot hospital.Valuable lessons for organisational success fromthe pilot hospital enabled rapid spread ofTeamSTEPPS across the rest of the health system.

INTRODUCTIONNumerous strategies exist to address theglobal issue of patient safety; however, theongoing occurrence of adverse events inhealthcare calls for adaptable andsustainable strategies that address

the challenge at many levels.1–3

Organisational leaders continue to createsolutions, expend time and effort toimplement them, yet find improvementsto be unsustainable. Staff faced with com-peting priorities and incessant innovationsoften regard new strategies as anotherflavour of the month.

BACKGROUNDSeeking to optimise the effectiveness andsustainment of safety initiatives, ourhealth system leadership concluded thattransforming to a culture of safety wasthe prerequisite to attain our patientsafety goals. The vision was to build asustainable culture of safety as the foun-dation for our organisation to guide dailypractice creating a zero tolerance forerrors, and empowerment to speak upand influence actions to facilitate safety.The impact of organisational cultures is

documented; it drives behaviour andinfluences performance outcomes.4 Ourexperiences also validate that ‘the chal-lenge of patient safety is not only clinical,but also organisational’,5 and justified thesolution to build a culture of safety.Creating a culture of safety in health-

care organisations requires the participa-tion of all members, as healthcaredelivery requires multiple caregivers towork together as an effective team withthe goal of achieving desired patient out-comes and preventing harm. The qualityof teamwork impacts the effectiveness ofcare, patient safety and clinical out-comes.6 Poor teamwork is cited as amajor factor in adverse events,7 however,effective teamwork requires training anddevelopment, and formal training isrecommended.6 8 Team training has beenidentified as a strategy for enhancingteamwork,9 reducing medical errorsand building a culture of safety inhealthcare.10

QUALITY IMPROVEMENT REPORT

Thomas L, et al. BMJ Qual Saf 2013;22:425–434. doi:10.1136/bmjqs-2012-001011 425

group.bmj.com on March 8, 2015 - Published by http://qualitysafety.bmj.com/Downloaded from

Elproyectoideal

Cultura y AN 38

of Feedback and Communication, Overall Perception ofSafety, and Staffing. Although the Dimension of Staffingshowed the highest improvement, the actual number ofstaff had not been changed. This is a testament to team-work effectiveness, although staffing had not increased,increased team collaboration contributed to the percep-tion of staffing improvement. Most of the other dimen-sions either increased or remained unchanged.However, in 2010, all dimensions show significantimprovement with three dimensions, (OrganisationalLearning, Supervisor/Manager Expectations, andTeamwork within Units), becoming organisationalstrengths (>75%).The system-wide results show the same trend seen in

the results of the pilot hospital pre-TeamSTEPPS andpost-TeamSTEPPS validating Kotter’s observation,23

‘real transformation takes time’. Comparison ofsystem-wide results of HSOPSC from 2009 (prior toTeamSTEPPS implementation) to 2011, showed sig-nificant improvement in the dimensions of ‘Feedbackand Communication about Error’ ‘Frequency ofEvents Reported’, ‘Hospital Handoff and Transitions’,‘Staffing’ and ‘Teamwork across the Units’. Consideredas an area of strength with scores >75% were‘Organisational Learning’ and ‘Teamwork withinUnits’.

Incremental changeIncremental changes were assessed by comparing pre-intervention and postintervention measures of vari-ables depicting the change. Examples includereduction of nosocomial infections, falls, improve-ment in process measures and decrease in adverse out-comes, birth trauma and return to the operating roomin perinatal services.24

We believe that TeamSTEPPS served to optimiseother initiatives and impacted the organisations’ deep

commitment to quality; NSLIJHS was honoured asthe recipient of the National Quality Forum 2010National Quality Healthcare Award.To date, 300 Collaborative Care Councils are estab-

lished across the 14 hospitals, ambulatory care andemergency medical services of the health system. Thecouncils keep the teams engaged, and the teamengagement improves our care delivery.

DISCUSSIONBased on our findings in the areas of transformationaland incremental changes, team training works. Thisfinding is consistent with previous reports of teamtraining impact, including improving team effective-ness and team training outcomes,7 25 and patient andorganisational outcomes.26 The meta-analysis con-ducted by Salas et al supports team training as anappropriate intervention for influencing team pro-cesses and performance.27 Our findings are similar torecent reports of the impact of team training usingTeamSTEPPS/modified TeamSTEPPS.10 28 29 However,methodological constraints still prevents us from dir-ectly correlating team training to clinical outcomes.30

LIMITATIONSThe scope of our implementation and train-the-trainermodel required a large number of trainers. Althoughthe curriculum is standardised, we could not monitorevery training session for delivery of content orunique attributes of the trainers that could positivelyor negatively impact the training.Although our TeamSTEPPS implementation was

planned and organised to be rapid, we could notcontrol the onslaught of ongoing changes or otherinitiatives impacting patient safety. This adds to thedifficulty in attributing TS as directly impactingseveral outcomes. In addition, logistical constraints of

Table 3 Pilot hospital results for ‘Hospital Survey on Patient Safety Culture’: difference in pre-TeamSTEPPS versus post-TeamSTEPPSimplementation

DimensionsImprovement from2007 to 2009 (%)*

Improvement from2009 to 2010 (%)

Improvement from2007 to 2010 (%)

Communication/openness +1 +6.7 +7.7Feedback and communication about error +4 +5.3 +9.3Frequency of events reported −1 +3.6 +2.6Hospital handoffs and transitions 0 +11.30 +11.3Hospital management support for patient safety +3 +8 +11Non-punitive response to error +3 +12.9 +15.9Organisational learning—continuous improvement −2 +13.7† +11.7†Overall perceptions of safety +6 +5.8 +11.8Staffing +8 +7.8 +15.8Supervisor/Manager expectations and actions promoting patient safety 0 +10.9† +10.9†Teamwork across hospital units +3 +11.1 +14.1Teamwork within units −2 + 13.9† +11.9†*2007—Pre-TeamSTEPPS.†Area of strength.

Quality improvement report

Thomas L, et al. BMJ Qual Saf 2013;22:425–434. doi:10.1136/bmjqs-2012-001011 431

group.bmj.com on March 8, 2015 - Published by http://qualitysafety.bmj.com/Downloaded from

BMJ Qual Saf 2013 22: 425-434

Sir Liam Donaldson

Cultura y AN 39

"Errar es humano, ocultar es imperdonable, y no aprender es

inexcusable”

¡Gracias!

40