David Watson, MD | Amplifying Safety Cultures in Healthcare Systems

"The idea of what is called a just culture and what that means is that we adopt the ability as an organization to look at things that happen as learning opportunities rather than opportunities to punish" David Watson, MD.


David Watson, MD is a physician surveyor for The Joint Commission. Dr. Watson work for The Joint Commission serving hospitals for accreditation one week every month.

 

About The Joint Commission

The Joint Commission is the accrediting body that goes around every three years and looks at hospitals to make sure that they meet certain standards of care and that they are able to demonstrate those as we walk through the facility. As we look at the way they take care of infection, the way that they prepare food, the way that they write orders and things in the chart. We then have an engineer check out the engineering of the facility.
The standards all started many many years ago back at the turn of the last century when the American College of Surgeons decided that hospitals needed to have quality done in the same way at each hospital. That is how The Joint Commission started. It eventually became a collaboration of several organizations in about 1960 with the hope that we could give the same quality of care to all patients who received it in the United States.

Safety & Quality in Healthcare

Well safety is the foundation of good health care. Right now The Joint Commission has adopted a new motto and that is “Zero Harm”. Our goal is to work towards that and all the safety measures help us reinforce those things. For a long time we thought that we couldn't adapt things that they do in industry, but we found that those high reliable processes work very well in medicine eliminating things that are infections on a recurring basis.
We know if we take certain steps we can prevent those and just looking at safety overall. Making sure that the sterilization process in the operating room is done properly so that they go through those steps. That scopes are used for doing endoscopy those are cleaned properly. Those are all safety things that are very important and we've heard the stories where they are not carried out properly.
The Las Vegas endoscopy clinic for example with all the problems that they had there. Someone needs to be making sure that happens.We are one of the many bodies but the largest by far of the hospitals that we survey and take care of and I really enjoy being part of that process.

Thoughts On Hospital Systems That Prepare For The Joint Commission's Visit

It’s one of the things that I always say to hospitals when I survey. The words I don't want to hear is “we prepared for the joint commission”. We’re here to look at you at a point in time and hopefully that allows us to come as just be another set of eyes and have the opportunity to look at what you're doing. If you don't meet the standard we're going to explain why and give you some options to help you.
If you exceed it, and have some really great things, I'm going to look for those too because I want to take those back. I have this philosophy about medicine that are no good secrets in medicine, people need to share the good stuff. This is not like inventions. These are things that have to do with the wellbeing of all mankind, so we should share them.

Collective Mindfulness; Going Beyond Policy To Ensure Safety, & Quality As It Relates To Healthcare Workers Experience.

Policies are crafted to make sure that we have coordinated consistent way of doing things. They are the framework by which we can have all employees do the same things for the same purpose. That's one of the things we look for in The Joint Commission. When there are things that we look at that we are concerned about we want to make sure that what the organization does agrees with the policy that they read. And, it's a very intricate part of the everyday survey.
There is a concept out there as far as safety goes and the concept basically is called collective mindfulness which means that every person in the hospital is a safety officer. Therefore, if you're walking down the hall and you see something on a tile that doesn't look right, you pick up the phone and you call the people in maintenance and say “Hey the tile outside of room 247 isn’t staying, maybe something is going on”, or a stain there may be some of them. I can take a look at it if things are dirty, if something is broken or something is outdated.
It's everybody's responsibility to take measures to make sure that that's corrected. One of the other things that I like to see is, I used to do interventional blocks. I like to see the count in the operating room tagged in such a way that not only do I know that it was inspected but I know that it was inspected within the last year. I don't just look for the number but a color code that says, when I pick that gown up and put it on to protect myself from the radiation. I know that it was checked and I know that I'm doing it not because there's a policy that says I should do it but also because I know it's going to protect me.

Just Culture | Balancing Accountability In A Non Punitive Way To Reduce System Errors, Ultimately Improving Patient Safety

It's an idea of what is called a just culture and what that means is that we adopt the ability as an organization to look at things that happen as learning opportunities rather than opportunities to punish. We are open to look at those things that don't go right to figure out why they don't go right.
As I said a little bit in my talk (#PESummit), I pointed out that even when these adverse events happen 85% of the time they don't involve a medical error and even when a medical error happens over 90% of that time it has to do with the system. That the system has not organized itself in a way to prevent people from being put in that position. That pretty much sums up why we need to look at this overall structure and say “hey these are opportunities to learn not to punish”.

Real Life Example:

While on orientation (day 3) a nursing assistant was instructed by an nurse to place a hot pack on a patient’s pelvis area. The hot pack became open at some point and hot fluid from within rushed onto the patient’s skin causing burning to the scrotum. The nursing assistant was immediately told to leave the facility after the accident.  

OK, this happened but why did it happen? Did that person do it intentionally? I don't think so okay. Was she trained properly? No. Is it a systems issue? Absolutely. That goes right down to leadership, it goes back to immediate supervisor. It goes back to one of the things that we look at, always look at competency for people to see if they've been trained.
If they've checked off on that every year and if they still have that competency level. She probably hadn't even been given the ability to have the competency to begin with. Ultimately the responsibility for what happened here lies with leadership and that's the way I would look at it. That's the way it would look if I were doing a survey.

Applying Emotional Intelligence in the Medicine

Well it's that balance between what you feel and what you know. If you can apply that in the sense that it gives you that feeling of what you're doing is right, for me it would be almost like that second voice of reassurance that you're on the right track.

Thoughts On The Future Of Healthcare When Coupled With Technological Advancements  

I think there are great opportunities out there for the use of the advancements in technology. We’ve seen so many things come. I was blessed to start in anesthesia back in the 1970’s where everything was manual. I pumped up the blood pressure cuff, I listened to the heart, I felt the patient's pulse, I looked in a patient's eyes. This is all done by machines now and that microchip has come a long way.
Other things that are coming in the future I think would even be far more changing. We have the capability now of putting up a little dot like a band-aid on your wrist and it can read your pulse, your temperature. It can even by impedance tell what your blood pressure is. Now a nurse 50 miles away and she has a computer is able to Skype. She can take that information, look at you on there and to say whether she needs to come out to your house today or not. This will allow healthcare to become more efficient and hopefully less costly.

Maintaining Enthusiasm In The Medical Field

I think the excitement for me is the possibility of leaving medicine better than I found it. I started medicine in the 70’s when things were rather crude compared to what today is. Along the way I've learned lots of things and hopefully I can share those with others in their journey to make medicine better. It's always that pursuit of excellence. That wanting to reach a little bit higher, to do it a little bit better and always with the goal in mind that we're taking care of patients and we never want to harm them.

Embodying Empathetic Cultures In Healthcare Systems


I think the empathy for me and the important part of this conference (#PESummit) is what I talked about earlier, that second victim these are healthcare workers that are involved in an adverse event. The empathy that needs to be expressed to them is that connection of realizing that they've been in a difficult situation and they need to be supported.
They need to be reassured and they need to know that they went into medicine for the right reasons. They take care of patients because they love what they do and they should continue to have that fire in their eye when they go to work every day to be totally engaged. We know that total engagement leads to less errors so we want our workforce to be engaged.

Closing Remarks

This has been a fabulous opportunity to meet with other people who are concerned about the welfare of patients and about the welfare of their fellow healthcare workers. An aspect that isn't often overlooked. We take great care of patients but we don't always take the best care of ourselves.

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