As advances in technology create increased access to data and metrics on patient care outcomes, health care organizations are placing more emphasis on identifying ways to foster a culture focused on patient safety with measurable results in mind. Nurses are becoming more central to driving their organizations’ patient safety culture.Emerging nursing leadership roles such as that of the Clinical Nurse Leader® (CNL) are helping to drive improved safety and quality in nursing through evidence-based practice.
Faculty from Queens University of Charlotte’s Presbyterian School of Nursing prepare nurses for leadership in their profession by teaching them to be interdisciplinary leaders who think critically and communicate with stakeholders across departments to drive optimal results for patients and efficiency for their units. In the literature review below, authors identify seven critical interdisciplinary subcultures within health care that contribute to an organization’s patient safety culture.
What is Patient Safety Culture? A Review of the Literature
In 2013, the Journal of Patient Safety published a study which estimates that between 210,000 and 400,000 deaths per year in U.S. hospitals were associated with preventable harm to patients. Using the lower estimate, more people die from medical errors in a year than from highway accidents, breast cancer, or AIDS. Healthcare organizations create an environment in which culture of safety is an explicit organizational goal and top priority, driven by leadership.
The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to an organization's health and safety management.
In response to recommendations from the Institute of Medicine’s 1999 report, “To Err Is Human”, healthcare organizations began the process of improving the widespread deficits in patient safety, including a focus on organizational safety culture.
Seven subcultures of patient safety culture have been identified:
The role of senior leadership is a key element to designing, fostering, and nurturing a culture of safety that permeates throughout every level of the healthcare system.
Engaged senior leaders are critical to an organization's successful development of a culture of safety, driving the culture by designing strategy and building structure that guide safety processes and outcomes.
Leaders acknowledge the healthcare environment is a high-risk environment and seek to align vision/mission, staff competency, and fiscal and human resources from the boardroom to the frontline.
Likewise, it has been reported that a lack of hospital level leadership is a barrier to patient safety. In 2002, Dennis O’Leary, then President of The Joint Commission, stated hospital CEOs see no business case for patient safety. Whereas strong leadership is often cited as critical to an organization's culture of safety, there are no easy answers as to how leadership can develop or be developed to assure a culture of safety. Leaders require basic insight into safety problems and need rationales for focusing on patient safety. They need to be educated on the science of safety and the power of data.
A spirit of collegiality, collaboration, and cooperation exists among executives, staff, and independent practitioners. Relationships are open, safe, respectful, and flexible.
Healthcare organizations are treating patients with increasingly complex disease processes and with increasingly complex treatments and technologies requiring stronger efforts toward applications of teamwork and collaboration among caregivers to achieve a system-wide culture of patient safety.
The original National Aeronautics and Space Administration (NASA) model for organizational safety is described as including deference to expertise wherever found. This need for teamwork requires a multidisciplinary and multigenerational approach crossing all levels of an organization.
Patient care practices are based on evidence. Healthcare organizations that demonstrate evidence based best practices, including standardized processes, protocols, checklists, and guidelines, are considered to exhibit a culture of safety.
Healthcare leaders refer to the aviation industry as a model for safety. Pilots use a standardized checklist before every flight to assure the aircraft, systems, and flight crew are ready and working as designed.
Incorporating best practices and standardization may be leadership's greatest challenge to developing a culture of safety. However, as new generations of physicians are trained, the use of standardized guidelines may become more widely accepted.
Effective communication exists where an individual staff member, no matter what his or her job description, has the right and the responsibility to speak up on behalf of a patient.
Assertive language such as “I need clarity” and structured language are communication techniques critical to a culture of safety. “Read backs” are an example of structured communication that clarifies and provides accuracy of verbal orders. “Time-outs” before an invasive procedure, to verify that the correct procedure, at the correct body site, is being performed on the correct patient is another example.
One suggestion is to implement forms of communication such as briefings at the beginning of procedures to assure all parties are introduced and that equipment, medications, and supporting documents are in place. A debriefing occurs again at the end of a procedure to allow for a review.
Finally, front line staff want to know that communications with managers are heard and acknowledged. Providing feedback or closing the loop builds trust and openness – important properties of a culture of safety.
