The Quality/Cost Connection
It’s time for a revolution in patient safety culture
A five-step approach for changing attitudes
By Patrice Spath, RHIT
Brown-Spath Associates
Forest Grove, OR
When implementing patient safety improvement initiatives, winning the hearts as well as the minds of people in your facility is important. Unless you convince people of the importance of the improvement endeavor, they will simply give it lip service — even if it’s mandated by management or the Joint Commission on Accreditation of Healthcare Organizations.
Why is it, for example, that patient care workers sometimes neglect proper hand-washing techniques, even though such techniques are required? In contrast, protective gloves are usually worn faithfully. Co-workers make certain that everyone wears them, and supervisors will not hesitate to enforce this rule. Clearly, people see the value of protective gloves but not that of proper hand washing. Regardless of institutional or regulatory rules, the hearts of health care workers must be won over if patient safety improvement efforts are to be successful.
When evaluating safety improvement opportunities, it’s important to look at more than just high-risk patient care processes. There is a culture in every health care organization that people must work within. This culture has more of an impact on patient safety and quality than most process problems.
An example of how culture affects our actions is the speed that people drive their cars on the highway. Few people drive at or below the posted speed limit. The police try to enforce the speed limits, but this enforcement has little impact on overall driving habits. Why? Many people see little value in traveling at or below the speed limit. If process improvement efforts are to succeed, the hospital culture must support a safer environment. People must learn to value compliance with safe practices.
Changing the way people think about patient safety is not easy. Culture change is not a program, which, by definition, has a beginning and end. Culture change is a process that, once embraced by the people, brings about lasting change — change that is passed on from one generation of workers to the next. Culture change does not take place overnight.
Quality consultants in private industry estimate that it takes five to seven years of continuous focus and hard work to change the culture of an organization. Those of you working hard to develop a nonpunitive incident-reporting environment should not get discouraged when this culture change does not happen overnight!
Time is one of the most difficult challenges to face when improving patient safety. The goal must be to change the culture and not merely to address problems as they occur. Expecting people to modify their attitudes overnight is unrealistic. There has to be a long-term commitment to support patient safety improvement goals in order to impact the true culture.
To change the culture of patient safety in your facility, use this five-step approach:
- Establish a vision of the desired patient safety culture and communicate it throughout the organization.
- Gather input to assess the culture’s strengths and weaknesses.
- Develop a strategy to realize the desired changes and allocate budget resources, personnel, training, and time to the program.
- Implement the strategy and hold people accountable for meeting objectives.
- Conduct ongoing progress evaluations.
Patient safety improvement must start at the grass-roots level. Employees should not be passively involved. They should be empowered to make safety improvements where needed. Instead of just passing suggestions on to management for implementation, staff members should be encouraged to take an idea for improving patient safety in their own work area and develop it to completion.
Issues that have a larger area of impact need to be reviewed jointly by management and the work teams. This builds a bond of trust between staff members and management and employees. Do department meetings operate on the principles of continuous quality improvement? All people present at the meeting must have an equal voice. The manager that participates has no more clout than the staff person. This attitude can significantly improve staff morale and the effectiveness of process improvements.
Patient safety awareness campaigns can help to change the organization’s culture. During the campaign, ask employees to report real or possible near-miss patient incidents. Sponsor some "What if?" round-table discussions that focus on hypothetical near-miss situations and how to prevent similar incidents in your organization. Such campaigns can be very successful in terms of safety improvements and culture change. First, making people aware of potential patient safety hazards reduces the likelihood of an incident happening. Second, employees become more willing to talk to each other about unsafe situations.
Create a safe communication network
Identify the hospital’s quality or risk management department as the hub of the patient safety communication network. Let staff members know that the purpose of this network is to share patient safety improvement successes and failures among departments.
People working in the quality or risk management department should be given the authority to act on patient safety problems, and everyone in the hospital should be aware of this authority. Staff must be able to directly contact this department when issues come up regarding patient safety. Employees are more willing to bring unsafe acts or circumstances to the attention of management when they are treated in a friendly, nonthreatening manner. Trust is essential for effective communication. You cannot expect people to report undesirable patient incidents unless they trust you to use the information for process improvement purposes only.
Earning trust step by step
Trust evolves in steps; it is not something that comes all at once. It is vitally important for everyone in the organization to understand that management and staff members all have the same goals when it comes to patient safety.
A safety culture revolution is needed in health care organizations. All employees must feel they are equal partners in safety improvement efforts. There can be no boss-subordinate or us-them relationship. Each staff member has unique skills to bring to the organization’s goal of providing high quality, safe patient care. A grass-roots patient safety improvement initiative can have positive results. The punitive aspects of mistakes are de-emphasized and replaced by a positive, lessons-learned approach.
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