6 Elements of a True Patient Safety Culture

Healthcare organizations across the country have significantly ramped up the focus on patient safety and quality improvement, and for good reason. Under the healthcare reform law, healthcare providers' reimbursements will be linked to the quality of healthcare services, including patients' experiences, starting in 2013. A slew of efforts — federal demonstration projects, provider-payor collaborations and provider-level pilot projects, to name a few — are cropping up, as the healthcare industry prepares for this shift in healthcare payment and delivery.

Amid all these efforts, healthcare organizations must maintain a fundamental aspect of patient safety and quality improvement — patient safety culture. Matthew Lambert, MD, senior vice president at the healthcare consulting firm Kaufman Hall and vice chair of the board of directors at Sisters of Charity of Leavenworth; Alex Vandiver and Coleen Smith, RN, of The Joint Commission's Center for Transforming Healthcare, discuss the six aspects of maintaining a patient safety culture.

1. Patient safety culture starts at the top. It would be difficult to establish and maintain a patient safety culture if it did not start at the highest level of the healthcare organization, Dr. Lambert says. Governing boards, directors and executive leadership must promote a culture of safety and make their commitment evident to the rest of the organization.

"[Healthcare leadership] has to let everyone know that the well-being of patients and the quality of care they receive is the organization's goal and reason for being," Dr. Lambert says. "It should be the first thing everyone thinks about when they come to work and the last thing they think about before going home. It's a tone set by leadership, not something you talk about once in a while."

Visibility to staff. As the old adage goes, executive leadership also must "walk the talk" in order to foster a patient safety culture at their respective healthcare organizations. Dr. Lambert says board members and executives must move from the meeting rooms to patient care units and connect directly with physicians, nurses and patients. Increasing visibility shows both staff members and patients that the leadership's commitment to patient safety does not stop in the board room or the C-suite.

Visibility to other leadership. Dr. Lambert adds leadership must convey its commitment to one another at regular board or management meetings by making quality and patient safety the very first topic on the agenda. This emphasizes that patient safety is the most important issue for discussion.

At Sisters of Charity of Leavenworth, quality/safety committee meetings always begin with a patient care story. "These patient stories, which can be good or bad, bring quality and safety to the board in real human terms," he says. "A member of the executive team delivers that patient story, which can represent a failure or success by the organization to delivery safe care. Everybody loves it, and it certainly makes the discussion much richer. In addition, the board chair and the system's CEO attend every meeting."

2. Patient safety culture is driven by a vision. Healthcare leadership must create a vision that will drive the organization's patient safety culture. This requires executives and board members to conduct a gap analysis to understand where the organization exists in the spectrum of safety and where it wants to be, Dr. Lambert says.

"Part of that understanding includes both clinical metrics to evaluate performance, such as compliance with recognized standards of care and complications such as wound infections or unexpected deaths, as well as metrics to evaluate the patient experience," he says. "Once the leadership establishes where the organization stands in the universe of safety cultures, then they can envision how to move forward."

3. Patient safety culture involves everyone at every level. Once the gap analysis is completed, hospital leadership can take steps to promote and develop a patient safety culture. Dr. Lambert says it begins with communicating the gap analysis — where the organization is and where it should be — to every employee, physicians, and members of the board. Everyone must be involved in developing the action plans necessary to close the gap and improve the quality and safety for every patient. Action plans developed without the input and buy-in of staff members and physicians will most likely fail, Dr. Lambert says.

Mr. Vandiver, who acts as director of business excellence at The Joint Commission's Center for Transforming Healthcare, adds leadership must encourage staff members to speak up and foster a safe environment of accountability. "When we talk about safety culture, it's also about building comfort levels between different levels of staff so they can discuss how to improve quality and patient safety," he says. "Often, this requires breaking down some of the traditional internal structures both between multidisciplinary team members and between clinicians and non-clinicians to enable this improvement discussion." The first step towards establishing a true culture of safety is a sense that every voice is heard no matter what level they are in the organization.

