University of Manchester, Storbritannien Säker primärvård Modul 3 Att ändra kulturen Kulturskifte James Reason Professor Emeritus University of Manchester, Storbritannien Part 3 is about safety culture in general and a ‘just culture’ in particular. The argument goes as follows. In complex, well-defended systems, culture is crucial because it reaches into all parts of the system. It is probably the only single factor that can influence the quality of the defences for good or ill, because they too are scattered widely throughout the system. An effective safety culture is an informed culture, one that knows where the ‘edge’ is without having to fall over it. To achieve that, we need people to report their ‘free lessons’, errors and near misses. But they won’t do that unless they trust the system and its management. And they certainly won’t confess their errors if they get disciplined for it. So, an effective reporting culture depends upon having a just culture. That is, an organisation in which people clearly understand where the line must be drawn between acceptable and unacceptable actions. In short, a just culture lies at the heart of a safe culture. The module argues that these cultural attributes can be socially engineered through the introduction of appropriate practices, especially with regard to disciplinary procedures.

är att begreppet är lika luftig som ett moln Problemet med kultur . . . är att begreppet är lika luftig som ett moln The term ‘culture’ sounds a very woolly idea—particularly to those used to technical precision. It’s certainly true that there are almost as many definitions of ‘culture’ as there social scientists. However, the notion is central to effective error management.

och ändå . . . Affärsflyget i hela världen använder ett fåtal flygplanstyper och har gemensamma standardiserade regler och procedurer. Risken att råka ut för en flygolycka med dödlig utgång varierar i hela världen med en faktor på 42 (1 på 11 miljoner till 1 på 260 000) Skillnaden beror till en del på infra-strukturen, men till största delen på kultur-skillnader. This slide illustrates one very practical reason why culture is important for safety. It shows that in commercial aviation—a domain that has a high degree of uniformity in standards and aircraft types—the risk of being involved in an accident with one fatality vary across the world’s airlines by a factor of 42, from one in eleven million departures in the first world major airlines to something of the order of 1 in 260,000 departures among some third-world airlines and the ‘new Russias’. Some of this difference has to do with resources and the quality of the infra-structure; but much of it is down to plain safety culture

Kultur: En möjlig definition Gemensamma värderingar (om vad som är viktigt) och uppfattningar (om hur saker och ting fungerar) samspelar med organisationens struktur och styrsystem, vilket leder till normer för beteenden (hur vi gör saker och ting här hos oss). There is no one agreed definition of organisational culture even among the so-called experts. But here is one that captures the important notions in clear and simple language.

Vad är en säkerhetskultur? En säkerhetskultur = en informerad kultur. I en informerad kultur vet man var säkerhetsgränsen går, utan att först ha behövt överskrida den. I en informerad kultur förutser man och hanterar riskfyllda situationer. Ett arbete pågår ständigt för att minska riskerna och öka säkerheten. Above all else, a safe culture is one that does not forget to be afraid. In order to keep up the proper level of intelligent wariness, we need to understand the hazards and risks that beset our operation. In short, we need to know where the ‘edge’ is. Many organisations do not discover this until they fall over it. It is better to know in advance. But how do we find out when information about adverse events is not shared between primary carers? The answer is that we need people to tell us about their errors, near misses and free lessons. In short, we need to engineer a reporting culture. NASA’s Aviation Safety Reporting System (ASRS) has achieved this through clever social engineering—much of which has to do with the issue of sanctions and immunity.

En säkerhetskultur har många komponenter Rättvis kultur Rappor- terande kultur Culture is not just one entity. It is made up of different sub-cultures. Reporting culture: This gives the organisation a memory. It can begin to learn from past events. This depends crucially on the willing participation of those in direct contact with patients. To achieve this it is necessary to engineer an organisational climate in which people are prepared to report their ‘free lessons’ and near misses. Just culture: An effective reporting culture depends critically on how the organisation handles blame and punishment. We need an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information. For this to happen, it is necessary that all levels of the organisation enter into a negotiation to decide where the line must be drawn between ‘honest’ errors and unacceptable unsafe acts. Flexible culture: This takes an number of forms, but in many cases it involves shifting from the conventional hierarchical mode to a flatter professional structure, where control passes to task experts on the spot in periods of high demand, and then reverts back to the traditional bureaucratic mode once the emergency has passed. Such adaptability is an essential feature of the crisis-prepared organisation and depends crucially on respect for the skills, experience and abilities of those on the frontline. But respect must be earned, and this requires a major training investment on the part of the organisation. Learning culture: This is the willingness and competence to draw the right conclusions from its reporting system, and the will to implement major reforms when their need is indicated. Flexibel kultur Lärande kultur

Komponenterna måste fungera ihop All of these different elements need to link together harmoniously. An informed culture depends upon a reporting culture and this, as noted earlier, depends critically upon establishing a just culture. Thus, building a just culture is the first major step in creating a safe culture. A just culture is the ‘engine’ that drives the other elements.

