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From a culture of safety to a culture of excellence: Quality science, human factors, and the future of healthcare quality
... In this regard, in U.S. health care there is not yet a ''culture of quality'' such as is prevalent in high performing organizations (e.g., as seen in nuclear power, aviation, maritime transportation, and some chemical manufacturing). [27][28][29] In a culture of quality, policies and processes are aligned to consistently and predictably achieve desired outcomes. To be sure, health care has islands of quality, but we are nowhere near having a universe of quality. ...
There are widespread and growing concerns about the variable and too often inadequate quality of health care in the United States. As a result, health care quality is being questioned and subjected to scrutiny as never before. Awareness of the quality deficits, combined with rising health care expenditures and changing attitudes of payers and consumers, has given rise to a nascent but growing quality improvement movement. Multiple barriers must be surmounted by this movement, but substantive work is under way on all fronts. Emergency medicine will definitely be affected by the quality improvement movement and should quickly move forward to define and establish performance measures for high-quality emergency care in an era when chronic disease dominates the agenda. Emergency medicine should also aggressively work to operationalize a culture of quality to minimize medical errors, to practice evidence-based medicine, to translate research results into clinical practice in a timely manner, and to establish accountability mechanisms for quality improvement and clinical excellence.
... In this regard, in U.S. health care there is not yet a ''culture of quality'' such as is prevalent in high performing organizations (e.g., as seen in nuclear power, aviation, maritime transportation, and some chemical manufacturing). [27][28][29] In a culture of quality, policies and processes are aligned to consistently and predictably achieve desired outcomes. To be sure, health care has islands of quality, but we are nowhere near having a universe of quality. ...
There are widespread and growing concerns about the variable and too often inadequate quality of health care in the United States. As a result, health care quality is being questioned and subjected to scrutiny as never before. Awareness of the quality deficits, combined with rising health care expenditures and changing attitudes of payers and consumers, has given rise to a nascent but growing quality improvement movement. Multiple barriers must be surmounted by this movement, but substantive work is under way on all fronts. Emergency medicine will definitely be affected by the quality improvement movement and should quickly move forward to define and establish performance measures for high-quality emergency care in an era when chronic disease dominates the agenda. Emergency medicine should also aggressively work to operationalize a culture of quality to minimize medical errors, to practice evidence-based medicine, to translate research results into clinical practice in a timely manner, and to establish accountability mechanisms for quality improvement and clinical excellence.
... We found that the institution of a printed set of guidelines posted in the patient's room emphasizing these special needs facilitated patient care and minimized confusion between team members at change of shift. We believe that this simple intervention reduced the "latent conditions for failure" in the system [32] and improved patient safety. We further encourage a gradual and stepwise approach to the institution of oral antihypertensive medications before discharge. ...
Paraplegia or paraparesis after otherwise successful thoracic or thoracoabdominal aortic reconstruction is a devastating complication for patient and physician. Interventions for its prevention have focused primarily on the intraoperative period. We have recently noted a significant incidence of delayed-onset neurologic deficit.
We reviewed our most recent 5-year experience with thoracic and thoracoabdominal reconstruction to examine the incidence of and potential contributors to delayed paraplegia or paraparesis.
Between June 1996 and June 2001, 60 patients (29 men, 31 women) underwent repair of isolated thoracic (n = 26) or thoracoabdominal aortic aneurysm (Crawford I, n = 7; Crawford II, n = 14; Crawford III, n = 12; Crawford IV, n = 1) by the cardiac and vascular surgical services collaboratively. Repair was performed endovascularly in 6, and open with either circulatory arrest in 12, partial left heart bypass in 37, or partial femorofemoral bypass in 5. Operative mortality was 9.3% (5 of 54 patients) for open repair and 0% for endovascular repair. Paraplegia or paraparesis occurred in 6 (10%) patients of which 83.3% (5 of 6) were delayed in onset. All patients with delayed paraplegia or paraparesis had degenerative aneurysms of Crawford extent II (n = 3) or III (n = 2), had intraoperative left heart bypass, and had perioperative spinal drainage. Delayed paraplegia or paraparesis occurred up to 27 days postoperatively, and was associated with a documented episode of hypotension in 60% (3 of 5) of patients.
