The Three Major Components of a Safety Culture

Despite tireless work to improve patient safety, sustainable gains have been hard to find. Why is this? It might have something to do with understanding the three elements of a safety culture.

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There likely isn’t a hospital in the world that hasn’t made patient safety a strategic imperative.

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:

  1. A just culture,
  2. A reporting culture, and
  3. A learning culture.

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:

  1. Values and Expectations: Do we recognize that we are all imperfect and that it is nobler to continuously work toward improved reliability?
  2. System Design: Have we designed our systems to anticipate human error, capture errors before they reach the patient, and permit recovery when harm occurs?
  3. Human Behavior: Have we anticipated that we will make mistakes, no matter how skilled and have we recognized the difference between human error, at-risk behavior, and reckless behavior?
  4. Learning Systems: Can we identify risk by observing the design of the systems in which we work, our behaviors, and the behaviors of those around us?
  5. Justice and Accountability: Do we hold one another accountable for the quality of our systems and our choices.

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.

  • Always provide positive feedback to the person submitting the incident report.
  • Congratulate staff for making the effort to report a concern or for taking ownership of a mistake.
  • Let staff see that something happens as a result of their report and that their concerns don’t just disappear into the ether.

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.

  1. The organization tries to avoid blame
  2. The organization believes minor errors as trivial
  3. The organization believes minor errors are human nature and cannot be prevented
  4. Violation is seen as the norm, so there is no need to report it
  5. Reports are not followed up

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:

  1. Reward continuous learning, which includes “creating a climate that nurtures critical thinking, where challenging authority and speaking up are encouraged, even if it means creating discord.”
  2. Give meaningful and constructive feedback, including feedback that is both positive and negative. “However,” the authors wrote, “negative feedback must be provided in a constructive and delicate way – it is a true art – as people are generally less receptive of it than of praise and appreciation.
  3. Lead by example. If you want your staff to take on new challenges, volunteer for something outside their comfort zone, or tackle a project that requires a new skill, then you must do the same.
  4. Hire curious people. People who are curious are natural learners and are more suitable for 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.

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