Trying to achieve a culture of safety without blueprints
For years, experts have said improving patient safety will depend as much on significant shifts in the culture of health care as on specific changes in the process of providing care. But there have been no blueprints for laying the foundation for a culture of safety.
The Commonwealth Fund supported research that resulted in "Stories from the Sharp End: Case Studies in Safety Improvement" in the March Milbank Quarterly. The research gives a snapshot of promising techniques for stimulating cultural change in health care organizations through case studies demonstrating that patient injuries are not an inevitable side effect of care.
The Fund notes that much safety culture theory originated in other industries such as nuclear power and aviation that are viewed as safety pioneers. Regardless of the industry, according to researchers Douglas McCarthy and David Blumenthal, the same interrelated attributes are present in work environments committed to improving patient safety: they are informed, just, and flexible; inspire individuals to report errors and near misses; and use safety data to learn and reform.
Mr. McCarthy tells State Health Watch the organizations studied followed one of two approaches — either 1) a concerted organizationwide effort to study safety throughout the organization and develop organizationwide strategies to be adopted by each unit; or 2) focused activities addressing specific organizations units with methods specific to each unit, which can yield learnings that are applied more broadly.
Safety improvement efforts in health care often run up against traditional aspects of medicine's culture, including steep hierarchies, tenuous teamwork, reluctance to acknowledge human fallibility, and a punitive approach to errors. Many of the initiatives launched by the case study organizations sought to overcome one or more of those potential barriers and adopt key safety attributes.
Mr. McCarthy says the six case studies used in the report were chosen by contacting recognized leaders in the patient safety field and asking them which institutions were, in their view, doing the most exciting work in patient safety. More than 20 potential cases were identified and 10 were chosen for study. The report covers six unique initiatives; the other four had similar interventions.
"All the programs we examined cited cultural change — creation of a 'patient safety culture' — within their organizations as critical to making patients safer," Mr. McCarthy says. "Thus the organizations seemed to differ chiefly in the methods they were using to create this safety culture. Some were trying to change culture directly. Others were using less direct methods by relying on particular reforms in the structure or process of care, such as promoting teamwork to improve safety vigilance or introducing methods to reduce variability in the processes of care, and hoping that attitudes would change as behavior changed. Some were using both direct and indirect approaches. But regardless of means they chose, our study organizations shared the goal of cultural reform."
Cultural changes are hard to study, he says, because culture is difficult to measure reliably and changes seem to occur incrementally and unpredictably in organizations. The lack of a clear road map for cultural change and the very elusiveness of safety culture as a destination make it a daunting goal for leadership to set. And yet, leadership commitment is essential to success.
Mr. McCarthy suggests that one function of the case studies included in the report "may be to assure leaders who are taking personal and organizational risks to create a safety culture that they are in good company and to offer ideas and examples that they can take back to their own institutions."
The report suggests a definition of safety culture from the nuclear power industry can be helpful: Safety culture is the product of individual and group values, attitudes, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of an organization's health and safety programs. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.
"As far as we know," Mr. McCarthy and Mr. Blumenthal wrote, "no health care organization a yet can offer a model of what other health care institutions should strive to achieve in their safety culture. Accordingly, health care leaders must determine their own objectives. In our view, this makes it all the more important that institutions share their aspirations, efforts, progress, and disappointments in as close to real time as possible."
Flatten hierarchies
As part of their safety interventions, Kaiser Permanente of California and Baltimore's Johns Hopkins Hospital launched initiatives to train surgical and critical care personnel to speak up about safety concerns and to cross-check each other's work. By doing so, they aimed to increase staff members' ability to make changes and to flatten hierarchies that traditionally exist among physicians and other clinical care staff.
Kaiser Permanente adopted strategies from aviation, including crew resource management training, pre-flight checklists, and crisis simulation, to improve teamwork and communication among their surgical and labor/delivery teams. Within six months, the organization reported, operating room staff became more willing to share their safety concerns and discuss mistakes.
At Missouri Baptist Medical Center in St. Louis, multidisciplinary rapid response teams helped to improve the flow of critical information across traditional boundaries to reduce communication breakdowns. Within two months, floor nurses recognized the teams' value as a safety resource and began to call for them any time a patient exhibited early warning signs of a problem. As a result, the hospital reported decreases in acute medical crises of as much as 60%.