A culture of learning exists within a hospital when the organizational culture seeks to learn from mistakes and integrates performance improvement processes into the care delivery system.
A learning culture creates safety awareness among employees and medical staff and promotes an environment of learning through educational opportunities. Education and training should include, at least, a basic understanding of:
(a)the science of safety
(b)what it means to be a high-reliability organization
(c)the value of a safety culture assessment
(d)the performance improvement process, including rapid cycle testing of change.
A hospital that is “data driven” has opportunity to learn not only from failures but from successes. A hospital should be transparent in reporting identified key safety indicators, and results should be posted and updated in a timely manner.
Learning cultures use root-cause analyses to investigate medical errors and near misses. However, as a hospital safety culture matures, learning cultures will become more proactive in identifying and improving potentially unsafe processes to prevent errors.
One way to define just culture is to think of a two-sided scale of justice. One side of the scale is individual accountability and the other side is system failure. One method useful to healthcare organizations to determine whether errors are individual failure or system failure is by asking four questions:
(a)Was the care provider's behavior malicious?
(b)Was the care provider under the influence of alcohol or drugs?
(c)Was the care provider aware they were making a mistake?
(d)Would two or three of the care provider's peers make the same mistake?
Just culture is characterized by trust. It is nonpunitive and includes a blame-free error reporting atmosphere.
A patient-centered culture embraces the patient and family as the sole reason for the hospital's existence. It promises to value the patient by providing a healing environment during the hospitalization and also to promote health and well-being as a continuum of care. It is the responsibility of leadership to commit to patient-centeredness as a core value.
The patient-centered hospital allows and empowers patients to be participatory in their care decisions. Leaders that share their patient-centered vision with their community allow the community to feel a sense of pride and ownership of their hospital.
Patient stories can be used to put a “face” on system failures leading to potentially serious adverse events. Stories enhance the richness of description and create an atmosphere where discussion can lead to safety action.
8. Conclusions and Policy Implications
Safety culture is a complex phenomenon that is not clearly understood by hospital leaders, thus making it difficult to operationalize.
There are many directions policy makers could take toward improving a culture of safety within U.S. hospitals. It has been stated that “policymakers could help stimulate a culture of safety by linking regulatory goals to safety culture expectations, sponsoring collaborations, rewarding safety improvements, better using publicly reported data, encouraging consumer involvement, and supporting research and education.”
A suggestion has been offered for policy makers: review patient/provider ratio standards and define roles and responsibilities of providers, especially care “extenders” such as physician assistants and nurse practitioners. Leaders must view linkages between organizational culture, a rapidly changing workforce, and financial and quality success. Finally, we suggest that medical, nursing, and ancillary academicians incorporate safety culture principles into educational curriculums.
There are many directions policy makers could take toward improving a culture of safety within U.S. hospitals but incorporating safety culture principles into educational curriculums and encouraging nurse leaders to take an active role in creating a culture of patient safety must surely rank as one of the most important.
Become a Leader in Patient Safety Culture as a CNL
If you are interested in contributing to the patient safety culture at your organization, the Clinical Nurse Leader (CNL) role may be right for you. CNLs are advanced clinicians who use evidence-based practice and collaborate with the various providers involved in patients’ care to devise comprehensive care plans. Since the role was introduced in 2003 to address challenges in the changing health care system, CNLs have been proven to reduce complications and improve patient outcomes across the industry.
Expert faculty in the online MSN with a Clinical Nurse Leader track at Queens University of Charlotte prepare nurses for the growing CNL role with advanced coursework in nursing theory, research, informatics and health policy. You will graduate equipped with the critical skills to drive real results for your patients in today’s complex health care environment. Call 866-313-2356 to speak with an admissions advisor, or request more information.
Adapted from: Sammer, C.E., Lyken, K., Singh, K.P., Mains, D.A. & Lackan, N.A. (2010). What is Patient Safety Culture? A Review of the Literature. Journal of Nursing Scholarship, 42(2), 156-165. [WWW document] URL http://onlinelibrary.wiley.com/enhanced/doi/10.1111/j.1547-5069.2009.01330.x/ [accessed July 7 2014]