Balancing Systems and Individual Accountability in a Safety Culture

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Consider a Case• The ED was busy. The trauma service was treatingother victims of the MVC.• Policy directs personnel to confirm two identifiersbefore administering blood products. After a “closecall” a year earlier, all ED and operating room (OR)personnel were retrained.Hickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.4NPSF Professional Learning Series
Consider a Case• Quality and risk teams will review records and scheduleinterviews.• Policy directs a root cause analysis (RCA) to beattended by involved personnel.• Other thoughts:• “I wonder what has been shared with the family.”• You also think about your team—nurses, physicians, or others—who are involved• You make a mental note to alert the wellness program directorHickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.5NPSF Professional Learning Series
Page 6 and 7: But how do we prevent…?6NPSF Prof
Page 8 and 9: Accountability“Systems”“Human
Page 10 and 11: But there is hope…• Elements th
Page 12 and 13: What are the prerequisites?• Shar
Page 14 and 15: Values and leadership (modeled)allo
Page 16 and 17: Our team members feel free toreport
Page 18 and 19: What are the prerequisites?• Surv
Page 21 and 22: Morbidity, Mortality &Improvement C
Page 23 and 24: Issues IdentifiedPEOPLEENVIRONMENTW
Page 25 and 26: What are the prerequisites?• Reso
Page 27 and 28: Accountability PyramidAdapted from
Page 29 and 30: Patient Complaints• “Dr. __ tol
Page 31 and 32: Accountability PyramidAdapted from
Page 33 and 34: PARS ® Progress ReportTotal # of h
Page 35 and 36: Back to the case• The RCA reveale
Page 37 and 38: Back to the case• Creation of int
Page 39 and 40: You meet with Nurse 2System Needs:
Page 41 and 42: Principles for “Informal”Conver
Page 43 and 44: “Awareness” Guiding PrinciplesH
Page 45 and 46: When Surgeon X yelled…“get the#
Page 47 and 48: Definition of Disruptive Behavior
Page 49 and 50: Consequences of Disruptive Conduct:
Page 51 and 52: “RN did not call the doctor about
Page 53 and 54:
Accountability PyramidAdapted from
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Resources and ToolsEvaluating and A
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Components of a Safety Culture• S
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Path to Compliance• In June 2009
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A Project Bundle1. Learning systems
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A Project Bundle3. Organizational r
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100%VUH Hand Hygiene Compliance Rat
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December 22, 2010To: Medical Direct
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VUMC Hand Hygiene Compliance (FY 10
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Balancing Systems and Individual Accountability in a Safety Culture

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