Steg på vägen Det sårbara systemet Det tillförlitliga systemet This slide depicts the long and difficult journey involved in effecting a radical change of culture. It’s starting point is the ‘Vulnerable System Syndrome’ (VSS) comprising three inter-related pathologies: blame, denial and the blinkered pursuit of the wrong kind of excellence. Research in other hazardous domains suggests that VSS plays a large part in the aetiology of adverse patient incidents. It is also evident that these pathologies afflict a large proportion of HC, in the primary as well as the secondary sectors—as a result of the dysfunctional medical culture. High reliability organisations are systems operating in hazardous circumstances, where the cost of accidents is unacceptably high, but who have less than their ‘fair share’ of adverse events. Observational studies carried out through the late 1980s and 1990s suggest that they possess a number of organisational characteristics that contribute to robustness and resilience. They are summed up in Karl Weick’s term ‘collective mindfulness’. These features do not guarantee immunity from bad events, but they represent the best model we currently have for a safe culture

Det sårbara systemet Tre huvudsymtom Skuld och syndabockstänk Förnekelse Jakt på fel sorts resultat Because complex, healthcare systems are protected by a variety of barriers, safeguards and defences, it usually requires some bad luck to bring about a bad event. Notwithstanding this chance element, organisations having bad accidents tend to be afflicted by the Vulnerable System Syndrome. The three parts to this condition are summarised below. Blame: The very human tendency to blame individuals for bad outcomes (or an excessive adherence to the ‘person model’ of error) is the most tenacious of the three pathologies, and perhaps the most pervasive in its harmful effects upon organisational safety. Denial: Once frontline individuals have been blamed for an adverse event, it is very easy to deny that there is anything wrong with the system as a whole. This apparently leaves the managers with the opportunity to pursue non-clinical goals. The blinkered pursuit of wrong kind of excellence: Or, having your eye on the wrong ball. This is demonstrated by a single-minded focus upon achieving certain numerical indicators of ‘excellence’. Managers live by numbers, but they don’t always appreciate their limitations. An obsession with indicators is not always understood by those who pursue these goals.

Varför är instinkten att skylla på individen så stark? Någon annans fel Illusion av fri vilja Livet är rättvist Efterklokhetens enögdhet Ledningen går fri Juridiskt enkelt The urge to blame individuals is enormously strong. It is driven by a variety of psychological, organisational and legal pressures. Attribution error: This is the universal tendency to see behaviour as being driven by the personality of the individual rather than by the surrounding circumstances. We over-emphasise these dispositional factors and under-appreciate the influence of the environment upon human action. Illusion of free will: We place great value on the belief that we are in control of our destinies. We can even become mentally ill if we feel deprived of this autonomy. Feeling ourselves to be capable of choice naturally leads us to assume that other people are the same. In short, they choose to make errors or cause bad outcomes. Just world hypothesis: This the belief shared by most children and many adults that bad things only happen to bad people, and conversely. In HC adverse events, frontline professionals are seen as bad by virtue of the unhappy outcome. Hindsight bias: This is the ‘knew-it-all-along’ effect—the universal tendency to see past events as more foreseeable than they actually were to those immediately involved. Our knowledge of the outcome unconsciously colours our judgements and perceptions of their actions. To us, with 20-20 hindsight, the warnings signs were obvious. But warnings are only effective for those on the spot if they know what kind of a disaster they are going to have. Managerial convenience: By blaming specific individuals for a bad outcome diminishes the organisation’s responsibility Legal convenience: It is much easier to prosecute individuals than organisations.

