Presentation
Building Capacity for Proactive Safety Within a Large Rural Primary Care Organization: An Application of the Systemic Contributors and Adaptations Diagramming Technique
DescriptionThis presentation shares the experience of advising a multisite rural primary care organization in its effort to develop a proactive patient and staff safety management capability during worsening financial duress and a deepening workforce shortage. This work was undertaken at the behest of organization’s Chief Executive Officer (CEO), who established the strategic goal of becoming a Coproductive Learning Health System (CPLHS) (Gremyr, A. et al., 2021), beginning with the implementation of a Patient Safety Evaluation System (PSES) as the organization's foundational learning structure (Boulanger, J., Keohane, C., & Yeats, A., 2019). Twenty-four months of embedded collaboration with staff at all levels of the organization followed; to identify structures, processes and strengths of practice that could be blended and shaped into a foundational PSES that would enable “guided adaptability” (Provan et al., 2018).
It quickly became apparent that, although serving more than 50,000 patients, the organization was entrenched in a reactive approach to managing operations that was largely divorced from frontline reality and neither systematic nor methods based. Consistent with work in any complex adaptive system--amplified by the absence of a continuous improvement structure--the managers and staff in the organization’s clinics, laboratories, and pharmacies developed myriad local workarounds to systemic problems. These adaptations operated ‘under the radar’ until either a patient harm event occurred, or revenue goals were not met. The organization’s response to either situation entailed managerial reviews that dwelled on the judgment exercised by staff, their deviation from policy, and what “they should have done”. Because the work practices of staff members involved in a patient harm event rarely aligned closely with policy, their “non-compliance” was often considered causal. The severity of disciplinary action would depend on the severity of the bad outcome. By overlooking systemic drivers of “work as performed”, leaders were blind to conditions that yielded both ongoing risk of harm and potentially desirable adaptations that could be scaled for safety, efficiency, and improvement of staff morale.
Twenty-one months into the experience of supporting staff through repeated setbacks in their efforts to develop a PSES as an operational structure and capability for organizational learning and improvement, a member of the organization’s executive team stepped-up as the CPLHS champion. Her advocacy pushed open the door to operations more fully, creating the opportunity to utilize Systemic Contributors and Adaptations Diagramming (SCAD) (Jefferies et al., 2022) to engage staff in developing an approach to overcoming systemic impediments to timely response and support for patients experiencing a mental health crisis. This effort was in response to concerns expressed by administrative and clinical staff for patient safety and staff welfare over a period of years.
This presentation will share the key events and lessons learned on the road to this breakthrough, including the benefit of identifying existing staff who have the professional knowledge and skill to readily engage in SCAD or other inquiry and observation-based approaches to safety management. The executive champion’s support to recruit these individuals and authorize their time to participate in this effort was invaluable within this organization given that staff were not otherwise authorized or supported to engage in learning methods for knowledge elicitation, analysis, and systemic change.
To make progress, the advisor teamed with a veteran psychotherapist to elicit staff experience of conditions that impeded or enabled timely and effective response to patients expressing suicidality. Although the interviewers were restricted to engaging with staff only during the staff members’ half-hour lunch time, there was universal staff desire to participate, across multiple roles and organizational settings. Subsequent analysis of narrative data from 16 interviews led to recommendations to optimize the process of connecting a patient expressing suicidality to a provider who is prepared to help. Additional recommendations to overcome constraints in performing other work in the same context were also elicited. The organization’s Patient Safety Committee, reinvigorated under the leadership of the executive champion, subsequently reviewed, and is implementing, recommendations developed through the SCAD process. The door has been opened for not only proactive assessment, but ongoing monitoring for intended and unintended effects of systemic change, across scale.
In addition to describing the fragile wayfinding to proactive safety in a rural organization, this presentation will note the burden on conscience (Jokwiro, Y., Wilson, E., & Bish, M., 2022). that may be experienced by embedded practitioners when there is an absence of leadership urgency for analyzing and mitigating conditions that that are harming patients and propagating moral harm among staff. Emotional distress experienced as an embedded practitioner can be significant and cannot be readily balanced by the gratification of helping personnel who want to develop a healthier organizational climate and proactive risk mitigation capability.
References
Boulanger, J., Keohane, C., & Yeats, A. (2019). Role of patient safety organizations in improving patient safety. Obstetrics and Gynecology Clinics, 46(2), 257-267.
Gremyr, A., Andersson Gäre, B., Thor, J., Elwyn, G., Batalden, P., & Andersson, A. C. (2021). The role of co-production in learning health systems. International Journal for Quality in Health Care, 33(Supplement_2), ii26-ii32.
Jefferies, C. M., Balkin, E. A., Groom, L., & Rayo, M. F. (2022). Developing Systemic Contributors and Adaptations Diagramming (SCAD): Systemic insights, multiple pragmatic implementations. Proceedings of the 66th Annual International Meeting of the Human Factors and Ergonomics Society, 66, 75–79. https://journals.sagepub.com/doi/pdf/10.1177/1071181322661334
Jokwiro, Y., Wilson, E., & Bish, M. (2022). The extent and nature of stress of conscience among healthcare workers: A scoping review. Applied Nursing Research, 63, 151554.
