Medical error is the third leading cause of death in the United States. To reverse this trend, hospitals are borrowing high reliability principles from other industries such as naval aviation, commercial airlines, and nuclear power where persistent mindfulness, systems thinking, psychological safety, and continuous learning drive a culture of safety. A high reliability organization (HRO) is one that operates in complex, high-hazard domains for extended periods of time without serious accidents or catastrophic failures. Marin General Hospital has borrowed some of these practices to enhance patient and worker safety by ensuring that medical teams listen and communicate as effectively as possible.
In this podcast, Ryan Rodriguez, Manager of Safety at MarinHealth Medical Center, shares the reliability behaviors and error prevention tools now in use at the hospital. All employees and physicians have been trained on the use of these practices. As you listen, you may find that this approach to communication could help you in your own life and work.
Selected Podcast
MarinHealth Medical Center Talks Safety
Featured Speaker:
Ryan Rodriguez
Ryan Rodriguez is Manager, Safety & Patient Mobilization. Transcription:
Bill Klaproth (Host): There are tools to help hospitals prevent avoidable complications of care and this is a central mission in all healthcare settings at Marin General Hospital. And here to talk about safety and reliability tools is Ryan Rodriguez Safety Manager at Marin General Hospital. Ryan thank you so much for your time. So, you have a list of five safety and reliability tools for everyone. Let’s quickly go through these five. Number one is, we practice clear communications. Tell us what that is.
Ryan Rodriguez (Guest): That’s right Bill. And thank you so much for having me on today. I really appreciate that. Sure, so high reliability organizations are organizations that operate in complex and high-hazard domains for extended periods of time without serious accidents or catastrophic failures. Examples of those would be the nuclear industry or aviation and aircraft carriers for instance as a good example. And so, what healthcare organizations have done is to borrow some of these best practices and tools from these other industries that operate in complex and dynamic high-hazard environments like hospitals.
And so, practicing clear communications is one such tool. We practice clear communications so that we ensure that our communication is clear and succinct and easily relatable and so there are a number of what we call error-prevention tools with that behavior. And it’s really a you know communication is part of culture so the way we use language is very important and part of that is also listening and attuning to our patients and families. You know we need to be humble enough to really listen to what our families and our patients are saying. And so, I think that really establishes the foundation for being able to clearly communicate with our patients and our families and each other. So, this is a lot about teamwork.
So, we use three-way repeat and read backs, much like air traffic controller and an airliner would do. So, if an airline pilot wanted to send you know altitude to 10,000 feet, the air traffic controller would say copy, you are clear to descend to 10,000 feet and then the pilot would then close the loop and say roger. You know that’s an example.
We also have clarifying questions. If there is any question or concern; you could say I have a clarifying question. We also use phonetic and numeric clarification so 15 and 50 might sound alike so we use one five or five zero very simple things like we use when we are on the phone with our credit card company. That’s M as in Mike for instance or F as in foxtrot using the phonetic you know NATO alphabet that military and EMS agents need to use. And then we have something called SBAR which is situation, background, assessment and recommendation request. It’s a really easy way to format information in a succinct way.
Bill: Well when you explain it like that, it makes total sense. Alright, let’s move on to number two. We speak up for safety.
Ryan: So, speaking up for safety involves two things. And one is to stop and resolve any issue. So, if we are unclear about anything, the most important message that we tell our – our staff is to stop in the face of uncertainty. Stop, take a breath, inhale exhale, stop and pause. Think about what you are doing. Review what you’re doing and then reassess you’re so what we say is its okay not to know. Which is hard in healthcare because we are expected to be the experts, but what we also say is it’s not okay not to find out. So, we actually need to be able to get second opinions and lean on each other to get the right information when in doubt. So, we also can use a safety phrase like I have a concern and that is to help us make a request for information or to get an emphasis on something that might be an issue. And so, we can also use our chain of command to report any safety issues. So, the idea is that we feel free and empowered to speak up for safety and that can be particularly challenging when you have something called authority gradients, you know from a nurse to a doctor or maybe an EVS housekeeper to a nurse or myself to the CEO you know how we are empowered to speak up for safety is really important and that’s part of the culture change throughout healthcare.