Följden av att skylla på enstaka individer Systemets svagheter uppdagas inte. Permanenta fallgropar identifieras inte. Ledningen fokuserar på fel saker. En skuldbeläggande kultur och en rapporterande kultur kan inte existera sida vid sida. By heaping blame upon the individual(s) at the sharp end, organisational managers isolate the error-makers from the context in which the error occurred. In so doing, they fail to identify and remedy the error-provoking factors in the workplace (the system’s ‘resident pathogens’). Even more seriously, it prevents the identification and removal of recurrent error traps—situations that keep on producing the same kind of error, regardless of who was directly involved. In short, management has its eye on the wrong ball. Equally significant is the fact that a blame culture and a reporting culture cannot co-exist. People at the sharp end do not trust management not to punish them for the errors and near misses that they report. So they say nothing and nothing is learned by the organisation. Blame may be emotionally satisfying for the blamers but it has little or no remedial benefit. Indeed, it is likely to be counter-productive to safety, leading to a culture of cover up and secrecy.

Westrums klassificering av tre olika säkerhetskulturer Patologisk Byråkratisk Proaktiv The American social scientist Ron Westrum distinguished three kinds of safety culture: pathological, bureaucratic or calculative and generative. The main distinguishing feature is the way in which an organisation handles safety-related information. Generative or high-reliability organisations ‘encourage individuals to observe, to inquire, to make their conclusions known’ and where these have safety significance bring them to the attention of higher management. In sharp contrast, pathological organisations muzzle, malign, or marginalise whistleblowers, shirk collective safety responsibility, cover up failures, and discourage new ideas. In short, they remain in denial. Bureaucratic or calculative organisations (the large majority) lie somewhere in between. They will not necessarily shoot the messenger, but new ideas often present problems and may be viewed as interfering with production goals. Safety management tends to be compartmentalised. Failures are isolated rather than generalised, and are treated by local fixes rather than by systemic reforms Den stora skillnaden ligger i hur säkerhetsrelaterad information behandlas. Vissa förnekar, andra välkomnar den.

Att tänka i orsaksserier hellre än i orsaksnätverk When dealing with complex systems, people have a tendency to think in linear sequences. They reason in causal series rather than in causal networks. They are sensitive to the main effects of their actions upon progress towards an immediate goal but frequently remain unaware of their side-effects upon the rest of the system. In a highly highly-interactive, tightly-coupled system, the knock-on effects of interventions radiate outwards like the ripples in a pool, but people can only ‘see’ their influences within the narrow sector of their current concern. Similarly, people are not good at controlling processes that develop in a non-linear fashion. They almost invariably underestimate their rate of change and are constantly surprised. Here is a real-life example taken from the history of the Royal Navy. In the mid-nineteenth century ships were changing from wood and sail and to iron and steam. Warships of Nelson’s era required large numbers of sailors to handle the ship and man the guns. But in the iron and steam era these needs for manpower were much reduced. Navy captains were faced with the problem of how to employ their crews. They hit upon the culture of ‘brightwork’. The British navy had few rivals in the nineteenth century. Most of their time was concerned with showing the flag to the far-flung outposts of the empire, so having shiny and freshly painted ships suited this purpose. Sailors spent a large proportion of their time painting the wood and metalwork and in polishing the shiny surfaces. The watertight doors between the various sections of the warships were scoured and polished until they were no longer watertight. This was to cost the Royal Navy dearly at the outset of the First World War. Okunskap om biverkningarna

Jakt på fel sorts resultat Ett evigt kretslopp Skuld Jakt på fel sorts resultat Förnekelse This diagram shows how the three pathologies interact to potentiate their damaging consequences. Blaming individuals leads to denial of system problems and this, turn, creates the opportunity to pursue ‘excellence’. The need to achieve productive and non-clinical financial goals is often cited as the reason why necessary systemic improvements can’t be made. In this way, the syndrome continues to create a vicious cycle.

Varning Ingen organisation är helt fri från symptom på det sårbara systemet. Det är djupt rotat i mänsklig tänkande. Vi måste hela tiden leta efter tecken och symtom på säkerhetsrisker. Förutsättningen för en effektiv riskhantering är förmågan att upptäcka varningstecken och en kollektiv vilja att ta dessa på allvar. The Vulnerable System Syndrome is so deeply rooted in human psychology that it exists in some degree in all healthcare organisations. Recognising its presence and taking remedial action is an essential prerequisite of effective risk management.

