Culture of Safety

This guide outlines the steps that managers can follow to shape the Culture of Safety in their departments:

Senior leaders, as well as physicians, pharmacists, and nurse leaders, can establish a trusting environment among all staff by modeling appropriate behaviors and championing efforts to stop intimidating actions but maintaining accountability.

1. Create and maintain an environment where staff members feel safe reporting issues and near misses, thus preventing harm from ever reaching a patient.
2. To establish psychological safety for staff:
3. Recognize that authority gradients and power hierarchies exist in all organizations and may inhibit open communication.
4. Use communication tools, such as TeamSTEPPS, to build an infrastructure that supports near-miss reporting and accountability.
5. Implement a “nonretaliation” policy for all staff reporting safety concerns.
6. Set up electronic event reporting software that provides options for anonymous reporting and allows anonymous reporting of unsafe conditions without fear of reprisal. Anonymous event reporting will show that leadership is interested in safety issues, not the people reporting them.
7. Reject intimidating behavior that suppresses reporting.
8. Address concerns in a timely manner.
9. Communicate with the staff about improvements and lessons learned.
10. Implement a Just Culture with Accountability. Just Culture requires that actions are separated from decisions. Staff should not be punished for human error but should always be held accountable for their decisions regardless of the outcome.

Ensure Transparency:

1. Emphasize teamwork, accountability, and shared purpose.
2. Listen to the voices of patients, families, and caregivers.
3. Ensure an open and transparent culture that encourages staff and patients to:
   1. Speak up when they perceive a problem with patient care and to self-report when needed.
   2. Question in an uninhibited but respectful and concerned way, even those with more authority.
   3. Create and sustain an environment where providers, patients, and families are actively engaged in open communication, accountability, and support.
4. Clearly define requirements to maintain trust, accountability, identification of unsafe conditions, strengthening of systems, and continuous assessment and improvement of the safety culture.
5. Create an infrastructure that provides training, staffing, budget, an electronic reporting system, oversight committees, and regular updates to board-level committees. This infrastructure should include a Patient and Family Advisory Committee (PFAC).
6. Use a Change Management tool to implement process improvements and support safety behaviors in daily practice. It should ensure acceptance, accountability, and sustainability of the changes.
7. Track and record data:
   1. Use survey tools such as the free AHRQ Survey on Patient Safety Culture and Safety Attitudes Questionnaire (SAQ) to identify areas for improvement and to track your progress.
   2. Implement an electronic incident reporting system that allows for anonymous reporting, tracking, trending, and response to aggregate safety data.
   3. Create a reliable means to capture and analyze good catches and near misses.
8. When there is an unexpected outcome, including if a preventable medical error causes patient harm:
   1. Address it with open disclosure among the healthcare team, patient, and family.
   2. Resolve the outcome promptly.
9. Use the CANDOR (Communication and Optimal Resolution) approach.
10. Implement thoughtful and memorable internal branding, such as through posters and staff emails, to keep safety expectations and behaviors top-of-mind throughout your organization.
11. Celebrate successes and progress toward zero preventable harm.
12. Share patient stories—in written and video format and in-person presentations—to identify gaps and inspire change in your staff.
13. Have a staffing budget that ensures an adequate number of full-time patient safety and quality improvement professionals.
14. Develop an interprofessional, multidisciplinary, comprehensive patient safety program plan, appropriately budgeted and approved through leadership and board channels, that is thoroughly implemented and monitored for success. To ensure accountability, the plan will require regular updates to quality and board-level committees.
15. Establish an internal working group that meets weekly to communicate, review, and resolve issues of concern that crosses departments, such as a Safety Adjudication Committee. Working group members should include leaders from quality, nursing, risk management, patient safety, patient advocacy, and regulatory areas, a member of the Patient and Family Advisory Committee, the chief medical officer, and others as appropriate.
16. Set up a multidisciplinary Patient Safety Committee to oversee patient safety activities throughout the organization. It should be accountable to the board and include representatives of all relevant stakeholders.
17. Create a “Good Catch” program to recognize and reward reporting of near-miss events, stop-the-line behaviors that prevent events, and/or other significant systems issues.
18. Implement a safety rounding program that collects data from leadership rounding, discerns trends, creates action items, and has a methodology for following up on action items. The rounding program must include executive leadership in the rounding schedule.
19. Provide an ongoing, systematic, and mandatory patient safety education program for staff that includes a training plan, certified instructors and coaches, data collection and analysis of its effectiveness, and data-driven training.
20. MOST IMPORTANTLY: SHARE PATIENT SAFETY DATA ACROSS THE HEALTHCARE SYSTEM.

In healthcare organizations, there must be transparency:

1. Between clinicians and patients—such as disclosure after medical errors.
2. Among clinicians themselves—such as peer review, the sharing of key safety metrics, and other mechanisms to share information.
3. Among healthcare organizations—such as regional or national collaboratives.
4. Of clinicians and organizations with the public—such as public reporting of quality and safety data.