Provan, D. J., Woods, D. D., Dekker, S. W. A., & Rae, A. J. (2020). Safety II professionals: How resilience engineering can transform safety practice. Reliability Engineering & System Safety, 195. https://doi.org/10.1016/j.ress.2019.106740
It quickly became apparent that, although serving more than 50,000 patients, the organization was entrenched in a reactive approach to managing operations that was largely divorced from frontline reality and neither systematic nor methods based. Consistent with work in any complex adaptive system--amplified by the absence of a continuous improvement structure--the managers and staff in the organization’s clinics, laboratories, and pharmacies developed myriad local workarounds to systemic problems. These adaptations operated ‘under the radar’ until either a patient harm event occurred, or revenue goals were not met. The organization’s response to either situation entailed managerial reviews that dwelled on the judgment exercised by staff, their deviation from policy, and what “they should have done”. Because the work practices of staff members involved in a patient harm event rarely aligned closely with policy, their “non-compliance” was often considered causal. The severity of disciplinary action would depend on the severity of the bad outcome. By overlooking systemic drivers of “work as performed”, leaders were blind to conditions that yielded both ongoing risk of harm and potentially desirable adaptations that could be scaled for safety, efficiency, and improvement of staff morale.
Twenty-one months into the experience of supporting staff through repeated setbacks in their efforts to develop a PSES as an operational structure and capability for organizational learning and improvement, a member of the organization’s executive team stepped-up as the CPLHS champion. Her advocacy pushed open the door to operations more fully, creating the opportunity to utilize Systemic Contributors and Adaptations Diagramming (SCAD) (Jefferies et al., 2022) to engage staff in developing an approach to overcoming systemic impediments to timely response and support for patients experiencing a mental health crisis. This effort was in response to concerns expressed by administrative and clinical staff for patient safety and staff welfare over a period of years.
This presentation will share the key events and lessons learned on the road to this breakthrough, including the benefit of identifying existing staff who have the professional knowledge and skill to readily engage in SCAD or other inquiry and observation-based approaches to safety management. The executive champion’s support to recruit these individuals and authorize their time to participate in this effort was invaluable within this organization given that staff were not otherwise authorized or supported to engage in learning methods for knowledge elicitation, analysis, and systemic change.
To make progress, the advisor teamed with a veteran psychotherapist to elicit staff experience of conditions that impeded or enabled timely and effective response to patients expressing suicidality. Although the interviewers were restricted to engaging with staff only during the staff members’ half-hour lunch time, there was universal staff desire to participate, across multiple roles and organizational settings. Subsequent analysis of narrative data from 16 interviews led to recommendations to optimize the process of connecting a patient expressing suicidality to a provider who is prepared to help. Additional recommendations to overcome constraints in performing other work in the same context were also elicited. The organization’s Patient Safety Committee, reinvigorated under the leadership of the executive champion, subsequently reviewed, and is implementing, recommendations developed through the SCAD process. The door has been opened for not only proactive assessment, but ongoing monitoring for intended and unintended effects of systemic change, across scale.
In addition to describing the fragile wayfinding to proactive safety in a rural organization, this presentation will note the burden on conscience (Jokwiro, Y., Wilson, E., & Bish, M., 2022). that may be experienced by embedded practitioners when there is an absence of leadership urgency for analyzing and mitigating conditions that that are harming patients and propagating moral harm among staff. Emotional distress experienced as an embedded practitioner can be significant and cannot be readily balanced by the gratification of helping personnel who want to develop a healthier organizational climate and proactive risk mitigation capability.
References
Boulanger, J., Keohane, C., & Yeats, A. (2019). Role of patient safety organizations in improving patient safety. Obstetrics and Gynecology Clinics, 46(2), 257-267.
Gremyr, A., Andersson Gäre, B., Thor, J., Elwyn, G., Batalden, P., & Andersson, A. C. (2021). The role of co-production in learning health systems. International Journal for Quality in Health Care, 33(Supplement_2), ii26-ii32.
Jefferies, C. M., Balkin, E. A., Groom, L., & Rayo, M. F. (2022). Developing Systemic Contributors and Adaptations Diagramming (SCAD): Systemic insights, multiple pragmatic implementations. Proceedings of the 66th Annual International Meeting of the Human Factors and Ergonomics Society, 66, 75–79. https://journals.sagepub.com/doi/pdf/10.1177/1071181322661334
Jokwiro, Y., Wilson, E., & Bish, M. (2022). The extent and nature of stress of conscience among healthcare workers: A scoping review. Applied Nursing Research, 63, 151554.
Provan, D. J., Woods, D. D., Dekker, S. W. A., & Rae, A. J. (2020). Safety II professionals: How resilience engineering can transform safety practice. Reliability Engineering & System Safety, 195. https://doi.org/10.1016/j.ress.2019.106740
Event Type
Oral Presentations
TimeWednesday, March 2711:00am - 11:30am CDT
LocationSalon A-3
Patient Safety Research and Initiatives