4. Patient safety culture requires some evolution. Ms. Smith, who serves as sentinel event specialist at The Joint Commission's Center for Transforming Healthcare, says patient safety culture is not a one-size-fits-all solution. Healthcare organizations are complex structures, comprised of many different units with different needs, different staff members and different patients. Data from AHRQ's Hospital Survey on Patient Safety Culture 2011 User Comparative Database Report supports Ms. Smith's insight. For instance, results from the survey show nonteaching hospitals consistently rated patient safety culture composite items higher than teaching hospitals. Ultimately, this means safety cultures will change and evolve to fit the needs of unique healthcare enterprises.

For example, some hospital units may have a good team structure, where staff members are supportive and willing to stop each other when they don't exercise patient safety. Other units might have staff members who are more hesitant to speak up when they see a colleague has not complied with patient safety protocols. The change in safety culture requires courage since some of the changes will be counterintuitive to traditional processes and protocols, Ms. Smith says.

"It's important for organizations to look at safety culture not as a one-time fix or a few simple steps to improve quality. It's recognition that this is a journey, and there are many steps the organization must take to make it a success," Mr. Vandiver says.

5. Commitment to patient safety culture is consistent. One of the most common pitfalls that typically undermines the development of a patient safety culture is inconsistency in the leadership's commitment, Dr. Lambert says. That commitment may be broken once priorities become misaligned.

"A hospital board and executive leadership may say they are committed to patient safety, but they may cut funding for patient safety education programs at the first sign that the organization is in a difficult financial position," he says. "That kind of message clearly says to the rest of the organization that safety is not the first priority, and that can really disillusion employees."

Another common inconsistency in the message can be found in how leadership handles a medical error. It is absolutely critical that the leadership remembers that medical errors are almost always the result of systematic flaws rather than individual incompetence, Dr. Lambert says. When medical errors happen, the leadership must look at ways to improve systematic processes in order to prevent future adverse events from occurring — rather than punishing the individual that made the mistake. "These kinds of inconsistencies can cause staff members to be more jaded and less involved with patient safety efforts," he says.

Ms. Smith adds the healthcare industry is beginning to recognize the importance of effective and responsible responsiveness to adverse events. "Over the last 10 years, we were seeing the industry go from one end of the spectrum to the other — from a culture of punishment to one that lacked accountability," she says. "I think the healthcare industry is generally swinging back so the safety culture balances accountability and honest mistakes."

Federal data suggests there is still work to be done in this area. Results from AHRQ's Hospital Survey on Patient Safety Culture 2011 User Comparative Database Report show that less than half of respondents (44 percent) feel a non-punitive response to medical errors.

6. Patient safety culture ultimately transcends the leadership. Eventually, successful implementation of a patient safety culture should come full circle. Dr. Lambert says the best measure of whether an organization has achieved this is to see how well the organization's patient safety culture continues to thrive once there is a change in leadership.

"If I was a CEO of an organization and I planned to move on, the patient safety culture should stay the same. The culture should not depend on any individual or any group, it naturally becomes a part of the fabric of the organization," Dr. Lambert says. "When the leadership goes back to survey patients and employees, there should be a real shift in attitudes and perceptions on how care is delivered over time and a consistent focus on the patient at the center of every effort at improvement."

Mr. Vandiver adds that the success of a safety culture will also manifest itself in many ways. "Safety culture is a big term that is a component of many specific efforts to improve patient safety, including hand hygiene compliance, and efforts to reduce wrong site surgery and surgical site infections," he says. "Beyond some of the core tactical barriers and problems that were identified by The Joint Commission's Center for Transforming Healthcare projects, safety culture was a contributing factor linked to some of the risks identified. Once the culture improved, that led to improved outcomes in these projects, but also helped enable patient safety beyond the scope of these projects."

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