Culture...again!

We hear it over and over and over again (and that probably should tell you something) - safety culture is one of the most importance issues to address in order for health care organizations to provide safe care.  If you've worked in health care for any length of time, chances are that you have heard about two reports that were published by the Institute of Medicine in 1999 and 2001, respectively - To Err is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century.  Both reports identified safety culture (defined by the Joint Commission as "the individual and group attitudes, beliefs, perceptions, and values that determine the organization's commitment to quality and patient safety") as an area for significant improvement in health care.  However, despite the incredible focus on culture to improve patient safety, a follow-up report in 2006 by the National Quality Forum identified 30 key practices for improving the quality of health care - safety culture was #1 on the list!  Notably, these recommendations have not changed over the years.  Creating and sustaining a safety culture should remain the top priority for improving the quality and safety of health care services delivered in the United States today.

Two of my favorite studies in this area compared safety climate/safety culture in hospitals to that in naval aviation.  As you may recall, naval aviation (specifically, aircraft carrier flight operations) was one of the original prototypes for the study of High Reliability Organizations (HRO's).  Given that many hospitals now aspire to become HRO's, it seems intuitive to compare and contrast the prevailing attitudes and level of commitment to safety in hospitals versus naval aviation.  The first study compared different hospital personnel with U.S. Navy pilots.  For the purposes of this study, "problematic responses" to a safety climate/safety culture survey were defined as those that suggested an absence of a commitment to safety.  The number of problematic responses was 12 times higher in health care workers in comparable high-hazard environments (the Emergency Department and Operating Rooms) compared to Navy pilots. 

The second study was performed over 5 years later and found that safety climate was three times higher, on average, among U.S. Navy aviators compared to hospital workers (this was a really large study that involved nearly 15,000 naval aviators and 15,000 hospital workers).  More interesting was the fact that responses of U.S. Navy commanders (the individuals "in charge") were congruent with the rest of the aviators that were surveyed.  In other words, both the leaders/managers and frontline workers felt that there was a true commitment to safety in their organization.  In contrast, hospital managers often felt that there was a commitment to safety when frontline workers did not! What does it say when hospital leaders feel that their organization is committed to safety and the frontline workers feel quite differently?

So, with this in mind, what can we, as hospital leaders, do to create and sustain a climate of safety?  It absolutely starts with something that Harvard Business School researcher,  Amy Edmondson has called "psychological safety".  Leaders create the kind of environment where workers are free to speak up about their concerns without fear of retribution or ridicule.  "Psychological safety" means that individuals can openly admit their mistakes and learn from them. 

Want an example of psychological safety?  Look no further than a study recently published by investigators from the Northern Arizona University.  These investigators looked at the climate of safety at several NCAA Division I football programs during the 2017 college football season.  Football players were significantly more likely to self-report the signs and symptoms of a potential concussion if   they felt that safety was important to their coaching staff.

Imagine what that would look like in the hospital environment and ask yourself this one question.  How frequently do providers at your institution self-report needlestick injuries? How frequently do they report potential safety concerns about a patient?  If you don't hear these kinds of reports at your organization, chances are that you have some work to do around safety culture.