Taking the Lead in Patient Safety: How Healthcare Leaders Influence Behavior and Create Culture

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Fast forward to modern day health care. While patient safety is always the top priority, some of the errors that do occur may go unreported — often for many of the same reasons, experts say. But as concepts in patient safety have evolved in the last decade, health care is moving toward modern safety models that focus on learning from errors to improve safety. Acknowledging that even experienced professionals make mistakes can lead to an open and safe reporting system where everyone can speak up without fear of reprisal.

This can lead to shared learning from errors and an eventual culture shift that prevents errors from occurring again. A term coined by safety experts, just culture is a philosophy and concept that is increasingly being adopted by health care institutions, including radiology departments. Just culture originated in the s in the aviation industry, where safety errors can have catastrophic results. To help reduce aircraft accidents, there was systematic review of the technology, the training and the culture in aviation.

It was recognized that the conditions for accidents were often known by people in the workplace who were afraid to speak up for fear of being reprimanded or humiliated. Larson said.

Leadership in Improving Patient Safety Video - Brigham and Women's Hospital

Kadom said. She added that shifting from blaming individuals to looking at the system as a whole in a just culture ultimately leads to a more productive organization and a more enjoyable work environment. Employees want to do the right thing, particularly when that means voicing concerns about safety.

A just culture fosters an environment in which individuals are not afraid to disclose and discuss a mistake. Just culture is not a tool or a method limited to certain aspects of the work, according to Dr. In a just culture, there is a shared recognition that adverse events may be multifactorial and systems and processes play an important role in increasing the likelihood of individual human errors.

A just culture stresses the importance of creating systems and processes that decrease that likelihood.

Everyone is responsible for a culture of safety

Making the shift from a culture of blame to one of safety requires strong, compassionate and caring leadership. Slanetz said. Only then can health care organizations add value, and most importantly, be able to provide the highest quality of care. Leaders who want to move to a just culture must realize that when it comes to managing safety, they often cannot trust their instincts, according to Dr.

Reading about just culture and learning from other organizations that have adopted the approach is probably the best way to start aligning policies and practices to support a just culture. It will remind staff that managers are humans too.


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Since so many areas of radiology depend on human performance, the specialty stands to benefit greatly from just culture, according to Dr. How far along is radiology in embracing just culture? The tools might be in place, but we still need to figure out how to use those tools effectively to shift the culture successfully. While there are often up-front costs associated with adopting such a widespread culture change, such as culture assessment, staff education, etc.

As learned through the IOM report, system-wide initiatives are crucial to creating a culture of safety in healthcare institutions. After the publication of the IOM report healthcare research related to patient safety increased. Along with an increase in safety literature, the IOM report also propelled a shift in the kind of safety research conducted. Although the IOM report brought attention to the issue of patient safety, much like at the time the report was published the healthcare industry continues to struggle today in improving safety Free from harm, Later in this chapter, we discuss how employee safety is the next crucial step in healthcare safety, a step that may improve patient safety as well Organizational Safety Culture-Linking Patient and Worker Safety, n.

Best Practices for Creating a Culture of Safety In current literature, there are several practices identified to be contributors to producing a culture of safety. The presentation of these practices in many unique research articles demonstrates that these practices are evidenced-based and serve as best practices for improving safety. The particular practices, which will be examined here, were selected because they are broadly accepted as manners in which to improve safety. The following section address the themes found across the literature related to creating a culture of safety in healthcare institutions.

Mark Jarrett, the chief quality officer at Northwell Health in New York, points out that in order for employees to feel comfortable expressing safety concerns or reporting safety events, they must feel that their reporting will not lead to negative repercussions Jarrett, A just culture focuses on accountability for all members of the healthcare team, from the frontline staff up to executives. Everyone in the organization must embrace this just culture; particularly those who hold a leadership role, as they ultimately are the individuals who will or will not enforce punishments for involvement in safety events.

Along with executive leaders who often do not serve in clinical roles, frontline leaders who do serve in clinical roles are crucial in implementing a just culture. Frontline leaders such as nurse managers or charge nurses are intricately involved in patient care, and thus, have a strong understanding of safety needs and barriers to safety.

When frontline leaders respond in a supportive manner after safety events, they demonstrate a just culture through their actions and thus contribute toward a supportive safety culture in their clinical area Tarantine, Safety Reporting Systems Additionally, literature emphasizes the importance of implementing safety reporting systems to achieve a culture of safety. Mary Gregg, the chief medical officer of MAG Mutual Insurance, reported the importance of learning from safety incidences reported through safety reporting systems Gregg, A safety reporting system alone is not enough; leaders who review safety data must act quickly to make changes after safety events.

By responding quickly, leaders demonstrate their focus on safety as well as provide encouragement to employees to report safety events QAPI leadership rounding guide, n. Leaders who respond efficiently to safety concerns reported will demonstrate to employees that reporting can lead to positive outcomes. Additionally, it is crucial that leaders continue to assess the data in order to avoid complacency and to move toward continued improvement The essential role of leadership in developing a safety culture, Transparency Further, literature discusses the benefits of transparency Creating and sustaining a culture of safety, In order for a widespread culture of safety, leaders must be transparent regarding safety occurrences and initiatives.

