Yet, despite healthcare’s collective best efforts, significant patient safety improvements have been difficult to achieve. In 1999, the Institute of Medicine reported that at least 44,000 people, and perhaps as many as 98,000 people, die in U.S. hospitals each year because of preventable medical errors. By 2018, a study by Johns Hopkins revised that number to more than 250,000 people, making medical errors the third-leading cause of death after heart disease and cancer.
If you are like us, you might be wondering what’s going on.
Sure, there have been pockets of noticeable improvements from organization to organization. One hospital might report that it hasn’t experienced a ventilator-acquired pneumonia in more than two years, while another boasts that it has all but eliminated surgical site infections.
Despite those intermittent improvements, all-too often we still read about patient harm events. Just this year, hospitals in San Diego, Rhode Island, Houston, and Boston have made headlines because of patient deaths. Certainly, each of these hospitals likely had well-designed policies, procedures, pathways, and work flows that were supposed to prevent these types of mishaps from occurring. If so, then what went wrong.
We suspect it has something to do with understanding safety culture.
Research has shown that the three major components of a safety culture are:
While it might be easy to think of this as a three-legged stool, a better model might be to consider these three elements as interconnected spokes on a wheel. Here’s why. First, a just culture is the key ingredient in a reporting culture, because staff who are fearful of repercussions when reporting errors, mistakes, and other adverse events will be unlikely to report at all. Second, a reporting culture – fueled by a just culture – is the key ingredient in a learning culture, because if nothing is being reported, learning simply cannot exist.
Let’s explore each of these three elements in a little more detail.
The Five Essential Elements of a Just Culture
Just culture is the process of attempting to manage human fallibility through system design and behavioral choices that we have within our organization. Unfortunately, in healthcare, culture has largely consisted of punishing people for mistakes. When that happens, we don’t have the ability to learn from it, and we lose the opportunity to improve.
So, to ensure your culture is “just,” focus on these five elements and ask yourself the five corresponding questions:
Tips for Creating a Proactive Reporting Culture
In 2013, Airways New Zealand CEO Ed Sims authored an article for Business Leaders’ Health & Safety Forum entitled, “Building a Reporting Culture.” Airways runs New Zealand’s air traffic control operations and has 750 staff; zero harm is as important to Airways as it is to any hospital around the world.
In that article, Sims offered three tips for creating a reporting culture.
In addition, Paul Drouin, who has served as Master on Canadian Coast Guard vessels, as well as a marine accident investigator and senior marine investigator, has identified five barriers that prevent organizations from creating strong reporting cultures.
Four Ways to Create a Learning Culture
Much has been written about learning organizations and how companies that promote continuous learning are able to accelerate the success curve. In 2018, management gurus Tomas Chamorro-Premuzic and Josh Bersin co-authored, “4 Ways to Create a Learning Culture on Your Team,” for Harvard Business Review, where they revealed these four science-based recommendations for creating a learning culture:
As the healthcare industry relentlessly pursues zero preventable harm, it is, of course, important that the right systems are in place. Equally important, though, is that the right culture is in place, too.