Tillämpad logik från det sårbara systemet Skuld: Det kan finnas några rötägg, men flertalet medarbetare är bra. Förnekelse: Om flertalet är bra, är den som påstår något annat illvillig - när hade vi senast en negativ händelse? Jakten på fel sorts resultat: Nu när vi har bestraffat rötäggen och tystat tjallarna, kan vi koncentrera oss på att uppnå våra finansiella mål. This slide summarises the managerial reasoning that lies behind the Vulnerable System Syndrome. An adverse event occurs and the ‘guilty’ parties are suspended or dismissed. This leads to the view that while the primary care trust may have a few careless or reckless people on its payroll, the system as a whole is in good shape, and anyone who says differently must have some malicious purpose, so they are either ignored or sidelined. Having identified the ‘guilty’ parties and assured themselves that the system is healthy, the managers now have the opportunity to pursue pressing financial targets or to strive to satisfy political pressures regarding waiting lists and the like.

Två aspekter på kultur Vad en organisation är: gemensamma värderingar och uppfattningar. Vad en organisation har: strukturer, metoder och system. Att förändra strukturer, metoder och system är lättare än att förändra värderingar och uppfattningar. The social science literature has many definitions of culture. But they can be grouped into two clusters. Those that stress the unspoken attitudes and beliefs of the organisational members: something the organisation is. And those that stress what the organisation does in the way of structures, practices and systems: something the organisation has. There can be no doubt that it is extremely difficult to change adult attitudes directly. Think how long it has taken to reduce the number of smokers to a relatively small group. It has taken around 40 years to achieve this. Smokers have known throughout all of this time that smoking could kill them. But this knowledge alone did not significantly change their behaviour. Now, most buildings have outlawed smoking. To satisfy their need, smokers have to indulge their habit outside the front door or in foul-smelling and dirty rooms set aside for the purpose. This practice has greatly reduced their desire to smoke. They are also tired of being treated as pariahs. In short, changing practices has changed attitudes.

Att skapa en säkerhetskultur Metoder och strukturer Uppfattningar och värderingar Använda och göra Tänka och tro This slide spells out in diagrammatic form the message of the previous slide. Getting people to change the way they do things (by changing organisational practices) eventually changes the way they think and believe if these practices are shown to be effective.

Kan en god säkerhetskultur skapas i ett socialt sammanhang? Till en viss grad, JA Genom att skapa ett system, som samlar in säkerhetsdata, analyserar och sprider information om händelser, tillbud och andra "gratislektioner". EN RAPPORTERANDE KULTUR För att lyckas behövs personalens förtroende. EN RÄTTVIS KULTUR This slide argues that it doesn’t require some kind of mystical experience to change culture. The changes can be socially engineered through the implementation of specific practices.

Att skapa en rättvis kultur En kultur utan skuld är varken möjlig eller önskvärd. Det finns ageranden som kräver sanktioner. En rättvis kultur styrs av Personalens tillit. Personalen känner till och instämmer i skillnaden mellan acceptabelt och oacceptabelt beteende. Decades ago, most high-technology organisations were punitive cultures: people got punished if they caused damage without regard to the nature of the actions involved. Many HC institutions still operate this way. In the 1980s, the phrase ‘blame-free’ culture came along. But that is equally inappropriate. Some actions deserve punishment. Some people are truly reckless and should be removed from the system. The important thing that everyone must understand is where the line should be drawn between acceptable and unacceptable actions, between blameworthy and blameless behaviour.

Enligt brittisk lagstiftning Försumlighet: ett handlingssätt som en "klok och förståndig person" borde ha förutsett och undvikit. Handlingen behöver inte vara avsiktlig. Främst en civilrättslig fråga. Vårdslöshet: innebär att ta en avsiktlig risk som inte kan rättfärdigas. Främst en straffrättslig fråga. The law identifies two kinds of actions: those that are merely negligent and those that are reckless. The latter involves a deliberate departure from safe practice and deserves a severe sanction, even dismissal.

Patientsäkerhetslag - SFS 2010:659 gäller fr.o.m.2011-01-01 3 kap. Vårdgivarens skyldighet att bedriva ett systematiskt patientsäkerhetsarbete 1 § Vårdgivaren ska planera, leda och kontrollera verksamheten på ett sätt som leder till att kravet på god vård i hälso- och sjukvårdslagen respektive tandvårdslagen upprätthålls. 6 kap. Skyldigheter för hälso- och sjukvårdspersonal m.fl. 4 § Hälso- och sjukvårdspersonal är skyldig att bidra till att hög patientsäkerhet upprätthålls.

