Pergeseran Paradigma K3RS dari

Pemenuhan Standar Akreditasi

menjadi Sebuah Budaya
H. Yahya Thamrin, SKM, M.Kes, MOHS, Ph.D

Dipresentasikan pada Seminar K3 PAKKI Sul Sel 11 Mei 2018

Outlines
• Paradigm shift
• Quality control vs quality assurance
• Organizational and safety culture
• Total safety culture
• Conclusions
• Q&A
Paradigms & Paradigm Shifts
• Paradigm shift is the term first used by Thomas Kuhn in his 1962 book
The Structure of Scientific Revolutions to describe a change in basic
assumptions within the ruling theory of science.
• Thomas Kuhn argued that science is not a steady, cumulative acquisition of
knowledge.
• It has since become widely applied to many other realms of human
experience as well.
• After such revolutions, "one conceptual world view is replaced by another"
[Nicholas Wade, 1980].
• A dramatic change in methodology or practices
• A progressive change
There are a number of "classical cases" given for
examples of Kuhnian paradigm shifts in science

• The transition from a Ptolemaic cosmology to a Copernican one.

• The acceptance of Plate tectonics as the explanation for large-scale
geologic changes.

• The transition between the worldview of Newtonian physics and the

Einsteinian Relativistic worldview.
Recently

• The term "paradigm shift" has found uses in other contexts,

representing the notion of a major change in a certain thought-
pattern — a radical change in personal beliefs, complex
systems or organizations, replacing the former way of thinking
or organizing with a radically different way of thinking or
organizing.
Penjaminan mutu

Serangkaian proses dan sistem

yang terkait untuk
mengumpulkan, menganalisis,
dan melaporkan data mutu
tentang kinerja, staf, program,
dan lembaga.
 Paradigm shift
1. Pengendalian mutu menjadi penjaminan mutu
2. Mutu menjadi urusan sebagian orang menjadi
urusan urusan setiap orang
3. Mutu tanggung jawab sebagian orang menjadi
tanggung jawab setiap orang
4. Peningkatan mutu didorongan dari dalam (quality
assurance), bukan dari luar (quality control).
5. Hanya focus pada dokumen akreditasi yang
temporal menjadi menumbuhkan budaya K3
(organizational and safety culture) yang
berkelanjutan
Definition of Safety Culture
• Enduring, shared, LEARNED1 beliefs and behaviors that reflect an
organization’s willingness to learn from errors2
• Four beliefs present in a safe, informed culture3
• Our processes are designed to prevent failure
• We are committed to detect and learn from error
• We have a just culture that disciplines based on risk taking
• People who work in teams make fewer errors

1. Schein, E.H. Organizational Leadership and Culture 4th ed. San Francisco: John Wiley & Sons; 2010.
2. Wiegmann. A synthesis of safety culture and safety climate research; 2002. http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf
3. Institute of Medicine. Patient safety: Achieving a new standard of care. Washington, DC: The National Academies Press; 2004.
The Role of Organizational Culture

Organizational Culture Safety Culture

• Allows us to make sense • A cross cutting contextual
of environment
• Reflects common
language… is heard and
observed
• Leaders create/teach
culture
–Share information
–Reward, provide feedback
–Hold people accountable
factor
• Moderates effectiveness
of patient safety
interventions
• Associated with adverse
events and patient
satisfaction
9
Three Levels of Organizational Culture

“…values reflect desired behavior but are not reflected in

observed behavior.” (Schein, 2010, pp. 24, 27)
Desired Behavior: Observed Behavior:
Behaviors Round to assess catheter Do not participate in
appropriateness rounds

Value: Value:
Beliefs & Teamwork Autonomy
Values

Assumption: Assumption:
Underlying Safety is a system Safety is a result of
Assumptions property individual competency
10
Four Components of Safety Culture

HRO
1. Reporting Culture
2. Just Culture
3. Flexible (Teamwork) Culture
LEARNING
4. Learning Culture
5. High reliability organization

Effective reporting and just cultures FLEXIBLE

create atmosphere of trust

Sense making of patient safety

events and high reliability result JUST
from an explicit plan to engineer
behaviors from each component of
safety culture
REPORTING
11
 Continuous Quality Improvement

Measure
Action
Beliefs and
Plan
HROs Engage Behaviors

in Continuous
Improvement Implement
Practices

We can not change what we do not measure!