Error report systems — a strategy explored by many of the case study organizations — can present opportunities for future learning. By focusing on change rather than blame, they also can help increase an organization's level of trust. OSF St. Joseph Medical Center in Bloomington, IL, enabled informal reporting of errors and near-misses among nursing staff by holding safety briefings at shift changes and through "walk rounds" — routine visits on nursing units — by the hospital's executives. To reduce medication errors, the hospital also instituted a telephone hotline to simplify adverse drug event reporting and allow pharmacists to analyze potential problems each day.
Within 10 months of enhancing its patient safety reporting system, the Veterans Health Administration saw a 30-fold increase in reporting of events, emphasizing the importance of a confidential, nonpunitive system. By training frontline staff to use structured analytic tools and techniques when investigating safety incidents, staff began to see more errors are preventable.
Frustrated by the slow pace of organizational improvement at Sentara Norfolk General Hospital in Norfolk, VA, officials changed direction and worked to make specific safe behaviors, such as clear communication, a regular practice. Their strategies involved repeating back instructions or asking clarifying questions, and establishing high-priority "red rules" — such as verification of surgical sites — to emphasize the critical nature of certain safety steps. Adherence to the behavioral standards became part of staff performance reviews and overall organizational performance monitoring.
Mr. McCarthy says the cases illustrate how health care organizations are working to instill five characteristics of high-reliability safety culture. First, they are seeking to become informed about system vulnerabilities that threaten patients' safety so they can plan and prioritize system improvements. Thus, Sentara Norfolk General Hospital and OSF St. Joseph Medical Center have integrated performance indicator systems that track progress in meeting safety goals by measuring safety-related attitudes, behaviors, events, risks, and outcomes using multiple data sources such as surveys, assessments, incident reports, direct observation, medical records, and malpractice claims.
Next, case study organizations encourage reporting safety incidents and concerns, including near misses or close calls, through internal and external reporting systems, safety briefings, and executive walk rounds. Mr. McCarthy says they appear to have "moved beyond a superficial preoccupation with the volume of reports as a barometer of safety culture to a more mature outlook that values reports for the learning that they enable when accompanied by effective analytic tools." To encourage participation and build trust in the efficacy of reporting, the case study organizations have established feedback loops to discuss with both management and frontline staff what they are learning and doing as a result.
Third, the organizations recognize the necessity of providing a psychologically safe environment for reporting medical errors so mistakes can be identified, learned from, and prevented rather than hidden out of fear of punishment. While some have characterized this as a "blame-free" environment for patient safety, others have more carefully defined it as a nonpunitive or just culture that protects the reporting of honest errors while recognizing that misconduct, in which an individual intentionally endangers patients, is not an error.
A flexible culture, the fourth attribute, encourages greater teamwork and collaboration across disciplines to help maintain and improve patients' safety under the often complex and demanding delivery of health care.
Finally, study organizations seem to be promoting a learning culture by undertaking system reforms based on data and knowledge gleaned from both inside and outside their local environment.
Lessons learned
Mr. McCarthy says the lessons learned from the case study organizations include:
1. Dramatic safety improvements, such as elimination of documented catheter-related bloodstream infections in the ICU and a tenfold reduction in detected adverse drug events, seem to challenge the assumption that adverse events must be tolerated as an inevitable side effect of health care.
2. Safety principles and techniques developed in other industries may be applicable to health care for similar human factor issues. Simple human factor engineering approaches such as standardization and simplification of processes and independent checks to catch errors often seemed to be effective. But knowledge and tools must be adapted to fit the culture of medicine and the particular organizational context and safety threat.
3. Safety awareness and vigilance that can be taught by training and coaching staff to use practical skills, tools, and behaviors so they gain the ability and confidence to identify safety threats and mitigate their causes, in both real-time work and later analysis.
4. An organization's leadership that can motivate and support a "bottom-up" approach to safety improvement among physician leaders and other frontline clinical staff. Some improvements require direct financial investment, and all require dedicated staff time to plan and implement. Several organizations noted the importance of repeatedly telling stories about successful improvements to introduce and reinforce desired cultural values and behaviors and to build momentum for change.
