Identify Culture презентация

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Improving Culture: Not as easy as it appears Culture: How is it relevant to better care? What is current state TRIZ: a way to get the front line engaged Teamwork

Слайд 1Identify Culture
Communication

Behavior

Rituals

Tolerance

From Dr. Scott Ellner, St Francis Hospital & Medical Center,

presented June 27, 2013

Слайд 2Improving Culture: Not as easy as it appears
Culture: How is it relevant

to better care?
What is current state
TRIZ: a way to get the front line engaged
Teamwork and Communication “Ins and Outs”
How can you apply some of these tools?



Слайд 3Why culture?
Silence Kills Study
90% of JAHCO never events linked to communication
17

years to implement best practice
Reviews of academic literature conclude correlation between culture & outcomes

1. Disease-Specific Care Certification – National Patient Safety Goals. Oak Brook Terrace (IL): The Joint Commission; 2008. Available from: www.jointcommision.org.

Слайд 4HCAHPS
92
50
Medication Errors per Month
2.0
6.1
Days between C Diff Infections
121
40
Days between Stage 3

Pressure Ulcers

52

18


Illustrative Data:
Extracted from
Blinded Client Data

Слайд 5What are you seeing around culture issues?
Poll Everywhere

Слайд 7Complex adaptive systems are composed of many interdependent, heterogeneous parts that

self organize and co-evolve.

Unpredictable

(Camazine, 2001; Kauffman, 1995; Allen & Varga, 2006)

Слайд 8Three Core Elements Our System
Structure
Process
Patterns of Behaviour





Fritjot

Capra

Слайд 10At present, prevailing strategies [in healthcare] rely largely on outmoded theories

of control and standardisation of work. More modern and much more effective, theories seek to harness the imagination and participation of the workforce in reinventing the system Don Berwick, Former CEO, Institute for Healthcare Improvement

Слайд 12Self-Organization

Self-organization is a process whereby local interactions give rise to patterns

of organizing.

ADAPTIVE – RESILIENT – UNCERTAIN
(and difficult to manage)

H.J. Lanham et al., How complexity science can inform scale-up and spread in health care:
Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)

Слайд 13Interdependencies Overarching term for relationships, connections, and interactions among parts of a

complex system.

Pre-Intervention

Post-Intervention

Lindberg, C., & Clancy, T. R. (2010). Journal of Nursing Administration

Слайд 14Sense Making


Слайд 15So now what? How do we lead in a complex system…
Acknowledge Unpredictability
Allow

design to be tailored to local contexts
Emphasize discovery in each intervention setting

Recognize Self-Organization
Develop “good enough”
Facilitate sense-making


H.J. Lanham et al., How complexity science can inform scale-up and spread in health care:
Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)

Слайд 16So now what? How do we lead in a complex system…
Facilitate Interdependencies
Reinforce

existing relationships when effective or foster new ones
Encourage sense-making

Encourage Experimentation
Encourage participants to ask questions, admit ignorance and deal with paradox
Seek out different points of view


H.J. Lanham et al., How complexity science can inform scale-up and spread in health care:
Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)

Слайд 17Adaptive in leadership style
Ask more questions rather than issuing more directives
Build

extra time into meeting agendas so that the adaptive challenges do not get either bypassed in favor of more immediate concerns or treated with short-term technical fixes
Expand the circle of individuals who need to be consulted in exploring possible solutions to the problem 

Ron Heifetz

Слайд 18Stay close to those who oppose your ideas; spend time with

them, ask for their input on your initiative, listen closely to their reality (especially when it differs from yours), and take their temperature.

Ron Heifetz

Слайд 19

TECHNICAL
CULTURE/ ADAPTIVE

Слайд 20
Ron Heifetz, The Practice of Adaptive Leadership
2009
Distinguishing technical problems
and

adaptive challenges


Слайд 21Example Reducing Urinary Tract Infections on my unit

Слайд 22“the most common cause of failure in leadership is produced by

treating adaptive challenges as if they were technical problems.”

Ron Heifetz

Слайд 24Culture eats strategy for lunch!

Слайд 25“The source of energy at work is not in control, it

is in connection to purpose.”
Don Berwick

Слайд 27Christina Costello,
Babson Entrepreneur Experience Lab

Слайд 28“I have a dream”
“I have some new clinical guidelines for you….”

Слайд 29Framing
Connect with people’s hearts and minds
Turning opportunity into action
Hooks to pull

people in
Springboards for mobilizing support
Need to be authentic and connect with reality

Слайд 33TRIZ
DESIGNING A PERFECTLY ADVERSE SYSTEM
THE WORST POSSIBLE RESULTS FROM YOUR

WORK

Слайд 34Lipmanowicz, McCandless


PALETTE OF LIBERATING STRUCTURES
Designer: Lesley Jacobs

Слайд 35Why do we use TRIZ?
Creative destruction

Challenge the status quo & sacred

cows

Gives permission to discuss taboo subjects

Builds trust

Слайд 36TRIZ – First Step

Be creative! Make yourself laugh! This is SERIOUS

FUN…..

