Culture of Safety and Just Culture

Accreditation Insider, December 21, 2015

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The ability of a hospital or health system to deliver quality clinical, financial, and operational outcomes is highly contingent upon the availability and use of a variety of resources, including supplies, equipment,
and technology, the physical plant that houses these items, and the critical, competent human resources needed for the delivery of care, treatment, and services.

To promote and foster an organizational culture that drives quality clinical, financial, and operational outcomes, the organization relies on its governing body and senior leadership to articulate a clear and compelling vision,1 lead effectively, and proactively plan for and manage all aspects of the organization’s human and capital resource needs.

Faced with declining reimbursements, increased review of the appropriateness of medical care and services, and the shift of care from inpatient to outpatient settings, hospital leadership and the governing body of these organizations must critically assess the programs and services offered and the human and capital resources required to achieve and sustain organizational success. Evaluating the past, present, and future demand for hospital care and services, managing the cost of achieving and sustaining a competitive edge in a time of economic downturn evidenced by declining reimbursements and a growing uninsured population, and meeting the expectations of the organization’s key stakeholders are challenges for the hospital CEO and leadership team. Engaging in strategic and financial planning and developing plans to drive the current and present future and sustainability of the organizations requires careful thought and effective, proactive leadership.

Organizational culture describes the shared beliefs, attitudes, perceptions, and expectations of individuals within the organization. Organizational culture is linked to many aspects of organizational performance, including clinical performance, financial performance, customer and employee satisfaction, operational outcomes, and the overall success of the organization. Because of the shared nature and understanding about organizational norms and values, organizational culture has a significant effect on efforts to change specific systems, processes, or procedures. To promote and foster an organizational culture that drives best practice and outcomes in clinical, quality, financial, and operational outcomes, the organization relies on its governing body and senior leadership to lead effectively and manage all aspects of the organization.

Aligning quality and safety in today’s complex healthcare environment requires strong, capable leadership to promote and foster integrated patient safety systems of care that, according to the PS chapter, should include:

• A culture of safety
• Validated methods to improve processes and systems
• Standardized ways for interdisciplinary teams to communicate and collaborate
• Safely integrated technologies

In this ideally integrated environment, or patient safety system, frontline staff and their leaders work collaboratively to create a culture of safety, promote a shared vision of quality and safety, treat each
other with respect, and learn from safety events and near misses or other system failures. The Institute of Medicine (IOM) study “To Err is Human: Building a Safer Healthcare System” noted that adverse events occur in 2.9% to 3.7% of all hospitalizations and that 44,000 to 98,000 patients die per year as a result of medical errors that could have been prevented. According to the IOM report, medical errors are defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.

The IOM report made a number of recommendations on patient safety that included having a nonpunitive system to report and analyze errors, a team to address and improve patient safety, and a patient safety program using evidence-based patient safety standards of care and research. There are many patient safety issues resulting in errors that, according to the report, can be classified into four overarching categories:

• Diagnostic: Error or delay in diagnosis. Failure to employ indicated tests. Use of outmoded tests or therapy. Failure to act on results of monitoring or testing.
• Treatment: Error in the performance of an operation, procedure, or test. Error in administering the treatment. Error in the dose or method of using a drug. Avoidable delay in treatment or in responding to an abnormal test. Inappropriate (not indicated) care.
• Preventive: Failure to provide prophylactic treatment. Inadequate monitoring or follow-up of treatment.
• Other: Failure of communication. Equipment failure. Other system failure.

This is an excerpt from the HCPro book The Compliance Guide to The Joint Commission’s Patient Safety Systems Chapter. Visit HCPro Marketplace for more information and to order.

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