Bill: So important to speak up especially when you need to clarify. So, let’s move to number three. We speak without judgement as equal members of the team.
Ryan: Yes Bill, so, that’s gets to the point I just made which is that we feel free to speak freely amongst each other as a team. Healthcare now is a team sport and also medical error is now the third leading cause of death in the United States, which is astounding. So, having this ability to be able to communicate concerns, concisely and clearly and as a team working together to look at the system issues that impact being able to – to give and receive safe care is really paramount in this day and age with almost 400,000 people in the US dying every year from preventable medical errors. So, speaking without judgement as equal members of a team means that we are a team and we need to be able to speak up and work together and hold each other accountable and encourage the behaviors we want to see like teamwork and clear communications with each other. So, one of the tools we have is something called peer checking and peer coaching using five to one feedback. Five to one feedback is this golden ratio of encouraging behaviors that you want to see fives times as often as you are correcting. So, this works with actually your relationships and in your personal life and it’s also been proven to work in the classroom. So, there’s a lot of evidence behind this five to one feedback ratio.
Bill: And number four we pay attention to detail by self-checking.
Ryan: Yes so, paying attention to detail by self-checking is about mindfulness. It really is one of the hallmarks of a high reliability organization it’s the condition of persistent mindfulness and intentionality that we give to each task that we do. So, we have a tool for that which is called STAR and it stands for stop, think, act and review. And we have a – a fun teaching tool that we use for STAR and that is that we fondly refer to our vending machines as our STAR simulators. So, if you think about what you need to do to get something from the vending machine, it really mimics what we would do in our everyday tasks, right, you need to get the money, you need to find out what it is that you want from the vending machine, get the correct change, look to see what number in what row that item is in the vending machine and maybe triple check that and then you push the button and you watch your item fall down and you collect your item. So, those are very much like stop, think, act and review. So, it’s really about mindfulness with your tasks. And using that has been shown to have a great impact on safety and reliability.
Bill: Absolutely. Stop, think, act, review. I think we can all use that in our lives. And number five finally, Ryan we support
Ryan: Absolutely.
Bill: It’s true. And number five we support and promote a questioning attitude. Tell us about that.
Ryan: Yes supporting and promoting a questioning attitude is not taking things at face value. You know we talk about our intuition, our internal smoke detectors and really paying attention to our experience, our gut feelings and if something isn’t really sitting right with us, to really go the extra steps to make us feel comfortable about proceeding when we are working with patients or it could be lab results or it could be any number of things and across – and as this just isn’t clinical – this is across the enterprise. You can be in finance or HR or IT, environmental services or you can be at the bedside with the patient. But being able to qualify the source of the information and then validating that information and does it fit with what you know to be true and then verifying and you can look at policies or procedures or get second opinions or other means to verify if that information that you have is accurate. So, again, it’s really about double checking to make sure everything is correct before proceeding.
Bill: And Ryan lastly, if you could wrap it up for us. I just want to ask you about disaster preparedness and if you can share with us information about drills that you have managed.
Ryan: Natural disasters aren’t going away, and they are becoming more severe due to climate change. So, I think the more we recognize the impact that climate change is having on – on our environment, the better off we are going to be because we do have to be prepared. So, hospitals take an all-hazards approach to emergency preparedness. We have to be prepared for the natural disasters and for unfortunately things like mass shootings that we are seeing in the schools and anything that can happen like an earthquake or something that happens inside our facility like a utility failure – one of the more recent one of the more recent drills that we’ve done has been to address mass casualty incidents. So, that means responding to an incident with mass casualties and being able to triage and set up to receive up to 50, that’s five zero patients in less than 15 one five minutes and that takes a lot of organization and planning to be able to do that – to do it right and so, like we are on our way to being able to do that very efficiently.