Improvements in intraoperative management may have reduced immediate paraplegia or paraparesis among vulnerable patients only to leave them at risk of delayed-onset deficit. Postoperative care, including assiduous attention to avoidance of even transient hypotension, must be tailored to this patient population.
... Merry points out the fundamental design flaws of the medical staff structure. 6 Berwick's observations on physician commitment continue to be applicable both to outpatient and hospital practice: "the challenge of involving physicians is an issue that has arisen repeatedly in health care quality improvement efforts… How shall we involve doctors, who do not seem to see themselves as players in processes, whose financial incentives impede participation in project teams and data collection activities, and who do not strongly believe that their interests are tied to the improvement of the health care organizations they work in? In fact, barriers to physician involvement may turn out to be the most important single issue impeding the success of quality improvement in medical care." ...
A case-based examination of perceptions of ethical violation across administrative and operator roles in aviation maintenance, health care, and industrial settings. Themes in ethical dilemmas across domains, and a decision making framework for ethical decision making are presented and discussed. Patankar, Brown, and Treadwell
In Safety Culture: Building and Sustaining a Cultural Change in Aviation and Healthcare, the four authors draw upon their extensive teaching, research and field experience from multiple industries to describe the dynamic nature of a culture-change process, particularly in safety-critical domains. They use a stories to numbers approach that starts with felt experiences and stories of certain change programs that they have documented, then proceed to describe the use of key measurement tools that can be used to analyze the state of a change program. The book concludes with a description of empirical models that illustrate the dynamic nature of change programs. © Manoj S. Patankar, Jeffrey P. Brown, Edward J. Sabin, and Thomas G. Bigda-Peyton 2012. All rights reserved.
Objective
To characterize communication strategies of labor and delivery nurses and their physician colleagues during perinatal decisions.DesignA quantitative descriptive design was used.SettingA perinatal setting in an urban acute care facility.ParticipantsTwenty-nine perinatal nurses and 11 attending physicians.MethodsA model of team communication derived from research on cockpit crew communication served as a framework for this analysis. Data were taken from transcriptions of audio-taped conversations and discourse analysis.ResultsFindings indicated that nurses and physicians tended to use status-based communication styles and rarely employed team-centered communication strategies.Conclusion
Nurse and physician status-based communication styles may hinder optimal patient outcomes.
Research in healthcare operations has grown in interest and importance over the last decade, as the healthcare environment continues to become more complex and challenging. This study investigates the relationships among organizational culture, knowledge management, and patient safety performance. Drawing on existing literature, the authors develop and test a model for patient safety performance using data from a nationwide survey of more than 200 hospitals. Structural equation modeling is used to provide empirical support for the model. In particular, they find that different dimensions of organizational culture are related to more effective knowledge management, which in turn is associated with better patient safety performance. The authors conclude by discussing the major implications of their study for operations managers and healthcare practitioners and then provide directions for future research.
According to the United Kingdom's National Patient Safety Agency, one out of every 10 National Health Service (NHS) patients will experience a patient safety incident. Team-based working may help reduce errors. Using an abbreviated Operating Room Management Attitudes Questionnaire, researchers recorded clinical and non-clinical grades' experience of, and attitudes towards teamworking at an NHS District General Hospital. Two hundred and twenty-six employees completed a questionnaire. Data revealed a pronounced mis-match between most employees' preferred method of working (effective inter- and intra-disciplinary teamwork) and that which obtained (a generally hierarchical system of top-down management). Eighty per cent of respondents "agreed strongly" with the statement "I enjoy working as part of a team" and 73%"agreed strongly" with the statement "Senior medical staff should encourage questions and input ..." (no respondent disagreed with this statement). Only 33%"agreed strongly" with the statement "I feel fully integrated with and valued by my colleagues in my work area". While 68% of respondents preferred a consultative style of management, only 35% experienced it. Three conclusions were drawn. First, managers at the subject hospital must improve teamworking (because effective teamworking can help reduce levels of medical error). Secondly, adaptations of proven team-building techniques, like aviation's crew resource management protocol, may provide a solution. Thirdly, those members of the staff responsible for the status quo at the hospital may resist reform.
