Presentation
Moving towards proactive safety: pragmatic guidance, powerful findings
DescriptionThis panel will bring together practitioners and academics who have been wrestling with how to operationalize the theories on how to implement proactive safety practices in order to keep patients safe. In synthesizing our experiences, we identify two major shifts in thinking that opened up the possibility of doing this work. We introduce these shifts as a framework of stages of safety management capability, moving from incident-based (IBS) to competency-based (CBS) to adaptation-based safety (ABS). We use the language of stages because even though they imply roughly independent targets for where safety management energies are directed, adopting later-stage perspectives encompasses the earlier-stage targets. This newly-adopted perspective will invariably influence how the safety management work is conducted. For example, after a group has adopted the adaptation-based perspective, such as Systemic Contributors and Adaptations Diagramming (SCAD, Jefferies et al., 2022), work to investigate incidents will be performed through the lens of adaptation (e.g., through event-based SCAD). In this example, the Adaptation-based Safety perspective changes how we consider the incident that is being encompasses Incident-based Safety work. This framework does not imply that any of these stages are bad, but describes how perspectives that are absent in earlier stages are critical to understanding the overall work of the system as well as the work of the safety management function in later stages. It also reinforces that later-stage programs will not and should not abandon the targets of inquiry of earlier stages (e.g, incidents), but instead will invariably see them in a different way. Later-stage organizations will not necessarily do more proactive safety work than earlier-stage organizations, but are more likely to do so, as these later-stage perspectives require tools and methods that are more conducive to proactive work.
Topics of the panel will include:
1. The three stages of safety management capability, how they are different from each other, and how an organization can move through them.
2. The differences between reactive, responsive, and proactive safety work
3. How our work at our individual medical centers is aligning with each of the three stages of safety management capability.
4. How different parts of our organizations are currently at different stages than each other, and how that causes inter-organizational tension.
5. How we spearheaded efforts in our own local teams and in socializing across our organizations
6. The barriers and facilitators of adopting the IBS, CBS, and ABS stages of capability.
Our moderator will be Dr. Mike Rayo, the director of the Cognitive Systems Engineering Laboratory (CSEL) and Associate Professor of Integrated Systems Engineering at The Ohio State University. He co-invented SCAD with David Woods and has been working with organizations in multiple sectors to implement proactive safety programs focused on competency-based and adaptation-based perspectives of safety and performance. He is currently working with two groups at The Ohio State University Wexner Medical Center (OSUWMC), the Sterile Processing Department (SPD) at the Medical University of South Carolina, and the Air Force Installation Contracting Center (AFICC).
Our panelists include:
• Dr. Kenneth Catchpole: Dr. Catchpole is the SmartState Endowed Chair in Clinical Practice and Human Factors and leads the embedded Human Factors team at the Medical University of South Carolina. He will be speaking about how his work on shifting from only looking at incidents and focusing on blame to focusing on how work is really done at his institution and supporting that work has led to interesting insights that were not previously obvious to the organization.
• Christine Jefferies: Ms. Jefferies is a PhD candidate in the CSEL laboratory and is leading the proactive safety and performance efforts at OSUWMC and AFICC. She will speak about obstacles and difficulties in socializing later-stage perspective to key organizational stakeholders, and how the OSU team is using extramural grant funding to create an extended safety organization to prove out the value of these later-stage perspectives and produce valuable insights that otherwise would remain hidden.
• Dr. Nicoleta Kolovos: Dr. Kolovos is an Attending Physician at St. Louis Children’s Hospital and an Associate Professor of Pediatrics at the Washington University School of Medicine. She will speak about her experience in being part of the first team to use the SCAD method to reveal new insights about her institution, their current progress, and the barriers that they have faced in expanding their program.
• Jeff Brown: Mr. Brown is a Principal at the System Safety Group and Safer Healthcare, and until recently has been leading efforts to implement a proactive patient safety capability in a multi-site rural primary care organization. He will talk about his efforts and successes in moving this program forward in the face of extreme resource and funding constraints, and its ability to create a healthier organizational climate and proactive risk mitigation capability.