12
How do we measure safety culture?
• Qualitative • Quantitative Survey
• Focus Groups Tools…use best tool for your
setting
• Structured Interviews
• Goals of assessment
• Observation
 The process will lead to

Total Safety Culture!

The Characteristics of a
Successful Total Safety Culture
• Safety is held as a value by all employees
• Each employee feels a sense of responsibility for the safety of their
co-worker as well as themselves
• Each employee “Actively Cares”
• Each employee realizes their responsibility to speak- up when a fellow
employee is at risk
Values, Intentions and Behaviors
Cautioning co-workers about performing unsafe acts
100%

90%

Percent Agreement with Survey Statement

80%

70%

60%

50%

40%

30%

20%

10%

0%
S h o u ld Willin g Do
(Va lu e ) (In te n tio n s ) (B e h a v io r)
Safety Triangle

1
Environment Person
Equipment, Tools, Machines,
Housekeeping, Heat/Cold,
Engineering
2
Knowledge, Skills, Abilities,
Intelligence, Motives,
Attitude, Personality

Behavior

3
Putting on PPE, Lifting properly, Following procedures,
Locking out power, Cleaning up a spill,
Sweeping floor, Coaching co-workers
Focus: Accident Prevention

Fatality

Serious Injury

Minor Injury

Total
Near Miss
Safety
Culture
At-Risk Work Practices
Developing Safe Habits

Unconsciously
Incompetent
Developing Safe Habits

Consciously
Incompetent

Unconsciously
Incompetent
Developing Safe Habits

Consciously
Competent

Consciously
Incompetent

Unconsciously
Incompetent
Developing Safe Habits
Unconsciously
Competent

Consciously
Competent

Consciously
Incompetent

Unconsciously
Incompetent
Direction Is NOT Enough

Direction

Motivation

Behavior
ABC Model
What Motivates Behavior?
Activators Behavior Consequences
Guides or directs
behavior

A B C
Signs
Policies
Directive Feedback
Training/demonstrations
Goal Setting
Modeling
Lectures
ABC Model
What Motivates Behavior?
Activators Behavior Consequences
Guides or directs Actions
behavior

A B C
Signs Driving the speed limit
Policies Putting on PPE
Directive Feedback Locking out power
Training/demonstrations Using equipment guards
Goal Setting Giving a safety talk
Modeling Cleaning up spills
Lectures Coaching others about safe
work practices
ABC Model
What Motivates Behavior?
Activators Behavior Consequences
Motivates the future
Guides or directs Actions
occurrence of
behavior
behaviors

A B C
Signs Driving the speed limit Self-approval
Policies Putting on PPE Supervisor approval
Directive Feedback Locking out power Reinforcing feedback
Training/demonstrations Using equipment guards No injury
Goal Setting Giving a safety talk Pizza Lunch
Modeling Cleaning up spills Co-worker approval
Lectures Coaching others about safe Thank You
work practices
Effective Activators

Activators must be
• Specific
• Used sparingly
• Clear
• Vary
• Imply immediate consequences
Actively Caring
Increases Effectiveness

Please hold Caution!

handrail when Stairs may be
going up and wet.
Please hold
down stairs
handrail on stairs.

Set a safe example

for others. Please
hold handrail on
stairs
Activators are NOT Enough

Activators

Motivation

Behavior
Consequences that Motivate
• The consequences that motivate behavior are:
• Certain to happen
• Happen immediately
• Have significant impact
• Least effective consequences are:
• Uncertain- injury or discipline do not occur every time
• Delayed- loss of hearing happens over time so the consequence of not
wearing ear plugs is delayed
• Insignificant
Using the ABC Model
• Identify the consequences that encourage and discourage the at-risk
work practices

• Identify the activators

• Consider changing and/or modifying both the consequences and/or

the activators to create an unconsciously competent work practice
Positive VS. Negative
Consequences
• What works best?
• Positive consequences
• Negative consequences

• How does each effect the employee?

