Human infallibility is completely impossible. It doesn’t matter how much training and education we receive—we all make mistakes. They can happen everywhere, and they do happen to everyone. It’s a sobering thought, particularly in the field of healthcare, where each day clinicians are confronted with life and death situations.
Instead of just hoping we are infallible, we need to take steps to limit the effect of our mistakes by building a support system of an interactive team who are all working together to create a culture of safety. This team-based support system can catch and neutralize mistakes before they have a chance to negatively impact a patient.
For this support system to work as intended, every healthcare organization needs checklists and protocols for their team that are rooted in fact. These processes help clinicians organize their thoughts, and ensure that they haven’t overlooked anything critical. These can’t be off-the-shelf processes. Instead, organizations have to give staff an opportunity to give input and make changes.
The second half of this is the harder part to address: organization culture. Providers need everyone, including the most junior people, to be comfortable using ‘stop the line’ language, even with the most senior members. This culture of communication is intrinsic to a support system. According to the Joint Commission on Accreditation of Healthcare Organizations, nearly 70 percent of all sentinel events in healthcare have communications breakdowns as a root cause.
For the past twenty years, I’ve worked to help healthcare organizations adapt the TeamSTEPPS model, which is a set of evidence-based tools to increase teamwork and strengthen communication with the aim of improving patient outcomes. Here are two of the keys to success:
1. Get physician support by conveying the right message. Most hospitals make a mistake by selling these changes as a patient safety issue. But many surgeons hear that message and think, “I already provide safe, quality care. Talk to someone else.” Instead, hospitals should approach it as a change that will provide a better place for the physician to practice medicine. Say, “We know you provide safe, quality care. But if you will take this journey with us, what you get out of this is a better place to practice medicine. Our teams will be more efficient, your cases will start and end on time, and your team will respond to you better with fewer communication mistakes. We’ll take care of your patients better.”
2. Leaders must get off the sidelines on onto the field of play. Changing culture is not a spectator sport for hospital administrators and leaders. Their continuous participation in change activities is the KEY ingredient in sustainable success. Rounding, coaching, mentoring, measuring, celebrating, rewarding, and hardwiring are just a few of the critical leaderships actions needed to succeed.
So yes, to err is human. But by creating a team of experts and the right culture, we can spot each other’s mistakes and neutralize them. By doing so, we’ll improve safety for patients and employees.
Posted By Steve Harden
For more information on adaption the TeamSTEPPS model, please watch the recent webinar led by Steve Harden.