Reflect in your small group, make a list of “to do’s” in answer to:


Слайд 37How will we make the best ideas fail?

How will we stifle

creativity in our staff?

How can we be sure that our staff morale is rock bottom?

How do we ensure that our we harm patients/residents when they are here?

Pick one you like!

Слайд 38TRIZ – Second Step
Go down the list and ask:

Is there anything

on this list that we currently practice, even remotely?
Is there an element of truth in here?


Cross out the ones that you are not doing EVER.

Слайд 39TRIZ – Third Step
Look at your list…what items do you want

to commit to avoiding?

Pick your top two. What will you do to avoid those items?

Do you need leadership or organizational help?
What needs to stop or change? Be as concrete as you can.

Слайд 40When you are dealing with an adaptive challenge that requires creativity,

you have to tolerate the pains of processes that increase the odd that new ideas will lead to new adaptive capacity.

Ron Heifetz

Слайд 41Teamwork and Communication “Ins and Outs”
Allison Muniak, M.A.Sc
Human Factors Specialist
BC Patient

Safety and Quality Council

Слайд 42The Culture Toolkit


Слайд 45What is Human Factors?

Слайд 46 designing for human use

a body of information about human abilities, human

limitations, and other human characteristics that are relevant to design

Chapanis, A. (1995, p. 11). Human Factors in Systems Engineering. Toronto: John Wiley.

Слайд 47 the application of human factors information to the design

of tools, machines, systems, tasks, jobs, and environments for safe, comfortable and effective human use

Chapanis, A. (1995, p. 11). Human Factors in Systems Engineering. Toronto: John Wiley.

Слайд 50 We cannot change the human condition,

but we can change the

conditions under which humans work


James Reason
(BMJ 2000;320:768)

Слайд 52Teamwork

Слайд 54Perception

Слайд 55Fatigue

Слайд 56Attention

Слайд 57Improving Culture
Team-Building Games
Power Distance Index
Observations
Peer coaching teams
Debriefing

Слайд 58TELEPHONE GAME

Слайд 59Rules:
Speaker cannot repeat the message
No one can ask questions
Do not write

anything down

Слайд 60How did it go?

Слайд 61What tactics did you use to remember?

Слайд 62Please mix me 2 gm of Ancef in 100 ml bag

of normal saline which you need to run down to Dr. Bossy in OR 4 to catch the orthocase starting at 10 am.

Слайд 63Rules:
The person who hears the message repeats back what they heard
They

may also ask a clarifying question
The speaker can repeat the message or clarify discrepancies
*Each person can only repeat-back once for this exercise

Слайд 64How did it go?

Слайд 65How was your memory during Round 2?

Слайд 66Mrs. Johnston needs to have her antipsychotics reduced as I think

it is too much for her. Can you be sure to raise this in the care meeting today but make sure to tell them that she used to be on half the dose she is on now and functioned much better.

Слайд 67Critical Language
A phrase that is commonly understood to imply “stop

the line – there is a safety concern”


Example: I need clarity

Слайд 69GP: I’m concerned about how sick your mother is. Her breathing

is getting worse. How are you doing looking after her?

Daughter: It’s just me looking after her and it’s getting tougher and tougher doing this all by myself.

GP: It sounds like this is becoming more of a problem and I’m getting uncomfortable with having this load on you at home.

Daughter: I’m just about at the end of my rope, I don’t think that I can look after her anymore.

GP: I think that we will have to stop what we are doing and get you some help caring for her.

Daughter: I found her on the floor this morning and hurt my back getting her back into bed by myself.

GP: This is becoming a safety issue for both you and your mom. We can get some home care to help with her medication and personal care and give you a break until she gets better.

Слайд 70Power Distance Index

Слайд 71 “Power distance is the extent to which less powerful members of

organizations and institutions accept and expect that power is distributed unequally.”

A high power distance score accepts a hierarchical order in which everyone has a place that needs no further justification.

The higher the power distance in a culture, the less likely those in subordinate roles will question the actions or directions of individuals in authority.

Geert Hofstede’s Power Distance Index
www.Clearlycultural.com

Слайд 72High Power Distance Index Cultures
Authority and demonstrate rank.
Subordinates expect clear guidance

from above.
Subordinates are expected to take the blame for things going wrong (Collateral damage).
The relationship between boss and subordinate is rarely close or personal.
Class divisions within society are accepted.