Naturally Rewarding Consequences
Actively Caring and the
Safety Triangle

1 2
Environment Person
Making sure needed equipment Sharing skills and knowledge
is available. with each other.
Posting warning signs, Listening, helping
housekeeping, in a crisis, recognizing
cleaning other’s work team member contributions.
area.

Often neglected in
Behavior traditional safety

3
Observing co-workers,
giving feedback,
modeling behavior.
approaches. Little or no
feedback on or
encouragement of safe
behavior.
Conclusions & Key Points of TSC
• We need to have paradigm shift
• Creating a Total Safety Culture requires:
• Safety is held as a value by all employees. A value is a belief that does not
change with the situation

• Each employee feels a sense of responsibility for the safety of their co-worker
as well as themselves

• Each employee performs “Actively Caring”

• Each employee is willing and able to “go beyond the call of duty” for others
What’s Next?
• What do employees need to do to support the shift to a Total Safety
Culture?
References
1. Schein, E.H. Organizational Leadership and Culture 4th ed. San Francisco: John Wiley & Sons; 2010.
2. Wiegmann. A synthesis of safety culture and safety climate research; 2002.
http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf
3. Institute of Medicine. Patient safety: Achieving a new standard of care. Washington, DC: The National Academies Press;
2004.
4. Weaver SJ, Lubomski LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: A systematic review.
Ann Int Med. 2013;158:369-374.
5. Mardon RE, Khanna K, Sorra J, Dyer N, Famolaro T. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf
2010;6: 226-232.
6. Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. Exploring relationships between patient safety culture and patients’ assessments of hospital care.
J Patient Saf 2012;8: 131-139.
7. Reason, J. (1997). Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited.
8. Battles et al. (2006). Sensemaking of patient safety risks and hazards. HSR, 41(4 Pt 2), 1555-1575.
9. Nieva VF, Sorra J. Safety culture assessment: A tool for improving patient safety in healthcare organizations. Qual Saf Health Care 2003; 12(Suppl
II): ii17-ii23.
10. Jones, Skinner, Xu, Sun, Mueller. (2008). The AHRQ Hospital Survey on Patient Safety Culture: a tool to plan and evaluate patient safety programs.
Advances in Patient Safety: New Directions and Alternative Approaches http://www.ncbi.nlm.nih.gov/books/NBK43699/
11. National Quality Forum (NQF). Safe practices for better healthcare--2010 update: A consensus report. Washington, DC: NQF; 2010. Available at:
http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_–_2010_Update.aspx
References cont.
12. AHRQ. Hospital Survey on Patient Safety Culture. Available at: http://www.ahrq.gov/professionals/quality-patient-
safety/patientsafetyculture/hospital/resources/index.html
13. Leape, L.L. (2002) Reporting adverse events. The New England Journal of Medicine, 347, 1633-1638 Institute for Healthcare
Improvement.
14. Conduct Safety Briefings. Available at: http://www.ihi.org/knowledge/Pages/Changes/ConductSafetyBriefings.aspx
15. Institute for Healthcare Improvement. Patient Safety Leadership WalkRounds. Available at:
http://www.ihi.org/knowledge/pages/tools/patientsafetyleadershipwalkrounds.aspx
16. Singer SJ, Rivard PE, Hayes JE, Shokeen P, Gaba D, Rosen A. Improving patient care through leadership engagement with
frontline staff: A Department of Veterans Affairs case study. The Joint Commission Journal on Quality and Patient Safety.
2013;39:349-360.
17. Marx D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives. New York, NY: Columbia University; 2001.
Available at: http://psnet.ahrq.gov/resource.aspx?resourceID=1582
18. Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: the tools to achieve
high reliability. HSR. 2006;41(4),PartII:1690-1709.
19. Wachter RM, Pronovost PJ. Balancing "no blame" with accountability in patient safety. N Engl J Med. 2009;361:1401-1406.
20. AHRQ. Patient Safety Primers. Disruptive and Unprofessional Behavior. Available at:
http://psnet.ahrq.gov/primer.aspx?primerID=15
Thank you

Q&A