5. Focusing on patient needs, which can be a powerful motivator for change.
6. Seeking and measuring improvement in both systems and outcomes seems to enhance sustainability by validating clinical success factors while helping make a valid and meaningful case for patient safety.
According to Mr. McCarthy, interviews with staff at the case study organizations suggest that the organizations are internally motivated to perform well. Reputational rewards appear paramount, he says, typically to fulfill high public expectations but in some cases as part of a wider effort to shore up reputation.
Several organizations also cited the financial and operational benefits of safety improvement, such as reductions in hospital length of stay and nursing staff turnover as motivators for change. And accreditation requirements are viewed by the case study leaders as a floor on which to build. In contrast, he says, accreditation requirements appear to be the primary driver of safety efforts in most hospitals.
Mr. McCarthy tells State Health Watch that it is difficult to generalize from the case studies. "Organizations have shown that it is possible to make the kinds of changes that put safety at the top of the agenda and show very positive outcomes that appear to be replicable," he asserted.
In a Commonwealth Fund commentary on the study, Joint Commission on Accreditation of Healthcare Organizations senior vice president Paul Schyve said there is no dispute that patients suffer too much preventable harm. He said while the science, patient safety tools, and knowledge of safe practices have advanced rapidly since the 1999 Institute of Medicine report on errors in health care, that has been the easy phase of change. "It turns out that developing and maintaining a safe culture is the hard phase and the real, underlying challenge to successfully applying safety science and safe practices throughout health care," he said.
Mr. Schyve said changing culture is hard work because of the nature of culture in general, and of a safety culture in particular. With culture defined as the customary beliefs, values, and behaviors shared by members of a group, he said, it is difficult to change one element, such as behaviors, without making corresponding changes to the other elements.
"No wonder changing the existing culture is hard," he said. "We are asking health care professionals to change not only their traditional ways of thinking and doing, but their image of themselves. That is why many health care organizations, after translating some of the science and tools into safe practices and implementing them, have begun to feel they have 'hit the wall' of culture change. Further changes to advance patient safety seem increasingly difficult to make and sustain."
According to Mr. Schyve, in the new safety culture, health care professionals are obligated to be committed and competent, recognizing that they still will make mistakes; be active participants in reporting and studying errors and in redesigning systems to prevent them; commit to improve the safety of all patients, not just their own; train, through practice, to make better judgments at the sharp end of patient care; and be vigilant.
Vigilance is a key, he said, because safety must be a continuous, conscious focus in a safety culture and can't be assumed. Also, risks from latent system failures often are difficult to recognize until the failures align and a patient accident occurs. And third, whenever systems are changed, there will be unexpected consequences.
"The more complex the system [and health care systems are very complex], and the more multiple systems interact [and health care systems are open systems], the less we are able to predict all the consequences of planned change — both in the system we are changing and in the systems within which it interacts," he said. "Unfortunately, vigilance is neither easy nor pleasant, and itself creates fatigue."
Meanwhile, the Institute for Healthcare Improvement's "100,000 Lives Campaign" claimed midyear that its efforts to reduce lethal errors and unnecessary deaths in U.S. hospitals have saved an estimated 122,300 lives in the last 18 months.
"I think this campaign signals no less than a new standard of health care in America," said Harvard professor Donald Berwick, who is the institute's president.
Berwick announced his 100,000 Lives Campaign in December 2004 and set a June 14, 2006, deadline for signing up at least 2,000 U.S. hospitals in the effort and to implement six types of change. Perhaps the best known of the six changes is to deploy rapid response teams for emergency care of patients whose vital signs suddenly deteriorate. Another urged checks and rechecks of patient medications to protect against drug errors, while a third focused on preventing surgical site infections by following certain guidelines, including giving patients antibiotics before operations. The other three changes are to deliver reliable, evidence-based care to heart attack patients, prevent central line infections, and prevent ventilator-associated pneumonia.
Contact Mr. McCarthy at (970) 259-7961, e-mail [email protected]. Contact Mr. Schyve at (630) 792-5685 or e-mail [email protected]. Contact Mr. Berwick at (617) 301-4800 or e-mail [email protected].
For years, experts have said improving patient safety will depend as much on significant shifts in the culture of health care as on specific changes in the process of providing care. But there have been no blueprints for laying the foundation for a culture of safety.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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