Becoming Deeply Safe

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One of the sessions I attended at the Institute for Healthcare Improvement’s conference in early December really got me thinking. I enjoy it when I’m challenged on assumptions or my usual approach to doing things, and am given something new to think about. I registered for this session because, perhaps like many of us who have been working on improving safety, I had been feeling stuck. The speaker was Carol Haraden, PhD, a Vice President at the IHI, and I’ll summarize what I took away from her talk – this blog may not represent literally what she said, but it’s what I learned.

• Establish a ‘culture of dissatisfaction’ – always be on the lookout and find all the ways to fail.
• Embrace the safe work-arounds, and measure their effect. We know that staff are remarkably creative at developing work-arounds, which exist largely because what we try to impose does not work. If the work-around is safe, learn from it.
• Standardize that which can be standardized, and nothing more; allow improvisation and adaptation; cultivate a culture where these adaptations are not ‘breaking the rules.’ Insist on discussing and learning from both standardization and adaptation.
• What appears safe and reliable is often an infrequent event just waiting to happen; “non-events” do not demonstrate that the system is safe.
• Two questions that leaders can ask of staff:
  • ‘Have you ever been in a situation where you couldn’t follow a policy/procedure designed to make care safe?’
  • ‘Have you ever been in a situation where you have had to manage off-service patients on your unit (e.g., orthopedic surgery patients on a neuro floor)? How did you manage to safely care for them? ‘ Carol pointed out that we wouldn’t want to put up a billboard saying “You’ll get safe care at our hospital…as long as you are only taken care of on the floor specific to your condition, and cared for exclusively by staff who take care of only patients with your condition.”

A concept Carol presented that opened my eyes is what I’ll call “safety creep” although its official name is “System Migration to Boundaries.” First, there is a right way of doing things: this is an expected ‘safe space’ of action defined by professional standards. For example, two nurses check each unit of blood before administering it, and one checks the patient’s ID band: this is the safe space of action.

Over time the behavior starts to creep over to the “illegal but normal” real life standards, aka usual way of doing things: when we’re busy, we still have two nurses check the bag, but it’s ok not to check the ID band (we know who are our patients are, right?).

Creep continues into the ‘illegal illegal’ or very unsafe space, with increasing chance of accidents. For example, now we don’t find a second nurse to check the bag, nor do we check the ID band. Most of us would call that ‘an accident waiting to happen.’ These are the circumstances where, when something bad happens, anyone can say in retrospect, “Why did they keep doing that? Didn’t everyone see how unsafe it was?”

One reason for erosion in safe practices is that as new staff enter this work environment, they are oriented not to the ‘safe space’ or right way of doing things, but to the ‘illegal but normal’ standards that are the practice in that setting. Thus they perceive these standards as the safe space of action, when in fact they are illegal but normal. Unless we continually work to move back to the expected safe space from the usual space, and orient/train to the safe space, we are allowing safety to degrade.

Best wishes for a safe and happy new year.

Thoughts? Share with me here. Miriam Marcus-Smith, Program Director, WPSC

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