Six steps to creating a culture of safety

A culture of safety is old news—or is it?  In the early 90s, the Advisory Committee on the Safety of Nuclear Installations defined an organization’s safety culture as “…the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management.” The advisory committee went on to describe organizations with a positive safety culture as those that are characterized by “communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.” Although the Advisory Committee on the Safety of Nuclear Installations is not a healthcare organization, its definition lays the foundation for all industries to build a culture of safety.

Certainly with health reform, value-based purchasing initiatives, and increased attention to physician/hospital alignment strategies on our doorsteps, the spotlight is once again on building and maintaining a healthy culture of safety.

An institution that fosters a culture of safety is keenly aware, that as long as human beings are involved, errors are inevitable. Therefore, the culture must be one that proactively seeks to identify and correct errors and potential errors. Individuals must feel comfortable reporting errors and “near-misses” without fear of retribution. An effective culture must also work across departments, be willing to dedicate resources to improving safety, and be willing to analyze and learn from errors that have occurred in an effort to prevent future errors.

When developing and enhancing a culture of safety, hospitals and medical staffs should address the following six areas: 

• Assessment of the current culture
• Teamwork
• Patient involvement
• Systems
• Openness and transparency
• Accountability

Let’s break these down one at a time.

Assessing the culture: There are multiple ways hospitals and medical staffs can assess their current culture.  A simple (and free) assessment tool is available from The Agency for Healthcare Research and Quality (http://www.ahrq.gov/qual/patientsafetyculture/). This tool assesses 12 areas of safety:
 

• Communication openness
• Feedback and communication about error
• Frequency of events reported
• Handoffs and transitions
• Management support for patient safety
• Non-punitive response to error
• Organizational learning and continuous improvement
• Overall perceptions of patient safety
• Staffing
• Supervisor/manager expectations and actions promoting safety
• Teamwork across units
• Teamwork within units

Teamwork: Because the healthcare industry is exceedingly complex, a central component of maintaining safety is the efficient functioning of teams. Safety is everyone’s job, and because of that, the culture must encourage individuals to identify and report potential safety issues. This must be done in a non-threatening and non-punitive manner.

Patient Involvement: Having patients or their families involved in safety initiatives brings a unique perspective to the process.  Many healthcare providers have lost the ability to see things through the eyes of the patient, so involving the non-medical public can prove quite useful. Prior to engaging patients and families in the hospital’s or medical staff’s safety initiatives and inviting them to safety meetings, address any confidentiality, legal, and risk management issues.

Systems: Hospitals and medical staffs should create error reduction strategies to mitigate against some of the human factors that play into safety problems. Simple systems such as checklists, the surgical time-out procedure, and more complex systems such as computerized decision support, are necessary. Since the goal is to “get it right” every time, relying on human memory is no longer sufficient.

Openness and transparency: Openness allows all members of the healthcare team to feel comfortable reporting errors or potential errors without the fear of retribution. Gone are the days (or should be gone) when errors where thought to be someone’s fault. Although individual mistakes remain a cause of errors, errors are more likely a failure of the system. The ability to share errors in a transparent manner improves the likelihood of future reporting and overall error reduction.

Accountability: In this context, accountability refers to the fact that all members of the organization realize their responsibility in maintaining a safe environment. Although individuals should be held responsible and accountable for their actions, the culture should be such that everyone feels responsible for maintaining a safe environment.

Creating and maintaining a culture of safety is as important, if not more important, today as it was in decades past. Physician leadership needs to take an active role in raising awareness and implementing practices that improve safety. A first step is to assess the current state of safety and then create actions plans to address the areas in need of improvement. The AHRQ survey tool is an easy place to start. The rewards of creating and sustaining a culture of safety far exceed the investment of time and energy. Providing a safe environment for our patients and staff should be one of the reasons we come to work every day.

William Mills, MD, MMM, CPE, FAAFP, is the senior vice president of quality and professional affairs for the Upper Allegheny Health System in New York and a blogger for www.MedicalStaffLeader.com.