Safety Culture Proven to Improve Quality
May 1, 2016
With more evidence continuing to show the relationship between patient safety and quality of care, hospitals are devoting more resources to developing a patient safety culture. But how does a patient safety culture influence quality, and how do you know if you have instilled that culture throughout your organization?
A recent study added to the data suggesting that a patient safety culture improves overall quality within the healthcare organization. Researchers found that an embedded patient safety culture may be as important to delivering high-quality patient care as more technical issues like the skill of a surgeon or the latest high-tech equipment. (See the story later in this issue for more on that research.)The research reinforces an idea that has emerged in recent years, says Coleen Smith, RN, MBA, CPHQ, CPPS, director of high reliability initiatives with the Joint Commission Center for Transforming Healthcare. Quality leaders have come to realize that patient safety is about more than just not harming patients; it’s also about improving the quality of care overall.
However, instilling a patient safety culture is proving to be a challenge for hospitals. Based on measurements from the Agency for Healthcare Research and Quality (AHRQ), hospitals are making slow progress in creating a culture in which patient safety is paramount, Smith says.
“Hospitals are showing good results in some areas, like trusting the others in your unit to protect patients’ safety. But other areas have had a very low positive response,” Smith says. “One of the most persistent challenges is the fear of a punitive reaction to speaking up. People consistently report that they are afraid of a negative reaction and punishment if they rock the boat in an effort to improve patient safety.”
Responses to a survey question regarding fear of punitive actions have held steady around the 50% mark for years, Smith says, meaning that about half of those surveyed do not report patient safety concerns for fear of getting in trouble.
“That’s kind of a relic from 15 years ago when it was true that if you reported something, you might get fired,” Smith says. “It‘s taking us a long, long time to move the needle on that. It’s almost like an urban myth. People are insistent that reporting concerns will get you in trouble, even though it doesn’t.”
HOSPITAL LEADERS SET THE TONE
Senior leaders in the hospital must demonstrate their commitment to a patient safety culture, says Robin Diamond, MSN, JD, RN, CPHRM, NEA-BC, CPHQ, senior vice president for patient safety and risk management at The Doctors Company, the largest liability carrier for physicians in the country. No matter how much managers and supervisors promote patient safety, the culture will not improve if people do not believe the C-suite executives and board members are fully on board, she says.
“They set the tone for what the organization truly believes and will stand by if push comes to shove,” Diamond says. “Senior leadership must set the expectations for developing a very healthy patient safety culture, the vision and values of the organization, and the regular assessment of the culture.”
Throughout the organization there also should be patient safety champions who promote the right culture and spearhead the training that can change behavior, Diamond says. This person might be a nurse manager, for instance, who can address patient safety at each staff meeting with updates on safety scores, improvements in procedures or equipment, and encourage people to voice their concerns or suggestions.
Patient safety also should be part of each employee’s performance evaluation, Diamond suggests. A patient safety culture involves specific behaviors that can be measured in an objective way, along with more subjective assessments of the person’s commitment to patient safety, she notes.
“Many organizations are now interviewing potential new hires with questions about how well they will integrate into the culture of that workplace,” Diamond says. “A strong, healthy patient safety culture will be served best by bringing on people who are comfortable with the importance of patient safety concepts like team communication and reporting errors.”
That screening can be as simple as asking the person what he or she knows about the importance of a patient safety culture, Diamond says. Someone who has worked in an organization that values patient safety will be able to talk about the need for teamwork, safe handoffs, time outs, reporting errors, or asking questions. Other questions could address how the person works in a team environment and how they communicate with team members who may be their superiors. Interviewers also can ask how the person would respond in a particular situation, such as a nurse thinking that a surgeon is about to perform the wrong procedure. Would the applicant be comfortable calling a time out in the operating room or pulling the surgeon aside to confirm the procedure?
“The response can tell you a lot about that person’s experience with a culture of safety and their personal comfort level with doing what’s right for the patient even in a difficult situation,” Diamond says. “You might learn that this person will enhance your efforts to create a patient safety culture, or that this person will set you back.”
BE TRANSPARENT IN ALL WAYS
Transparency is the best way to defeat the fear of punitive action, Smith suggests. Hospital leaders should strive for complete transparency in patient safety matters, publicizing all improvement efforts and praising employees who speak up about patient safety. Unless the person wishes to remain anonymous, quality leaders can publicly validate the person’s concerns and thank him or her for speaking up. Even if the person voicing a concern does not want to be named, hospital leaders still can acknowledge that someone brought up an issue about a particular topic and that the administration appreciates the heads up.
This type of recognition can come in the form of laudatory announcements during staff meetings, in newsletters, on the employee website, or any other public format, Smith notes. A personal thank you note from the employee’s supervisor or a senior hospital leader also will go a long way toward showing that there is no need to fear a punitive reaction, and you can count on that employee telling coworkers about it.
Smith notes that the public acknowledgment and appreciation does not have to wait until the patient safety matter is investigated and resolved. Even if the investigation reveals that there is no issue to resolve, the employee still should be praised for speaking up, she notes.
