Safety Culture An Epic Journey. Jeff Goulding Assistant Director of Human Factors

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1 Safety Culture An Epic Journey Jeff Goulding Assistant Director of Human Factors

2 Safety Culture What do I do? Quality Improvement (AQUIS) Education (work with partners AQuA and University of Liverpool) Resilience in Stressful Events Management and Prevention of Incidents Freedom to Speak Up

3 The Importance of Culture Culture eats strategy for breakfast and operations excellence for lunch and everything else for dinner Attributed to Peter Drucker, 2006

4 Safety Culture Term safety culture first used following Chernobyl disaster in 1986 (Antonsen, 2009). the accident can be said to have flowed from deficient safety culture. IAEA (1989) The Piper Alpha report also cited cultural issues as playing a significant role in causing the accident. It is essential to create a corporate atmosphere or culture in which safety is understood to be and is accepted as, the number one priority (Cullen 1990).

5 A Model for Healthcare Carthy and Clarke (2009) Patient Safety First, Implementing Human Factors in Healthcare

6 I m struck by how much of our perceived culture is wrapped up in how we prevent, respond to and manage incidents and accidents.

7 A Model for Healthcare Carthy and Clarke (2009) Patient Safety First, Implementing Human Factors in Healthcare

8 Do we have the balance right?

9 Safety I Our approach to risk is described as a Safety I approach We focus on why things go wrong. A Bi- Modal approach to risk Function (Work as imagined) Success (No adverse events) Acceptable outcomes Malfunction (non-compliance Error) Failure (Accidents, incidents) Unacceptable outcomes This model assumes that things that go wrong and things that go right have a different aetiology leads to outcome bias.

10 Safety II From Safety I to Safety II ask not why did it go wrong, but why does it go right so often? Success (No adverse events) Acceptable outcomes Everyday work (Performance variability) Failure (Accidents, incidents) Unacceptable outcomes Things that go wrong and things that go right have the same aetiology

11 Safety: a dynamic non-event Humans are heroes and make timely interventions Less likely in tractable industries; aviation, nuclear fuels etc. Healthcare is intractable. Healthcare workers have to work in sub-optimal conditions, can t always stop the line. Therefore safety in healthcare requires operatives to adapt and adjust to changes in the environment. This often traps, mitigates or eliminates errors and prevents harm. Therefore failures are not unique individual events. Rather they are expressions of everyday performance variability. Something that goes wrong will have gone right many times before.

12 Violation as Adaptation In the face of the complexity of healthcare violations become necessary adaptations In the hands of skilled professionals they are necessary to get the job done Often routine and reasoned violations produce real benefits in terms of productivity James Reason (1990)

13 Culture

14 Active Failures Intended actions Violations Mistakes Routine Reasoned Reckless Malicious Rule Based Knowledge Based Unsafe acts Unintended actions Basic Error Types Lapses Slips Skill based errors Memory failures Skill based errors Attentional failures

15 Absolving People of Responsibility? A relatively small number of harms are the result of reckless, or even malicious behaviour. Lines need to be drawn to eliminate or deal with unacceptable behaviour. Where to draw the line may not be the difficult question for a small number of cases. However, for the rest - who gets to draw the line and against what criteria is the key.

16 Why do things go wrong? This is an important question Equally important is: why, when things do go wrong, doesn t that always lead to harm? Understanding the answer to both these questions helps us to prevent, mitigate and recover from failure Appreciating the role human beings play in preventing routine failure from causing harm is crucial. Creating a culture in which they can make timely interventions and compensate for system failures is a key prerequisite to developing high reliability.

17 Easy to see. Difficult to see. Complicated aetiology. Uncomplicated aetiology. Difficult to change/manage Easy to change/manage Easy to see. Complicated aetiology. Difficult to change/manage Adjustments by humans prevent failure Often taken for granted Current safety focus (accidents and incidents) Generally ignored or unknown Gratefully accepted

18 Is Safety Culture Enough? Carthy and Clarke (2009) Patient Safety First, Implementing Human Factors in Healthcare

19 Thank You

20 Questions?