GI Unit Leadership: (Re)Starting Your Quality Program (Virtual only)

08_Martin_Safe Culture
Pdf Summary
In this presentation, Dr. John Martin discusses the importance of creating a safe culture for patients in healthcare settings. He defines patient safety culture as the extent to which an organization's culture supports and promotes patient safety. This includes values, beliefs, and norms shared by healthcare practitioners and staff that influence their actions and behaviors. Patient safety culture exists at multiple levels, from the unit level to the organization and system levels.<br /><br />Dr. Martin emphasizes the need to address medical errors and avoidable accidents in healthcare, as patients continue to be harmed. He mentions the book "To Err is Human" by the Institute of Medicine, which highlights the problem of good people working in bad systems. Medical errors are estimated to cause 98,000 deaths per year, surpassing deaths from MVAs, breast cancer, or AIDS.<br /><br />While the numbers may be debated, Dr. Martin acknowledges that work needs to be done to improve patient safety. He quotes Mark Chassin, President of The Joint Commission, who emphasizes the need for healthcare leaders to commit themselves to achieving zero harm and to overhaul the culture within their organizations. This includes supporting staff who report safety issues, encouraging error sharing, modeling safety behavior, and treating staff fairly when mistakes are made.<br /><br />To transform the culture, Dr. Martin suggests focusing on equality, responsibility, openness, systems, accountability, and privacy. He also discusses the use of process improvement methods such as Lean, Six Sigma, and rapid process/cycle improvement. These methods help reduce waste, remove defects, and improve processes in delivering care.<br /><br />Dr. Martin mentions the Joint Commission's National Patient Safety Goals and the need for standardization in medical error investigation. He suggests learning from other industries, such as the airline industry, which thoroughly investigates accidents and shares the results to prevent future incidents.<br /><br />In his own institution, the Endoscopy section at Mayo Clinic, Dr. Martin mentions practices like daily huddles, time-outs before procedures, patient safety measures during procedures, reconciling specimens and instructions post-procedure, detailed signouts, managing complications, and regular quality committee and performance reviews.<br /><br />Dr. Martin concludes by emphasizing the importance of a commitment to zero harm and a safety culture that benefits patients and the organizations themselves. He stresses that creating a safe culture requires more than just superficial changes but requires a shared goal, a supportive culture, and a reliable process for addressing risks.
Keywords
patient safety culture
healthcare settings
medical errors
avoidable accidents
To Err is Human
Institute of Medicine
zero harm
process improvement methods
National Patient Safety Goals
Mayo Clinic