Beyond slogans: How to build a culture of safety

Red rules, raising risk awareness are keys

Safety culture (n): 1. A set of values and beliefs that results in fewer employee injuries and medical errors. 2. What all hospitals want but too few have.

In employee health, "safety culture" is the Holy Grail. If you have a strong one, employees are more likely to comply with rules and use equipment designed to protect them and their patients. But what is a safety culture? How do you get one?

Those are questions that Craig Clapper, PE, CQM, MBA, partner and chief operating officer of Performance Improvement International in San Clemente, CA, has studied — not just in health care, but in the work of business effectiveness gurus such as Jim Collins, author of Built to Last, and the efforts of the nuclear power industry, where accidents could be catastrophic.

He has adapted techniques that can be put in place in hospitals to make "safety first" more than just a slogan. "People aren’t really articulating what this thing called safety culture is. We’re just complaining that we don’t have it."

In fact, everyone has a safety culture, Clapper says. Some are strong; many are weak. "In health care, the culture is one of work arounds and shortcuts." By starting with basic values, setting up a few absolute rules, and establishing behavior-based expectations, hospitals can create an environment that places a higher premium on safety, he says.

A case in point: Sentara Norfolk (VA) General Hospital launched a safety initiative that included commitment from top leadership, a safety coaches program, and a four-hour hospitalwide training program: Behaviors for Error Prevention. Clapper has helped the hospital assess its current safety climate and establish a performance improvement plan.

"This isn’t just a project to improve patient safety. This is an initiative to improve the overall safety of everyone who works, visits, or is treated at our hospital," says Carole Stockmeier, MHA, director for cancer services and one of the coordinators of the safety initiative.

"We’re not just going to go for a behavioral change. We’re trying to make a change to our whole foundation and create a culture in which safety is what we’re all about," says Cindy Parker, director of operational support and also one of the coordinators of the safety initiative. "This isn’t flavor of the month. It’s there in everything we do."

Here are a few key aspects of the Norfolk General safety initiative:

The vision thing. It might sound trite, but every successful program starts with a slogan. At Norfolk General, the hospital stated, "Patient safety starts with me."

The idea is to link all aspects of safety — for patients, employees, and visitors — and to personalize it. Everyone shares the responsibility.

Senior administrators endorsed the program and agreed to provide resources for consultants, training, and ongoing performance improvement.

"Changing culture is a very long process," says Stockmeier. "It requires that you stick to it and that you don’t allow other things to divert your attention from the task you have at hand."

The vision and the mission give a sense of purpose to your program, Clapper adds. "To change culture, you probably do have to start out with a poster. You have to define and demonstrate that new expectation that we want everyone to believe in. Companies that do well with safety culture have amazingly simple mission statements."

Of course, the vision is just the beginning. Leaders then need to follow up with a set of behaviors and expectations, "describing what behaviors are consistent with that overall statement of purpose," Clapper says.

Red rules. Sometimes, there is no compromise for safety. You want the staff to follow the rule in all cases. Clapper calls that a "red rule. It gives you the ability to convey [a strong] expectation or conviction."

For example, Norfolk General has a red rule that requires surgeons to identify the surgical site and confirm it with the surgical team before taking hold of the scalpel. No exceptions.

Zero lift is an example of an employee health-related red rule. A hospital might set up a policy that requires the use of a lifting device with any fully dependent patient. Norfolk General is in the process of identifying additional red rules.

"Some red rules will be the same across all departments. Others will be specific to departments," Stockmeier says. "You want them to be few in number, and you want them to be significant. It’s a few key words that focus an employee in on remembering a specific action or behavior." She estimates that the hospital will settle on a maximum of three to five red rules per department.

Managers will designate the red rules, and senior leadership will sign off on them. Then employees will receive information about the rules and expectations. "We are going to be reminding managers that we have a code of conduct policy," she says. "That code of conduct policy covers failure to comply with performance expectations."

The three-factor formula. There are three factors that work together to determine how likely employees are to comply with safety practices, Clapper explains. Consider the perceived burden or effort as the numerator. In the denominator is the risk awareness and the culture of compliance.

"Whenever the [perceived] burden is high, noncompliance is high," he says. "Whenever risk awareness is low, noncompliance is high. Whenever your culture or your shared value on safety is low, then compliance is low. It’s very situationally specific."

For example: At one hospital, workers smelled smoke coming from a cable tunnel. They went to investigate a fire. "The work rule is that we verify that the atmosphere contains enough oxygen and doesn’t have explosive gas until we enter. Our little gas meter is actually stored at another facility. The time and effort to get it gives you the burden. So they chose just to go in," says Clapper. Five employees had to be treated for symptoms of headaches and dizziness for not using the proper protective equipment while handling the fire.

Another case in point: Needlesticks occur when employees fail to activate the safety features of needle devices. Most likely, they do not have a strong sense of risk awareness, he says. A consistent emphasis on needle safety, through training and accountability, can also build better work habits and a culture of compliance, he says.

"The people who go to driving school are not taught about how to drive better. Their risk awareness is raised about the importance of driving better," Clapper points out. "The other thing I’d work on is the culture of compliance — half of it comes from leaders, the other half comes from peers. You have to define it, then work on the knowledge and skills, and then work on accountability."

Continual feedback. Accountability for safety can be built into performance evaluations. But continual feedback is critical, as well — and it should be delivered in a dose of five times as much positive feedback as negative, he says. Nurse managers should conduct "safety rounds" and catch employees doing something right — using alcohol-based hand rubs for hand hygiene, for example, or activating safety devices. A simple look of approval or thumbs up is all that is needed.

"You take all the rah-rah out of it," he says. "You might sympathize with them, saying I know this is inconvenient for us, but it’s important.’ Health care workers are motivated by knowledge and excellence."