• Dr. Sudeep Hegde: Dr. Hegde is an Assistant Professor in the Department of Industrial Engineering at Clemson University. He will speak about his current work using SCAD to further his research on both formal and informal information flows, and how his findings and suggestions will be used to influence future interventions in SPD and perioperative care at MUSC.
REFERENCES
Jefferies, C. M., Balkin, E. A., Groom, L., & Rayo, M. F. (2022, October). Developing Systemic Contributors and Adaptations Diagramming (SCAD): Systemic insights, multiple pragmatic implementations. 2022 Human Factors in Healthcare Symposium.
Topics of the panel will include:
1. The three stages of safety management capability, how they are different from each other, and how an organization can move through them.
2. The differences between reactive, responsive, and proactive safety work
3. How our work at our individual medical centers is aligning with each of the three stages of safety management capability.
4. How different parts of our organizations are currently at different stages than each other, and how that causes inter-organizational tension.
5. How we spearheaded efforts in our own local teams and in socializing across our organizations
6. The barriers and facilitators of adopting the IBS, CBS, and ABS stages of capability.
Our moderator will be Dr. Mike Rayo, the director of the Cognitive Systems Engineering Laboratory (CSEL) and Associate Professor of Integrated Systems Engineering at The Ohio State University. He co-invented SCAD with David Woods and has been working with organizations in multiple sectors to implement proactive safety programs focused on competency-based and adaptation-based perspectives of safety and performance. He is currently working with two groups at The Ohio State University Wexner Medical Center (OSUWMC), the Sterile Processing Department (SPD) at the Medical University of South Carolina, and the Air Force Installation Contracting Center (AFICC).
Our panelists include:
• Dr. Kenneth Catchpole: Dr. Catchpole is the SmartState Endowed Chair in Clinical Practice and Human Factors and leads the embedded Human Factors team at the Medical University of South Carolina. He will be speaking about how his work on shifting from only looking at incidents and focusing on blame to focusing on how work is really done at his institution and supporting that work has led to interesting insights that were not previously obvious to the organization.
• Christine Jefferies: Ms. Jefferies is a PhD candidate in the CSEL laboratory and is leading the proactive safety and performance efforts at OSUWMC and AFICC. She will speak about obstacles and difficulties in socializing later-stage perspective to key organizational stakeholders, and how the OSU team is using extramural grant funding to create an extended safety organization to prove out the value of these later-stage perspectives and produce valuable insights that otherwise would remain hidden.
• Dr. Nicoleta Kolovos: Dr. Kolovos is an Attending Physician at St. Louis Children’s Hospital and an Associate Professor of Pediatrics at the Washington University School of Medicine. She will speak about her experience in being part of the first team to use the SCAD method to reveal new insights about her institution, their current progress, and the barriers that they have faced in expanding their program.
• Jeff Brown: Mr. Brown is a Principal at the System Safety Group and Safer Healthcare, and until recently has been leading efforts to implement a proactive patient safety capability in a multi-site rural primary care organization. He will talk about his efforts and successes in moving this program forward in the face of extreme resource and funding constraints, and its ability to create a healthier organizational climate and proactive risk mitigation capability.
• Dr. Sudeep Hegde: Dr. Hegde is an Assistant Professor in the Department of Industrial Engineering at Clemson University. He will speak about his current work using SCAD to further his research on both formal and informal information flows, and how his findings and suggestions will be used to influence future interventions in SPD and perioperative care at MUSC.
REFERENCES
Jefferies, C. M., Balkin, E. A., Groom, L., & Rayo, M. F. (2022, October). Developing Systemic Contributors and Adaptations Diagramming (SCAD): Systemic insights, multiple pragmatic implementations. 2022 Human Factors in Healthcare Symposium.
Event Type
Discussion Panel
TimeMonday, March 253:30pm - 4:30pm CDT
LocationSalon A-3
Patient Safety Research and Initiatives