Inadequate resource allocation, in turn, creates a number of vulnerabilities at the delivery level of the organization, such as understaffing, unwieldy caseloads, less time spent with clients to understand their issues, reduced in-service training, and inadequate supervision for inexperienced clinicians. It is the cumulative effects of these organizational weaknesses that come together and produce catastrophe at the delivery level of the organization. Sharp End and Blunt End In the language of human factors, the delivery level of the organization is referred to as the sharp end. It is the point at which active failures occur, and it is called the sharp end because it is the point where system vulnerabilities come together to produce a mishap. It is also that point in the organization where the clinician and client come together. In contrast, the blunt end describes latent (hidden) weaknesses. Latent factors range from external forces, such as state and federal legislation, to policy and management decisions within an organization. Legislation related to guns, lack of parity in reimbursement for mental illness relative to medical illness, and deinstitutionalization of people with mental illness without adequate funding to support them in the community are examples of external blunt end factors. An example of a blunt end weakness at the organizational level is the failure to develop policies around working overtime—a failure that can contribute to worker fatigue and compromise patient safety. Another example at the organizational level is the decision by management to cut staff positions without redesigning work processes so that remaining staff are not overburdened. Blunt end weaknesses emerge, sooner or later, at the sharp end. A faulty decision made at the blunt end can lay the groundwork for a disastrous encounter at the sharp end (Smith & Plunkett, 2019).
Seshia and colleagues (2018) sought to expand the Swiss Cheese Model and found factors contributing to human and systems error, namely unhealthy cultures, poor communication between one or more levels of care, inadequate resources such as staffing and equipment, and the of difficulty accessing resources. Their report went on to identify other negative factors: Failure to promote and practice person- and family-centered care, insufficient shared decision making, unpredictable situations, time and concentration factors, and failure to seek an independent reliable opinion (outside view) when the situation is critical. On the individual level, Seshia and colleagues (2018) found both provider and patient cognitive-affective states can catalyze error. Importantly, they note that cognitive- affective states influence human error, yet generally remain overlooked in patient safety research. These provider states can include: ● Biases in judgment and decision making (these can relate to the professional’s biases related to a patient’s social status, history, medical status [e.g., obesity], age, gender, and so on) ● Sleep deprivation/fatigue ● Psychological state, including dysphoria, personal life stressors, and burnout ● Cognitive overload that impairs the individual professional Patient-related factors that impact human error include: ● Communication challenges (e.g., language barrier and cognitive dysfunction) ● Adherence (compliance and concordance with medical advice) ● Cognitive-affective biases of patients that influence personal healthcare decisions (same as biases listed above)
UNDERSTANDING ORGANIZATIONAL CULTURE
● It is the result of group interactions and is thus a social construction. ● It exists in healthcare. Furthermore, there are drivers and factors that ultimately create or contribute to the creation of a specific organizational culture. One of these factors is identified as an artifact, namely processes and structures that have survived and existed within the organization for a considerable amount of time. These artifacts can be the direct result of espoused positions or goals of the organization that have also had a considerable life span, adopted and repeated by successive groups of leadership, providers, and frontline staff. Additionally, much of organizational culture can often be further linked to conscious and unconscious assumptions held within the organization by current staff or previous staff. Certainly, organizational culture is palpable, sometimes powerful, but this milieu of historical and assumptive factors can make it more difficult to objectify, study, and change (Oster & Braaten, 2021). designs work processes in which errors can occur without leading to disaster. Below are some of the characteristics of HROs as they might relate to behavioral healthcare. HROs create a culture of safety by first acknowledging the risky nature of their activities and then operate to effectively manage risky situations through organizational control and the ongoing calculation of probabilities of error. Clearly, this approach is typified by facing risks, understanding them, and trying to anticipate their probable occurrence.
The difficulty of culture is that it an abstraction, culled and created—at minimum-- from the milieu of subjective attitudes and behaviors of people, both individuals and groups. Moreover, there are varying definitions of what culture exactly is. It is real, but it is veiled, somewhat invisible. The visible effects are seen within the patterns of thought and behavior that the group demonstrates most often. Because of these characteristics, culture can often be unquestioningly accepted, followed, and continued by people. This can be a problem within groups. Organizational culture is no different from our larger human and societal culture (Oster & Braaten, 2021). Oster and Braaten (2021) point out that researchers who study organizational culture use several defining characteristics to help identify the elusive nature of
organizational culture. ● It does really exist.
● It is characterized by ambiguity. ● It can be malleable and specific.
Culture of Safety and High Reliability Organizations The concept of a safety culture originated outside of healthcare and emerged from studies of high-risk industries such as nuclear power, aerospace, and aviation. Researchers identified a culture of safety embedded within what they called a high reliability organization (HRO), which is best described as a complex organization that engages in high-risk activities but experiences few catastrophes (Oster & Braaten, 2021). Despite its hazardous environment, an HRO operates for long periods of time without catastrophe because of its “error-tolerant” culture, which means that it recognizes the futility of eliminating human error and
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