“Follow-up is very important, because people stop reporting when it seems the information goes into a black hole and nothing is done with it,” Smith says. “They need to hear back that you made a change in response to their concern, or that the needed change is more than you can do now but you’re aware and planning a solution. At least tell people that you heard them, you appreciate it, and you’re responding in some way.”
MEASUREMENT IS CRUCIAL
As with any quality improvement initiative, it is important to measure your progress so that you can gauge the effectiveness of your efforts and redirect resources as necessary. With patient safety, the most commonly used tools are the “Hospital Survey on Patient Safety Culture” provided by AHRQ and the Safety Attitudes Questionnaire (SAQ) from the Center for Healthcare Quality and Safety at the University of Texas. (The AHRQ survey is available online at . The SAQ is available online at .)The AHRQ survey is the one indicating that fear of punitive reaction is still a significant hurdle for instilling a patient safety culture.
Those tools should be used to measure the patient safety culture at regular intervals, and frequently, Smith says. In the past it has been common for hospitals to use those tools at three-year intervals, but Smith now recommends measuring patient safety culture every 18 months or two years.
“Particularly if you have been moving the bar, you may want to check it more frequently than every three years,” Smith says. “It’s important to know how your efforts are changing the culture within your organization, and three years is too long to wait if you want to confirm your effectiveness or change what may not be having enough impact.”
Smith cautions that simply handing out the surveys is not enough to get a true reading on your patient safety culture. Response rates can be very low unless administration promotes the survey and how important it is to hear the feedback from employees. Shoot for a response rate of at least 65%, Smith advises, to ensure the data will be meaningful and accurately reflect the safety culture. Also be sure to administer the surveys across the board to all employees, not just front line clinical staff. Patient safety is everyone’s job, so the survey should go to physicians, housekeepers, technicians, and essentially anyone who has any contact at all with patients.
“You can increase your participation rates through some mindful communication. You can’t just send an email and expect everyone to fill out the survey,” Smith says. “Consider strategies like meetings about the survey, full-time media campaigns, and frequent reminders about why the individual’s input is so important. The higher the participation rate, the better idea you’re going to get of what the culture really looks like.”
INVOLVE PHYSICIANS IN IMPROVING CULTURE
Patient satisfaction assessments also can help assess the hospital’s patient safety culture, Diamond notes. Gathering the data is not the end of the story, however. Too often, Smith says, hospital quality leaders do not follow up on the results and share them broadly with managers. When the data is shared with managers, there often is not enough follow-through to see that the information was used to improve the patient safety culture, she says.
Quality professionals should use the patient safety survey results to develop new strategies for improvement and to tweak existing efforts that are not producing the desired effects, Smith says. The results also should demonstrate what resources and efforts are paying off well. The survey data plans for improvement should be communicated to senior hospital leadership and the board of directors, she says.
Physicians should be directly involved in efforts to improve the patient safety culture, says Leon J. Owens, MD, FACS, president and CEO of Surgical Affiliates Management Group in Sacramento, CA. He and his colleagues have adopted a number of patient safety practices that they promote in their hospitals, and Owens notes that the hierarchical structure of medicine means a physician who is vocal about patient safety can encourage others.
One of the practices that Owens and his fellow surgeons follow, for example, involves a specific way to handoff a patient from one physician to another. The hand off always takes place in a quiet room with a mid-level practitioner present who has been involved with the patient’s care on a daily basis. The mid-level updates both doctors on the patient’s status and treatment, the goal being to avoid having one physician unaware of a change in the patient and therefore not conveying it the other.
The surgeons strive for uniformity in processes and procedures, following best practices but also uniform decisions on issues that usually are left to the individual physician, such as which antibiotics to prescribe. The surgeons also closely track complication rates. When surgeons from Owens’ group begin working at a hospital, the group requires access to the hospital’s patient safety data and looks for deviations that need attention. As necessary, the surgical group helps the hospital adopt better patient safety practices.
“We also incentivize our doctors to have this culture of safety by meeting certain metrics about antibiotics given at the right time, for instance, and catheters stopped at the right time,” Owens says. “Of course, the biggest part of patient safety is communicating well with each other, so we put a lot of energy into communicating.”
The biggest challenge for surgeons is fully committing to the team concept, Owens notes. The old school approach was for the doctor to lead and everyone else to follow without question, but a patient safety culture requires a more communal approach, he says.
“The doctor may still be the one who is ultimately in charge, but patient safety requires our physicians to work within a team,” Owens says. “They are part of a culture that says, ‘yes, how can I help you?’”
- Robin Diamond, MSN, JD, RN, CPHRM, NEA-BC, CPHQ, Senior Vice President For Patient Safety And Risk Management, The Doctors Company, Napa, CA. Telephone: (800) 421-2368, ext. 1243. Email: .
- Leon J. Owens, MD, FACS, President and CEO, Surgical Affiliates Management Group, Sacramento, CA. Telephone: (916) 441-0400. Email: .
- Coleen Smith,RN, MBA, CPHQ, CPPS, Director, High Reliability Initiatives, Joint Commission Center for Transforming Healthcare. Telephone: (630) 792-5349. Email: .
But how does a patient safety culture influence quality, and how do you know if you have instilled that culture throughout your organization?
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