Balancing Systems and Individual Accountability in a Safety Culture

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Prior to the meeting with Surgeon X• Review results of RCA• Review other performance/behavior data• 3 med mal claims• An apparent pattern on non-teamwork promoting (disruptive)behavior directed toward patient and staff• You previously spoke with Surgeon X about complaintsfrom coworkers and patients.• You find it concerning that Surgeon X failed to self-correctafter previous (awareness) feedback.52NPSF Professional Learning Series
Accountability PyramidAdapted from HicksonGB, Pichert JW, Webb LE,Gabbe SG. Acad Med.Nov, 2007.No∆PatternpersistsApparentpatternSingle“unprofessional"incidents (merit?)Level 3 "Disciplinary"InterventionLevel 2 “Guided"Intervention by AuthorityLevel 1 "Awareness"InterventionMandatedVast majority of professionals - no issues -provide feedback on progressMandated Reviews"Informal" Cupof CoffeeIntervention53NPSF Professional Learning Series
Page 4 and 5: Consider a Case• The ED was busy.
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: “RN did not call the doctor about
Page 55 and 56: Resources and ToolsEvaluating and A
Page 57 and 58: Components of a Safety Culture• S
Page 59 and 60: Path to Compliance• In June 2009
Page 61 and 62: A Project Bundle1. Learning systems
Page 63 and 64: A Project Bundle3. Organizational r
Page 65 and 66: 100%VUH Hand Hygiene Compliance Rat
Page 67 and 68: December 22, 2010To: Medical Direct
Page 69: VUMC Hand Hygiene Compliance (FY 10

Balancing Systems and Individual Accountability in a Safety Culture

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