Joint Commission Issues Sentinel Event Alert About Leadership’s Role and Safety Culture
Surgery center leadership plays a crucial role in creating an organizational safety culture, according to a recent Joint Commission Sentinel Event Alert.
- Leaders should follow and review the organization’s core values.
- Leaders must encourage open communication among staff.
- Leaders must eliminate and prevent intimidation in the workplace.
Healthcare, including ASCs, leadership plays a role in driving a safety culture, according to The Joint Commission.
“Leaders in all organizations that deliver care have to be responsible for building a culture of safety,” says Ana Pujols McKee, MD, executive vice president and chief medical officer at The Joint Commission in Oakbrook Terrace, IL.
“You cannot make improvements in healthcare without a solid foundation of a safety culture,” McKee says. “Whether its surgical site infections, wrong surgery, falls — whatever problems, if you have not built a safety culture, then you will not be successful in reducing or eliminating harm.”
The March 1 Sentinel Event Alert states that The Joint Commission has found that inadequate leadership can contribute to adverse events, including the following issues:
- offering insufficient support of patient safety event reporting;
- lacking feedback or response to staff and others who report safety vulnerabilities;
- allowing intimidation of staff who report events;
- refusing to consistently prioritize and implement safety recommendations;
- failing to address staff burnout.1
McKee makes the following suggestions for improving an organization’s safety culture:
- Review the organization’s core values.
“The first thing a leader does is go through the core values or code of conduct or description of safety culture,” McKee says. “They have to articulate that clearly and make sure everyone in the organization knows what those values are.”
Leaders also must demonstrate these values through their actions and address any poor behaviors in their staff.
- Encourage open communication.
“One principle of safety culture is to allow people to speak up freely,” McKee says. “That means behaviors that intimidate or ignore quiet people have to be eliminated.”
Daily, leaders should exhibit open communication and crack down on intimidation.
“It’s not something you do once a week,” McKee says. “Every day, the leader has to demonstrate and lead by example.”
The way a leader does this is by letting nurses, surgeons, and others know that behavior that intimidates staff is not acceptable. The goal is to create a culture where people are comfortable, she explains.
- Prevent and stop intimidation.
Intimidation by supervisors or workplace authorities can destroy open communication. It can create an unsafe atmosphere by making employees feel that if they speak up about a problem or unsafe situation, they will be ignored or worse.
“Intimidation can be subtle or very apparent,” McKee says. “It could be rolling your eyes when someone is asking a question, or not answering a pager or someone’s question.”
Intimidation includes body language or words that suggest, “That’s a stupid question” or “Isn’t that something you should know?”
The danger of intimidation shuts down lines of communication. Supervisors need feedback from staff to learn about obstacles to safety and quality care. “The price of shutting down someone is huge,” McKee says. “We know through a Sentinel Event database that it’s not rare to hear of someone in a surgical arena who knew it was the wrong surgery, but the safety culture was missing, so the person didn’t speak up.”
Although it may seem difficult to imagine an employee not speaking up when there’s something unsafe or wrong with a surgery, it happens, she notes.
“It could be the wrong surgery, wrong person, wrong procedure, wrong site — any of those,” McKee says. “The reality is that a person who has been chronically intimidated behaves differently than someone who has been respected.”
Leaders can stop unintentional intimidation by pointing out these disrespectful behaviors to the people involved. If the intimidation is intentional, then leaders should have a conversation explaining that the behavior is unacceptable in this organization, and if the leader sees it happen again, he or she will take disciplinary action, McKee says. (See story on signs of staff intimidation below.)
“You have to be very firm around someone who is trying to dismiss or intimidate another staff member,” she says. “Say it’s inconsistent with the organization’s values, and the organization will not tolerate those behaviors.”
- Assess system strengths and vulnerabilities.
Organizations should proactively assess medication management, electronic health records, and other system strengths and vulnerabilities.
For instance, with medication management, a surgery center could assess high-risk medications by performing a failure mode and effectiveness analysis, McKee says.
With each high-risk medication, ASC leaders could identify potential problems and rank the three most likely possibilities. Then, they can put in place a mitigation plan, she explains.
“You put into your process defense mechanisms or protections in the areas where you think there is the most risk,” she says.
An example might be the risk that a medication is administered to the wrong patient. The prevention plan would create a policy requiring two clinicians at the bedside whenever the medication is administered. One clinician would check the medication and dose.
“Build in redundancy in how it’s administered,” McKee says. “And you do that for every possible risk that you have identified as having a likelihood to happen.”1
- Develop a baseline measure of safety culture performance.
The Joint Commission recommends that organizations use a tool developed by the Agency for Healthcare Research and Quality called the Hospital Survey on Patient Safety Culture (HSOPS) or another tool, the Safety Attitudes Questionnaire.
The HSOPS identifies the following 12 dimensions of safety culture:
- communication openness;
- feedback and communication about error;
- frequency of events reported;
- handoff and transitions;
- management support for patient safety;
- nonpunitive response to error;
- organizational learning;
- overall perceptions of safety;
- supervisor/manager expectations and actions promoting safety.1
Although these are hospital tools, McKee recommends ASCs use them.
“There may be questions not relevant to that clinical environment, but when it comes to behavior, communication, and professionalism, it’s applicable across the healthcare spectrum,” McKee says. “It demonstrates their commitment and understanding of their safety data.”
- Consider accreditation.
Although non-hospital-based ASCs are less likely to see accreditation, it’s something they should consider, McKee suggests.
“For a freestanding center, it’s not necessarily something they would do, but this is very important for them to take on in the future,” she says. “Their issues are equivalent to other settings in the hospital.”
Accreditation could be one of the most important actions an ASC could take to improve its clinical environment, she adds.
“It’s a way to standardize their processes and give them a platform to improve,” McKee says. “Since so much has shifted to the ambulatory side, it’s in the public’s best interest for ambulatory surgery centers to be accredited.”
- The Joint Commission. Sentinel Event Alert 57: The essential role of leadership in developing a safety culture. Available at: http://bit.ly/2lqJbge. Accessed March 27, 2017.
Recognizing Signs of Workplace Intimidation
Workplace intimidation is similar to domestic intimidation. Both make people behave in ways that are hard to explain and justify, says Ana Pujols McKee, MD, executive vice president and chief medical officer at The Joint Commission.
“When you silence someone, all of these things go through their minds: ‘Am I right? What if I’m wrong?’” McKee says. “We want to eliminate that in healthcare because we want everyone to voice their concern.”
McKee offers the following examples of workplace intimidation:
- There are fewer event reports.
A workplace in which employees are intimidated tend to report events reported to the organization less frequently, she says.
“If a person feels that putting in a report about something that is unsafe can cause the person punitive consequences, then the person doesn’t make the report,” McKee explains.
- Employees are fired for process failures.
When a workplace’s culture includes staff intimidation, scapegoats are blamed for problems that are systemic.
“You might find that people have been fired for things related to process failures and not people failures,” McKee says.
- New ideas are stifled.
If employees never or rarely offer new ideas to improve the organization, it could be because they are afraid to be innovative, McKee says.
“Their new ideas are not rewarded,” she says.
- Leaders are unaware of the negative culture.
Sometimes, an organization’s leadership is unable to appreciate that the culture does not promote safety. For instance, the leadership might wrongly celebrate few safety problem reports, not realizing the lower number is because of employee intimidation, McKee says.
“They don’t appreciate that numerous reports are a sign of a healthy culture,” she adds. “So bad behaviors are tolerated, and employees feel they cannot speak up because leadership does not support a safety culture.”
Healthcare leadership plays a role in driving a safety culture, according to The Joint Commission.
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