Health care leaders consistently give voice to the importance of culture and safety. Asked to name the top leadership skills needed for success in the evolving health care environment, members of the NEJM Catalyst Insights Council — made up of health care executives, clinical leaders, and clinicians — put “building culture” in the top spot, with 47% citing it as a necessary skill in a 2016 report.
Leadership and culture also earned prominent mentions in a 2015 report from the National Patient Safety Foundation. The report’s top recommendation for advancing patient safety is for health care leaders to establish and maintain a culture of safety within their organizations.
So, what, exactly, is involved in building culture, and specifically, a culture of safety? How do health care leaders, experienced or not, acquire this skill and apply it?
Given the relative lack of specific guidelines for leaders around safety culture, the American College of Healthcare Executives and the National Patient Safety Foundation (which has since merged with the Institute for Healthcare Improvement) recently convened expert panels to address these questions. The 2017 report from that panel, Leading a Culture of Safety: A Blueprint for Success, is designed to be used as a practical, tactical guide for leaders at any stage in their organization’s culture transformation.
Culture has long been cited in the patient safety literature as being a driver of safe care delivery — or the lack thereof. In 2000, To Err Is Human: Building a Safer Health System called for health care organizations to develop a “culture of safety,” with personnel and processes focused on safe and reliable care. Since then, the health care industry has drawn lessons from other high-risk industries about culture, high reliability, and systems safety.
A culture of safety can be defined as one in which risk is acknowledged; the response to events or near-misses is blame free, encouraging reporting; collaboration across disciplines and settings is promoted to seek solutions; and there is a commitment to provide the resources necessary to adequately address safety concerns.
Yet recent surveys of hospital safety culture indicate that in too many organizations, staff still feel that mistakes or event reports will be held against them and become part of their permanent record. Lucian Leape and colleagues have written of dysfunctional cultures rooted in disrespect as being a barrier to patient safety.
Leading a Culture of Safety: A Blueprint for Success suggests that leaders seeking to transform their organization’s culture would do well to commit focused attention on six key areas:
- establishing a compelling vision for safety;
- building trust, respect, and inclusion;
- educating and engaging board members in patient and workforce safety issues;
- emphasizing safety in the development and recruitment of clinical leaders and executives;
- adopting just culture principles to focus on systems flaws over individual blame when things go wrong; and,
- setting and modeling behaviors such as transparency, active communication, and civility as expectations for all.
While each of these is an essential element for leaders to address, they are also interdependent. Self-assessment questions included in the Blueprint for Success note that if an organization is scoring poorly on the first — establishing a compelling vision — it may make sense to start there.
Many people confuse vision, mission, value statements, and similar guiding principles. By one definition, a vision focuses on the future ideal, but grounds an organization by providing context for its response “in the face of ambiguity and surprises.”
The new report points out that an organization’s vision should be aspirational as well as inspirational. Vision is about long-term goals, and it should resonate beyond the C-suite to reach and inspire people throughout the organization.
While creating a compelling vision for safety may sound easy, in fact, it may take significant time and resources, depending on how much leaders already know about the current state of culture in their organization. Is the organization routinely conducting surveys of patient safety culture and benchmarking itself against its peers? Do the CEO and executives participate in regular rounds to hear the concerns of clinicians and staff firsthand? Are safety metrics routinely discussed in staff meetings and presented to the board? These are just some of the methods by which leaders can begin to assess their organization’s safety culture. Without in-depth knowledge of the current state, leaders may stumble in establishing a vision and communicating it effectively.
An important point to note is that even after doing the hard work of creating a vision for safety, the work to communicate and sustain that vision never really ends. To some degree, that is where the work truly begins. Leaders must be unwavering in modeling the vision for safety through their actions. By doing so, they will in turn exert positive influence on progress in the other five domains that will help establish a culture of safety.
Leading a Culture of Safety: A Blueprint for Success provides a set of strategies and tactics for leaders to use to begin the process of culture transformation as well as a set to help sustain progress. Different organizations will be at different starting points, and some may already excel in one domain and seek to improve quickly in another. Underlying all of the work is a commitment to learning; continuous improvement; measurement, analysis, and interpretation of safety data; change implementation; and honest and open feedback.
There is no question that we are living in challenging times for health care organizations. Yet it is critical for health leaders to recognize that safety — or the lack of it — impacts many other elements within their organizations, from reputation to financial health to staff retention. Safety must become a core value of organizations, a foundation upon which they can build trust with patients and staff and from which other benefits will follow.