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The culture of safety: From a priority to a core value

Medical Staff Affairs Monthly, September 10, 2008

It is only fitting that thoughts of a culture of safety are top-of-mind as this column is formulated on an airplane miles above terra firma. There may be concerns about the operational excellence of airlines (i.e., what to do if you and your luggage don't arrive at the same time and place), but there is little question about the culture of safety that characterizes the modern aviation industry. When the plane lands, there are about twelve hospitals within a twenty-mile radius of the airport. If I end up in one, would my thoughts be different about the culture of safety? Consider the 2007 Institute of Medicine report, Preventing Medication Errors: Quality Chasm Series, which stated that a hospital patient can be subject to about one medication error for every day he or she is in the hospital and that does not include late or missed doses. And that's just medications!

The good news is that many medical staffs and hospitals are making the implementation of a culture of safety a top priority. The bad news is that this should already be a core value, not a top priority. Many medical staffs and hospitals struggle with the inherent dynamic tension that exists between safety and freedom. Patient safety is the paramount concern. Every organization requires firmly imbedded processes, skill sets, easy-to-use tools and rules to hold people accountable to the core value of safety. These things must be so firmly embedded in the organization's culture that they drive the desired behaviors. And yet, there must also exist some freedom to exercise the knowledge and technical skills honed from years of experience and organizational learning. As a society, we also struggle with this safety-freedom tension every time we check in at an airport or weigh the balance between individual freedom and safety of the whole group. The successful organization's development of best practices arises from a balance achieved after thoughtful reflection but anchored by clear expectations on how to prevent errors, implementation of standard tools to achieve these expectations, and leadership holding everyone accountable.

Unfortunately, many organizations have not approached this systematically and reel and rock from one set of safety initiatives to another without an anchoring core. One month it's this and the next month it's that, and the month after that is anything goes (i.e., freedom). The question becomes, what are the shared values and beliefs in healthcare that will keep us from making errors and promote the culture of safety as a core value? In the HCPro booklet, Building Your Culture of Safety, Ken Rohde outlines six behavioral expectations that should be expected of all of us to make sure our patients, coworkers, and medical staff are safe. These key behaviors include:

1. Pay attention to details
2. Keep a clear line of communication open
3. Have a questioning attitude
4. Use a clear and effective handoff process
5. Look out for each other as a team
6. Follow the rules

The next responsibility of leaders is to clearly establish these expectations and then provide easy-to-use tools to encourage safe behavior. For example, for key behavior 2, communication, many hospitals use the following tools:

• Scripting such as SBAR
• Three-way repeat back verbal messages
• Phonetic and numeric clarifications
• Clarifying questions

Finally, the leaders of the organization, including hospital management and medical staff leaders, must manage accountability to these expectations and use of the tools provided. This is no different than other complex and high-risk organizations such as aviation, nuclear power plants, and the chemical industry. The challenge is to have a uniformly high level of implicit trust in the safety of hospitals across the country as exists when sitting in this airplane seat at 39,000 ft. over water.

The Greeley Company, through its accreditation and medical staff services, has worked with hospitals and medical staffs across the country about a culture of safety for years. Let us know if we can be of help.

Until next time, be the best that you can be.

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