Bill: Ryan, this has been very interesting…
Ryan: And that really has to with high-reliability as well. High reliable processes.
Bill: Well Ryan this has been very interesting. Thank you so much for your time today. I have loved learning about this. For more information please visit www.maringeneral.org, that’s www.maringeneral.org. This is the Healing Podcast brought to you by Marin General Hospital. I’m Bill Klaproth. Thanks for listening.
Bill Klaproth (Host): There are tools to help hospitals prevent avoidable complications of care and this is a central mission in all healthcare settings at Marin General Hospital. And here to talk about safety and reliability tools is Ryan Rodriguez Safety Manager at Marin General Hospital. Ryan thank you so much for your time. So, you have a list of five safety and reliability tools for everyone. Let’s quickly go through these five. Number one is, we practice clear communications. Tell us what that is.
Ryan Rodriguez (Guest): That’s right Bill. And thank you so much for having me on today. I really appreciate that. Sure, so high reliability organizations are organizations that operate in complex and high-hazard domains for extended periods of time without serious accidents or catastrophic failures. Examples of those would be the nuclear industry or aviation and aircraft carriers for instance as a good example. And so, what healthcare organizations have done is to borrow some of these best practices and tools from these other industries that operate in complex and dynamic high-hazard environments like hospitals.
And so, practicing clear communications is one such tool. We practice clear communications so that we ensure that our communication is clear and succinct and easily relatable and so there are a number of what we call error-prevention tools with that behavior. And it’s really a you know communication is part of culture so the way we use language is very important and part of that is also listening and attuning to our patients and families. You know we need to be humble enough to really listen to what our families and our patients are saying. And so, I think that really establishes the foundation for being able to clearly communicate with our patients and our families and each other. So, this is a lot about teamwork.
So, we use three-way repeat and read backs, much like air traffic controller and an airliner would do. So, if an airline pilot wanted to send you know altitude to 10,000 feet, the air traffic controller would say copy, you are clear to descend to 10,000 feet and then the pilot would then close the loop and say roger. You know that’s an example.
We also have clarifying questions. If there is any question or concern; you could say I have a clarifying question. We also use phonetic and numeric clarification so 15 and 50 might sound alike so we use one five or five zero very simple things like we use when we are on the phone with our credit card company. That’s M as in Mike for instance or F as in foxtrot using the phonetic you know NATO alphabet that military and EMS agents need to use. And then we have something called SBAR which is situation, background, assessment and recommendation request. It’s a really easy way to format information in a succinct way.
Bill: Well when you explain it like that, it makes total sense. Alright, let’s move on to number two. We speak up for safety.
Ryan: So, speaking up for safety involves two things. And one is to stop and resolve any issue. So, if we are unclear about anything, the most important message that we tell our – our staff is to stop in the face of uncertainty. Stop, take a breath, inhale exhale, stop and pause. Think about what you are doing. Review what you’re doing and then reassess you’re so what we say is its okay not to know. Which is hard in healthcare because we are expected to be the experts, but what we also say is it’s not okay not to find out. So, we actually need to be able to get second opinions and lean on each other to get the right information when in doubt. So, we also can use a safety phrase like I have a concern and that is to help us make a request for information or to get an emphasis on something that might be an issue. And so, we can also use our chain of command to report any safety issues. So, the idea is that we feel free and empowered to speak up for safety and that can be particularly challenging when you have something called authority gradients, you know from a nurse to a doctor or maybe an EVS housekeeper to a nurse or myself to the CEO you know how we are empowered to speak up for safety is really important and that’s part of the culture change throughout healthcare.
Bill: So important to speak up especially when you need to clarify. So, let’s move to number three. We speak without judgement as equal members of the team.
