Are you holding staff accountable for safety?

Positive feedback helps build safety culture

If you asked your employees whose job it is to create a safe workplace, how would they answer? Would they point to you? Or would they recognize their own responsibility? Creating accountability for safety begins with job descriptions, performance evaluations, and training. But it also involves a more pervasive culture change that emphasizes safety, employee health experts say.

Safety should be part of core competencies

"There are some folks who think of safety as something separate from the job," says Charlene M. Gliniecki, RN, MS, COHN-S, vice president, human resources, at El Camino Hospital in Mountainview, CA. "Safe performance is actually a part of every activity, every function in a job performance or activity." El Camino Hospital emphasizes that fact by including safety in the core competencies expected of all employees. For example, performance objectives include consistently using personal protective equipment in appropriate situations.

But managers also can provide a myriad of more subtle incentives or disincentives to act safely. For example, if an employee is praised for acting without delay in transferring a patient, even though she cut corners by failing to use lift equipment, she gets the message that safety is of secondary importance, says Dean Veremakis, CSP, MEd, MA, product manager in the performance technology department at Liberty Mutual Insurance Group in Atlanta. "People will do what they have been reinforced to do," states Veremakis, who offers consulting in behavior-based safety.

Managers need to understand their role in ensuring safe practices, agrees Gliniecki. "We have a duty as an employer when someone does not follow safe work practice that we coach, counsel, and support people to do the right thing, and that could include discipline," she says. "[The Occupational Safety and Health Administration] will look to see if we have that process. How is it that your clinical staff give the right medication and hang the right IV? It’s considered essential to their function in their job. We would want to look at the same thing in safety."

Unfortunately, discussions about safety often turn into a blame session. The issue shouldn’t be who is at fault, but how future events can be avoided.

Observation and feedback

That’s why Veremakis has developed a program based on peer observation and positive feedback. "I might observe 25 people over an hour period using a very specific piece of equipment," he says. "I’ve observed it 100 times, and 80 times they used it the way they were supposed to. Twenty times they didn’t use it properly. They’re 80% safe. Do we want to get it up to a high of 90% safe? We’ve got to reinforce every time they do it right, rather than chewing them out when they do it wrong."

Such behavioral methods only work once the employer has provided other necessary components of a safety program: good training, protocols, necessary equipment, and accident investigation. (See "Hospitals discover secret to lower injury rates," in this issue.) "If we’re assured it isn’t something that can be fixed from a physical aspect, we look at how we can get people to do what they [the employers] want them to do," he says. "I do an analysis of the things that trigger or influence the behavior. I look at the consequences of the behavior."

Veremakis selects "very specific, critical" behaviors and develops a checklist that can be used by co-workers to continually monitor safety. "The observation sheet is strictly for that," he says. "It’s designed as a nonpunitive, peer-to-peer helpful tool."

Employees should be involved in the design of the checklists, just as they are the ones who carry out the observations. They don’t put co-workers names on the sheets; they’re observing the unit and looking for overall information on how often safe procedures and safety equipment is used. "You have to get it to the point where observations become a way of life," he says. "At any day, any time — they have to be done on a random, regular basis."

Injury and accident information is not an appropriate way to evaluate the performance of individuals or even of departments, cautions Veremakis. "[You may think because one] department has had no accidents, therefore the department is safe. That’s not necessarily true," he says. "They may have beaten the odds."

Leadership commitment is essential

While every employee should be responsible for safety, accountability ultimately lies with the leadership of the top administrators, stresses Gabor Lantos, MD, PEng, MBA, president of Occupational Health Management Services in Toronto. On the organizational hierarchy, employee health should report to a high-level administrator — a vice president or higher, says Lantos. Health and safety issues should be communicated to senior management, he says. For example, when senior managers look at quality indicators for the hospital, safety data such as needlesticks and immunization rates should be included, he says.

"If the organization has certain expectations of safety standards, people will live up to them," Lantos says. "People live up to the culture. If everybody wears a hard hat, you don’t make a fuss about it. You wear a hard hat."

In fact, ensuring that employees follow safe practices is a part of the leadership function reviewed by the Joint Commission on Accreditation of Healthcare Organizations, notes Gliniecki. For example, El Camino Hospital focused on reducing blood exposures, such as those from splashes, among labor and delivery staff. The staff, including nurses, nursing assistants, obstetrical technicians, and anesthesiologists, received feedback on blood exposures each quarter. They discussed the exposures and what barriers may exist to using safety equipment or safe practices.

While the managers guided the process, employee health provides the framework, says Gliniecki. "We are supporting the managers in their role, and we have a shared interest and we are a resource to them," she says.