To describe communication between nurses and physicians during labor within the context of the nurse-managed labor model in community hospitals and its relationship to teamwork and patient safety.
Multicenter qualitative study involving focus groups and in-depth interviews.
Labor and birth units in 4 Midwestern community hospitals.
54 labor nurses and 38 obstetricians.
Focus groups and in-depth interviews were conducted using open-ended questions. Data were analyzed using inductive coding methods to gain understanding from the perspective of those directly involved.
Description of interdisciplinary interactions during labor.
Nurses and physicians shared the common goal of a healthy mother and baby but did not always agree on methods to achieve that goal. Two clinical situations critical to patient safety (fetal assessment and oxytocin administration) were frequent areas of disagreement and sources of mutual frustration, often leading to less than optimal teamwork. Minimal communication occurred when the mother and fetus are doing well, and this seemed to be purposeful and considered normal. Physicians and nurses had distinct opinions concerning desirable traits of members of the other discipline.
Interdisciplinary communication and teamwork could be improved to promote a safer care environment during labor and birth.
As aircraft have become more reliable, humans have played a progressively more important causal role in aviation accidents, resulting in the proliferation of human error frameworks and accident investigation schemes. To date, however, few efforts have been made to systematically organize these different approaches based on underlying theoretical similarities, and formalized methods for evaluating the utility of these multiple approaches have not been clearly defined. Many safety professionals, therefore, have been at a loss when choosing which error analysis and prevention approach to use within their organizations. As a result, those tasked with instituting human-centered safety programs often rely primarily on personal experience and intuition to address their needs. The purpose of this article is to help remedy this situation by providing safety practitioners with an overview of the prominent human error perspectives in aviation, as well as a set of objective criteria for evaluating human error frameworks.
Recent years have witnessed strong progress in understanding how people make decisions in operational settings. The emerging field of Naturalistic Decision Making (NDM) is at a point to afford system developers (including design engineers, human factors engineers, ergonomics specialists) different tools and methods for designing interfaces/systems that will better support decision making in those settings. Decision requirements can be identified from the early conceptual design phase through redesign. The NDM framework attempts to describe the way in which people handle difficult conditions within the context of the overall setting or task. This SOAR describes various decision strategies used by individuals and teams to assess a situation, diagnose a problem, and select a course of action. The impact of stress upon these strategies is also considered. To help understand what people are thinking as they perform difficult tasks, the procedures for conducting Cognitive Task Analyses to examine design requirements are also examined.
Human error is considered a contributing factor in 70% to 80% of all aviation accidents. Because errors can never be eliminated completely, a further reduction of the already low accident rate in this domain will require investments in better support for error management. In particular, a better understanding of the nature and effectiveness of error detection mechanisms is needed. With this goal in mind, NASA Aviation Safety Reporting System incident reports were analyzed in terms of the formal characteristics of underlying errors, the cognitive stage, and the performance level at which these errors occurred, and with respect to the processes that led to their detection and, thus, prevented these incidents from turning into accidents. The majority of incidents involved lapses (i.e., failures to perform a required action) or mistakes, such as errors in intention formation and strategy choice. These errors were most often detected based on routine checks and the observed outcome of an action, respectively. Most slips appear to have been discovered by the crew before they could lead to a problem worth reporting. Our findings suggest a need for more effective feedback in support of data-driven monitoring, especially in the case of errors of omission and for shared knowledge of intent between airborne and ground-based operators to promote the more timely and reliable detection of mistakes.