Beteendemönster 10% 90% Skuldbelagd Ej skuldbelagd Sabotage Drogmissbruk Vårdslöshet, mm. Systemframkallade överträdelser “ärliga" misstag systemframkallade fel osv. Evidence from other areas—particularly aircraft maintenance (something that has a lot in common with frontline HC activities)—indicates that only about 10% of unsafe acts fall clearly into the culpable category. The vast majority are blameless, and so could be safely reported—if the reporters really trusted the system.

Beslutsträd 10 % 90 % Forma en säker kultur Minskande skuld Medveten överträdelse av regler? Fanns det regler, är de tydliga och korrekta? Vårdslös över- trädelse med oavsiktlig skada System- framkallad trädelse JA NEJ Kunde någon annan gjort samma misstag? Brister i utbildning & urval eller oerfarenhet? NEJ Eventuell för- summelse System- framkallat fel JA Var handlingen avsiktlig? Var följderna förväntade? Sabotage, avsiktlig skada, självmord m.m. JA NEJ Icke godkänd substans? Medicinskt tillstånd? Drog- missbruk Drogmissbruk med förmildrande omständighet NEJ JA Skuldfritt fel Historik av icke säkra sätt att agera? JA NEJ Skuldfritt fel men korrigerande utbildning eller rådgivning behövs 10 % 90 % Minskande skuld Det här beslutsträdet belyser några situationer som kan förekomma när man ska bestämma om handlingen ska följas av en påföljd eller inte. Vi föreslår att detta beslutsträd används som underlag vid en diskussion. Frågan är: var går gränsen? 2011 03 21

Skapa en rapporterande kultur Garanterad frihet från sanktioner. Sekretess och/eller anonymitet. Klipp banden mellan rapportering och disciplinpåföljd. Snabb, användbar och begriplig återkoppling. Enkel rapportering This slide summarises the features that have made aviation reporting systems successful. Reporters are not offered blanket immunity. Instead, they are given qualified indemnity against sanctions. Some reporting systems favour complete anonymity. But this prevents the analysts seeking more information from reporters. The general opinion is that reporters should be protected by confidentiality and/or de-identification. It is extremely important that those who collect and analyse the incident data should not also be the ones with the power to suspend or punish. No one will continue reporting if their efforts disappear without trace into some organisational black hole. Rapid, useful and intelligible feedback to the reporters is an essential feature. If the reporting forms are complex and laborious to complete, few people will take the time to use them. The general finding is that most respondents prefer free text accounts (rather than forced-choice tick boxes). This places the burden of analysis where it belongs—on the analysts.

Gemensam medveten närvaro Var ständigt uppmärksam på mänskliga, tekniska och/eller systemrelaterade fel. Räkna med att fel begås och utbilda personalen till att förutse och åtgärda dem. Arbeta hårt för att skapa en rapporterande kultur och lär så mycket som möjligt av den begränsade information som händelserna ger. Se tillbud och händelser som generella och inte lokala fenomen. Inventera nya risker i systemet som skulle kunna ge upphov till fel . Dr Karl Weick, a social psychologist (perhaps one of the greatest) at the University of Michigan Business School, coined the phrase ‘collective mindfulness’ to describe the essence of high-reliability organisations. The features of collective mindfulness are listed on the slide. They provide a concise description of the characteristics that organisations struggling to develop a safe culture might aspire to. They represent the opposite end of the spectrum from the vulnerable system syndrome described at the beginning of this module. Possession of these features does not guarantee immunity against bad events, rather they make systems more resilient, more robust, and better able to withstand the inevitable human and technical failures that occur, from time to time, in complex systems operating in hazardous conditions.

Slutsatser Nyckeln till en säker kultur är en förnuftig försiktighet i kombination med kunskap om var gränsen går mellan acceptabelt och oacceptabelt beteende. Det kräver: Ett effektivt system för säkerhetsinformation Tillit från personalen EN RÄTTVIS KULTUR är den avgörande faktorn Kultur är nyckeln eftersom den I sig själv (på gott och ont) påverkar systemets många och olika skydd och barriärer. If HC is to achieve greater levels of patient safety. It must strive to engineer a safer culture—something that affects all parts of the system. There is always a temptation to go out and acquire technological fixes that appear to make the system more error-proof. While such measures are necessary, they are not sufficient by themselves to achieve enduring patient safety. Often these technological fixes do not remove error provoking conditions, they merely relocate them to other parts of the system—the early years of radical automation on the flight decks of commercial aircraft demonstrated this harsh fact. What is needed is a radical change of culture and the development of ‘collective mindfulness.’