DENVER — If one major theme is starting to emerge from the TeamSTEPPS National Conference, it is this: Stop playing the blame game.
We’ve heard it before, and it may sound like a no-brainer, but for quality and patient safety to flourish, hospitals need to nurture a culture that supports open and honest communication across all levels of the organization.
As recently as 2014, an Agency for Healthcare Research and Quality study found that 56 percent of hospital employees did not report any medical errors throughout a 12-month period, which does not account for the actual number of adverse events that may have happened during the same time.
In what speakers termed a “just culture,” there is a clear distinction between human blunders in unreliable systems and intentional unsafe acts, which changes the paradigm from blaming the individual to one that investigates how flaws are embedded operationally. This should, in turn, embolden staff to report and learn from errors and system flaws instead of hiding them.
Of course, such a paradigm shift requires buy-in from all levels. Speakers cited examples from their own organizations about how implementing nonpunitive responses to safety from the top down resulted in markedly less worry from front-line staff about mistakes being kept on file, less fear of mistakes being held against them, and fewer staff feeling like “the person, not the problem” is being written up. These factors contributed to a culture of safety, illustrated by higher frequency of adverse event reporting, more open communication, increased teamwork and heightened facility management support for safety, in the speakers’ respective institutions.
Another key: crew resource management, which enables leaders to recognize the demand for and work to implement cognitive and interpersonal skills throughout their operations.
Jodie Gary, Texas A&M Health Science Center College of Nursing, mentioned two groups of people in the health care quality education track that tend to naturally possess these skills: nurses and younger faculty. Gary said that when trying to teach TeamSTEPPS to an interprofessional group (such as one made up of physicians, dentists, administrators, nurses and pharmacists) in an educational setting, nurses are often “highly effective champions of the process.” Embracing the help of younger faculty members is rewarding, too, Gary said, because they tend to react to change more positively than their older counterparts.
Getting staff to operate differently is a challenge in any industry, but health care seems especially ripe for the challenge, said Ron Culberson, a medical social worker, speaker, humorist and author, in his plenary address. Culberson preached the value of using humor to diffuse stress, and when implementing methodologies such as TeamSTEPPS, to tell stories instead of quoting numbers to “move [caregivers] to action.
“Health care is the best place to employ this because you’re working in an environment where you have to change your behavior,” he said. “Everyone resists that, so the more enjoyable you make it for them, the less resistance there will be.”