The phrase "safety culture" is widely used but rarely understood. Even if you do fully understand the concept, turning that knowledge into actions that positively influence your organization can be a challenge. Today, your organization's culture is creating the conditions and behaviors that will either produce excellent results or serious adverse events. If you are not actively trying to create a strong safety culture in your organization, it probably doesn't exist. The reason for this is that all organizations exist to provide a product or a service. Therefore there is a natural emphasis on production that is reinforced at every board meeting and every performance evaluation. Every employee knows their paycheck is tied to their efforts to help production. Conversely, a safety culture is not naturally built into a corporate structure. To create a strong safety culture, leadership must ensure the following four characteristics exist in their organization:
1. Everyone is empowered and expected to stop and question when things just don't seem right. This statement is important on multiple levels. Empowering a caregiver or support person to stop a procedure or a practice may be the final barrier that can prevent a serious event. This statement charges everyone in the organization with the responsibility to take action and actively participate in event-prevention and process improvement efforts. Since social norms will typically inhibit junior staff from challenging those in higher authority, leadership must advocate this expectation with both words and actions. Positive recognition for questioning is essential as is zero tolerance for intimidating behaviors. It is important to note that the statement does not say to stop when something is "wrong." With that standard, clinical judgment may be inferred and many people will defer to the expert in the room to decide when to stop. But anyone involved can identify when things "just don’t seem right." This simple practice of asking a question like, "Can you help me understand why…?" gives the person in charge an opportunity to pause and think, which may be all it takes to change course and prevent a significant adverse event.
2. Everyone is constantly aware of the risks inherent in what this organization does. No matter how complex or hazardous an activity is, if we do it repetitively, human nature will cause us to let down our guard. Most people don't feel there is much risk in what they are doing if they have successfully performed the task hundreds of times. Over-confidence and complacency are the concerns here. A strong safety culture is maintained with a healthy uneasiness where the norm is for the staff to "trust but verify." It is important to have discussions about adverse events or near misses that have happened inside or outside of the organization. Leaders must create an open environment where these near misses are discussed in regularly scheduled education sessions and everyone is reminded to look out for those inevitable errors that will occur.
3. Learning and continuous improvement are true values. When human errors or adverse events occur, the normal response in many organizations is to not discuss it openly. This occurs for various reasons. Sometimes it is the belief that making those involved feel uncomfortable is contrary to a non-punitive safety culture. However, the opposite is true. In an organization with a strong safety culture, these errors and events are considered valuable insights into vulnerabilities that exist and therefore they are key learning opportunities. A continuous feedback loop is needed that takes the lessons learned from human performance and process problems and incorporates them into education and process improvement activities. Incident reporting programs are the main tools used for this purpose in high reliability organizations. The most effective are those focused on identifying and correcting the precursor behaviors and conditions before they lead to events. By their very nature, a well-run incident reporting program reinforces all the key attributes of a strong safety culture. Achieving zero human errors is impossible, but zero significant adverse events (e.g., preventable patient harm) is attainable through continuous learning and improvement.
4. Teamwork is a requirement to work in this organization. Much like "leadership commitment," teamwork may appear to be an obvious component for the success of any organization. However, when building a safety culture, it is much more than that. Once again, leaders need to overcome some basic human behaviors to make this characteristic solid. When problems occur, the normal competitiveness and pride among close-knit work groups lead to defensive statements about how someone else, or "they" are the problem. Since organizational silos and subcultures naturally develop in a large organization, it must be emphasized that if anyone fails the whole organization fails. Leaders can reduce the negative impacts of these subcultures by trying to emphasize use of the word "we" versus "they." For example, "We were slow in getting the test results which resulted in a delay in starting treatment" is a learning opportunity, versus "They were slow getting us results and that caused the problem," which assigns blame and creates defensiveness. It is well known that good teamwork helps production, but more importantly, the lack of teamwork will ultimately lead to poor communications and therefore safety risks. Leadership must continuously reduce these risks by reinforcing that the organization is one team that must work together and help each other to be safe and successful.
The positive results from focusing on these four organizational characteristics have been demonstrated for many years in the nuclear power industry and other high-reliability organizations. Although the challenges are very different in healthcare, the human behaviors that will minimize or enhance safety risks are the same. Since we know a strong safety culture will reduce the risk for adverse outcomes, focusing on these four characteristics should be more than a priority. These characteristics should be non-negotiable values in your organization.
Howard Bergendahl is a certified professional in Patient Safety, a licensed attorney and a healthcare consultant who specializes in safety culture issues. After 20 years in various leadership roles in the nuclear power industry he founded the Bergendahl Institute, LLC in 2003. Howard assists healthcare executives incorporate high reliability techniques into their organizations.