Ryan: Yes Bill, so, that’s gets to the point I just made which is that we feel free to speak freely amongst each other as a team. Healthcare now is a team sport and also medical error is now the third leading cause of death in the United States, which is astounding. So, having this ability to be able to communicate concerns, concisely and clearly and as a team working together to look at the system issues that impact being able to – to give and receive safe care is really paramount in this day and age with almost 400,000 people in the US dying every year from preventable medical errors. So, speaking without judgement as equal members of a team means that we are a team and we need to be able to speak up and work together and hold each other accountable and encourage the behaviors we want to see like teamwork and clear communications with each other. So, one of the tools we have is something called peer checking and peer coaching using five to one feedback. Five to one feedback is this golden ratio of encouraging behaviors that you want to see fives times as often as you are correcting. So, this works with actually your relationships and in your personal life and it’s also been proven to work in the classroom. So, there’s a lot of evidence behind this five to one feedback ratio.
Bill: And number four we pay attention to detail by self-checking.
Ryan: Yes so, paying attention to detail by self-checking is about mindfulness. It really is one of the hallmarks of a high reliability organization it’s the condition of persistent mindfulness and intentionality that we give to each task that we do. So, we have a tool for that which is called STAR and it stands for stop, think, act and review. And we have a – a fun teaching tool that we use for STAR and that is that we fondly refer to our vending machines as our STAR simulators. So, if you think about what you need to do to get something from the vending machine, it really mimics what we would do in our everyday tasks, right, you need to get the money, you need to find out what it is that you want from the vending machine, get the correct change, look to see what number in what row that item is in the vending machine and maybe triple check that and then you push the button and you watch your item fall down and you collect your item. So, those are very much like stop, think, act and review. So, it’s really about mindfulness with your tasks. And using that has been shown to have a great impact on safety and reliability.
Bill: Absolutely. Stop, think, act, review. I think we can all use that in our lives. And number five finally, Ryan we support
Ryan: Absolutely.
Bill: It’s true. And number five we support and promote a questioning attitude. Tell us about that.
Ryan: Yes supporting and promoting a questioning attitude is not taking things at face value. You know we talk about our intuition, our internal smoke detectors and really paying attention to our experience, our gut feelings and if something isn’t really sitting right with us, to really go the extra steps to make us feel comfortable about proceeding when we are working with patients or it could be lab results or it could be any number of things and across – and as this just isn’t clinical – this is across the enterprise. You can be in finance or HR or IT, environmental services or you can be at the bedside with the patient. But being able to qualify the source of the information and then validating that information and does it fit with what you know to be true and then verifying and you can look at policies or procedures or get second opinions or other means to verify if that information that you have is accurate. So, again, it’s really about double checking to make sure everything is correct before proceeding.
Bill: And Ryan lastly, if you could wrap it up for us. I just want to ask you about disaster preparedness and if you can share with us information about drills that you have managed.
Ryan: Natural disasters aren’t going away, and they are becoming more severe due to climate change. So, I think the more we recognize the impact that climate change is having on – on our environment, the better off we are going to be because we do have to be prepared. So, hospitals take an all-hazards approach to emergency preparedness. We have to be prepared for the natural disasters and for unfortunately things like mass shootings that we are seeing in the schools and anything that can happen like an earthquake or something that happens inside our facility like a utility failure – one of the more recent one of the more recent drills that we’ve done has been to address mass casualty incidents. So, that means responding to an incident with mass casualties and being able to triage and set up to receive up to 50, that’s five zero patients in less than 15 one five minutes and that takes a lot of organization and planning to be able to do that – to do it right and so, like we are on our way to being able to do that very efficiently.
Bill: Ryan, this has been very interesting…
Ryan: And that really has to with high-reliability as well. High reliable processes.
Bill: Well Ryan this has been very interesting. Thank you so much for your time today. I have loved learning about this. For more information please visit www.maringeneral.org, that’s www.maringeneral.org. This is the Healing Podcast brought to you by Marin General Hospital. I’m Bill Klaproth. Thanks for listening.