This paper describes the definition and the characteristics of human errors. Different types of human behavior are classified, and their relation to different error mechanisms are analyzed. The effect of conditioning factors related to affective, motivating aspects of the work situation as well as physiological factors are also taken into consideration. The taxonomy for event analysis, including human malfunction, is presented. Possibilities for the prediction of human error are discussed. The need for careful studies in actual work situations is expressed. Such studies could provide a better understanding of the complexity of human error situations as well as the data needed to characterize these situations.
inquires why an industry would embrace change to an approach that has resulted in the safest means of transportation available and has produced generations of highly competent, well-qualified pilots / examine both the historic, single-pilot tradition in aviation and what we know about the causes of error and accidents in the system / these considerations lead us to the conceptual framework, rooted in social psychology, that encompasses group behavior and team performance / look at efforts to improve crew coordination and performance through training / discuss what research has told us about the effectiveness of these efforts and what questions remain unanswered (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Most of the current academic flexible manufacturing system (FMS) scheduling research has focused on the derivation of algorithms or knowledge-based techniques for efficient FMS real-time control. Here, the limitations of this view are outlined with respect to effective control of actual real-time FMS operation. A more realistic paradigm for real-time FMS control is presented, based on explicit engineering of human and automated control functions and system interfaces. To illustrate design principles within the conceptual model, an example of algorithmic and operator function models for a specific real-time FMS control problem are developed.
The Tenerife air disaster, in which a KLM 747 and a Pan Am 747 collided with a loss of 583 lives, is examined as a prototype of system vulnerability to crisis. It is concluded that the combination of interruption of important routines among interdependent systems, interdependencies that become tighter, a loss of cognitive efficiency due to autonomic arousal, and a loss of communication accuracy due to increased hierarchical distortion, created a configuration that encouraged the occurrence and rapid diffusion of multiple small errors. Implications of this prototype for future research and practice are explored. Peer Reviewed http://deepblue.lib.umich.edu/bitstream/2027.42/68716/2/10.1177_014920639001600304.pdf
Theoretical models of sensory-information processing by the human brain are reviewed from a human-factors perspective, with a focus on their implications for aircraft and avionics design. The topics addressed include perception (signal detection and selection), linguistic factors in perception (context provision, logical reversals, absence of cues, and order reversals), mental models, and working and long-term memory. Particular attention is given to decision-making problems such as situation assessment, decision formulation, decision quality, selection of action, the speed-accuracy tradeoff, stimulus-response compatibility, stimulus sequencing, dual-task performance, task difficulty and structure, and factors affecting multiple task performance (processing modalities, codes, and stages).
In aviation,accidents usually highly visible,and as a result aviation has developed standardised methods of investigating, documenting, and disseminating errors and their lessons. Although operating theatres are not cockpits, medicine could learn from aviation. Observation of flights in operation has identified failures of compliance, communication, procedures, proficiency, and decision making in contributing to errors. Surveys in operating theatres have confirmed that pilots and doctors have common interpersonal problem areas and similarities in professional culture. Accepting the inevitability of error and the importance of reliable data on error and its management will allow systematic efforts to reduce the frequency and severity of adverse events.
Many errors are attributable to characteristics of human cognition, and their risk is predictable. Systems can be designed to help prevent errors, to make them detectable so they can be intercepted, and to provide means of mitigation if they are not intercepted. Tactics to reduce errors and mitigate their adverse effects include reducing complexity, optimising information processing, using automation and constraints, and mitigating unwanted effects of change.
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Building a Culture for Team Safety: By Design and by Default
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Management Systems: A Positive, Practical Method of Cockpit Resource Management
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Improving Patient Care by the Application of Theory and Practice from the Aviation Safety Community
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Human Error and Accident Causation Theories, Frameworks and Analytical Techniques: An Annotated Bibliography
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