Slide courtesy of Ron Collins, 2014

Слайд 73http://www.reply-mc.com/2011/12/27/unraveling-social-interaction-part-4/

Слайд 74Can hierarchy cause plane crashes?

Слайд 75 “Korean Air had more plane crashes than almost any other airline

in the world for a period at the end of the 1990s. When we think of airline crashes, we think, ‘Oh, they must have had old planes.’ They must have had badly trained pilots. No. What they were struggling with was a cultural legacy, that Korean culture is hierarchical. You are obliged to be deferential toward your elders and superiors in a way that would be unimaginable in the U.S.

But Boeing and Airbus design modern, complex airplanes to be flown by two equals. That works beautifully in low-power-distance cultures [like the U.S., where hierarchies aren't as relevant]. But in cultures that have high power distance, it’s very difficult.”

Malcome Gladwell,
Outliers – The Story of Success

Слайд 76Canada
Power Distance Index

Слайд 77Canada
Canadian culture is marked by interdependence and value placed on egalitarianism.


Lack of overt status and/or class distinctions in society.
Hierarchy in Canadian organisations is established for convenience.
Superiors are always accessible and managers rely on individual employees and teams for their expertise. 
Managers and staff members consult one another and share information freely. 
With respect to communication, value a straightforward exchange of information.

Power Distance Index
Score = 39

Слайд 78What do you see in a high power distance index?
Senior-level people

get no information
Senior leaders perceive that everything is going well
Junior-level people do not bring ideas forward.

It’s hard to innovate under these conditions.

Geert Hofstede
http://geert-hofstede.com

Слайд 79Questions to ask yourself?
Are you aware of how others react to

you?
Do they start or stop talking when you enter the room?
Do you feel you can not talk to higher levels in the organization without permission.
Does your organization encourage the use of titles and position

Слайд 80Situational Leaders

Слайд 81Let’s Talk Culture! How can you create experimentation?

Слайд 82“best failure” ritual
Who is brave enough to share your biggest bomb

from last week?
Focus on what you’ve learned most from a mistake

Слайд 83Coaching

Слайд 84Coaching

Слайд 85Communication Approaches
Command
Team Obligation Statement
Team Suggestion
Query
Preference
Hint

Slide courtesy of Ron Collins, 2014

Слайд 86Example
A patient has been prepped and draped, and as the surgeon

reaches for the scalpel to begin a right total hip arthroplasty, the circulating nurse notes that the X-Ray on the screen is of a left hip!

This nurse must now assume the role of situational leader; her role is to raise the situational awareness of the entire operating team.

The question is this: “What does she say?”

Slide courtesy of Ron Collins, 2014

Слайд 87Slide courtesy of Ron Collins, 2014

Слайд 88Communication Approaches
Command
Team Obligation Statement
Team Suggestion
Query
Preference
Hint

Slide courtesy of Ron Collins, 2014

Слайд 90Hint
Is intended to be very general. A hint does not have

any personal reflection or engagement in it; it is not a personal statement! Think “insinuation, innuendo, pointer, whisper….”

For example: “It would be nice to get through the day without making any mistakes.”

Слайд 91Preference

Слайд 92Preference
A weakly stated request that recognizes that several options exist. The

person stating the preference does take personal ownership of their idea or request, but it lacks a really strong stance.

For example: “I wish I was in another OR right now!”

Слайд 94Query
A query is a question to draw other’s attention to a

situation without being very direct. The person asking the question is weakly attempting to raise the situational awareness of the rest of the team by calling into question the validity or accuracy of an emerging situation.

For example: “Is that the correct X-Ray?”

Слайд 95Team Suggestion

Слайд 96Team Suggestion
Elevates the personal statement of one member of the team

to engage the situational awareness of the rest of the team. It may be couched as a personal statement, but it clearly raises the comment to the level of the team; look for ‘we’! The suggestion is not a command and does not suggest an obligation to act: it is only raising awareness.

For example: “Can we check the X-Ray please?”

Слайд 97Team Obligation Statement

Слайд 98Team Obligation Statement
A team obligation statement is a strong call to

mobilize the situational awareness of the team. It involves a ‘we’ but includes a ‘must’ or a ‘should’ as well.

For example: “Before we go any further, we need to verify which side this patient has consented to.”

Слайд 99Command

Слайд 100Command
A command is the highest form of one member of a

team raising the situational awareness of the team. It is an imperative to either act or to not act due to impending harm.

For example: “Stop! We are about to make a mistake that will harm this patient

Слайд 101Slide courtesy of Ron Collins, 2014

Слайд 102
BCPSQC Menu of Support

Слайд 103Contact
Marlies van Dijk
mvandijk@bcpsqc.ca

Allison Muniak
amuniak@bcpsqc.ca

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