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In conjunction with the previously discussed safety reporting systems, transparency allows for all members of the healthcare team, from frontline staff to executives, to be aware of safety events. Transparency has a two-fold benefit. The initial benefit may seem rather obvious: transparency provides all staff members with information regarding safety events. While it may seem overly simplistic, knowledge of safety events is crucial for all staff members. When armed with knowledge regarding the number and types of safety occurrences, all members of the healthcare team can be aware of potential safety issues and therefore act to reduce safety incidences.

Shared learning from errors can lead to a culture shift that prevents errors from occurring again

Additionally, transparency encourages accountability among all employees related to safety occurrences. When safety data is regularly shared, everyone shares the responsibility of improving safety at the institution The essential role of leadership in developing a safety culture, Shared responsibility and accountability go hand-in-hand with the ever-important just culture, as all within the institution share the burden of improving safety rather than pointing fingers at individuals.

Along with transparency about the type and number of safety events, transparency also includes sharing information about initiatives made toward improving safety at the institution.


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Information regarding safety improvement efforts again encourages everyone to be accountable and responsible for implementing improvement initiatives Creating and sustaining a culture of safety, Leadership and Frontline Staff Engagement A just culture, a safety reporting system, and transparency are all requirements for a safety culture; however, without leadership engagement, a culture of safety is impossible to attain.

The Joint Commission, a national accreditation organization for healthcare organizations, implores healthcare leaders to focus on a culture of safety just as much as a focus on any other leadership topic such as finance or business growth The essential role of leadership in developing a safety culture, While human errors may occur, the literature emphasizes that the majority of safety issues stem from systematic issues. From their vantage point, leaders are in a unique position to approach safety from a whole systems approach Gandhi, It is necessary that leaders focus on separating human errors from systematic errors to allow for appropriate interventions Gandhi, A culture of safety must be a conscious effort on the part of employees, and leaders are encouraged to incorporate safety into all daily activities.

It is essential that leaders utilize an adaptive leadership approach.

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Adaptive leaders conduct themselves in a manner in which their behaviors reflect their goals for the organization and motivate followers to conduct themselves in a manner that will achieve these goals Northouse, Additionally, adaptive leaders encourage their followers to think for themselves to create positive change Northouse, As leaders incorporate safety into all activities, this behavior serves as a model to followers Creating and sustaining a culture of safety, In order to demonstrate active engagement in safety efforts, literature encourages leaders to have regularly scheduled time to interact with and shadow frontline workers.

The literature describes an emphasis on the importance of leaders engaging frontline staff in order to gain the best understanding of safety concerns in all areas of work. It is recommended that this interaction with frontline workers be systematic and regularly scheduled. Leadership walkroundsTM provide an opportunity for leaders to directly interact with frontline staff to discuss important safety topics. In addition to rounding by leaders, regularly scheduled safety briefings should be conducted.

During conversations with executives, any identified issues should be discussed.

Taking the Lead in Patient Safety: How Healthcare Leaders Influence Behavior and Create Culture.

As previously discussed, it is necessary for leaders to quickly address and respond to concerns that are identified, which serves as another manner to demonstrate to frontline staff that leaders are receptive and responsive to safety feedback. Next Steps: Employee Safety As advancements in patient safety continue, this goal of a culture of patient safety can be expanded to incorporate employee safety. The Federal Occupational Safety and Health Administration OSHA reported a strong relationship between a culture of safety and employees following appropriate infection control precautions, which is a contributor to both patient and employee safety Organizational Safety Culture-Linking Patient and Worker Safety, n.

The reader will gain understanding of the actions and steps taken to create this successful safety program. Additionally, a comparison is made between the literature on best practices and the Zero Hero program. In under the leadership of Chief Medical Director Dr. The Zero Hero program aimed to create a culture of patient safety at the hospital. The goal of Zero Hero was simple yet incredibly complex to achieve: zero instances of preventable harm to patients at the hospital Zero Hero, n.

While leaders at the hospital knew that zero instances of harm was a very lofty goal, they believed that the hospital needed to aim high as the ultimate goal is to avoid all preventable patient harm. Barr personal communication, February 9, In order to reduce these negative effects, beginning in , hospital senior leaders expanded the Zero Hero program to include employee safety Barr, et al. The priority of the hospital to encourage safety is evident as the Zero Hero program is introduced during hospital orientation for new employees and new employees are required to attend a Zero Hero training course during their on-boarding process D.

Through the patient safety initiatives, a safety reporting system called CS Stars was implemented. The CS Stars system provides a simple process for employees to directly report safety occurrences, including occurrences in which staff members correctly intervene to avoid potential harm.

To begin the employee safety component of the Zero Hero program, baseline data related to employee safety was collected through the CS Stars reporting system. Leaders took this data to create a preventable harm index for employee safety. The preventable harm index allowed leaders to prioritize safety initiatives in order to have the most effective impact on reducing employee harm. The employee safety initiatives incorporate frontline staff members to ensure that all perspectives are included. One component of engaging frontline staff members is through assessing CS Stars entries.

When a CS Stars report is entered, the report is shared with the employee safety team as well as with the department manager. In order to remedy systematic issues associated with the reported event, hospital leaders respond within one week to begin steps toward improving the issue. If events are severe, however, leaders will respond to the event immediately in order to quickly work toward reducing future such incidences. Additionally, safety initiatives are regularly shared with employees thorough a variety of channels.