As the Institute for Healthcare Improvements Web page on developing a culture of safety states, … an organization can improve upon safety only when leaders are visibly committed to change and when they enable staff to openly share safety information. Nurse leaders are in a position to set their facilities quality standards and foster a culture of safety. Its a mindset that starts at the management level but must permeate the nursing staffs work philosophy to be effective. And its a culture that promotes action as opposed to passiveness, both as teams and individuals.Lillee Gelinas, RN
Leaders define the culture, and culture determines the safety of the organization, says Lillee Gelinas, RN, MSN, FAAN, vice president and CNO of VHA Inc. in Irving, Texas. It starts with me.
Nurse leaders must possess the skills to address things such as safety and disruptive behavior and to lead initiatives that will reshape the organization into one that strives for zero omissions and errors, Gelinas says. A culture of safety means safe for patients, safe for physicians, safe for all staff, Gelinas says. This is not about tactics, the flash in the pan, the fad; this is about a number of strategies and activities that have to be done at the same time that send a signal to the staff that things are different.Denise Murphy, RN
Denise Murphy, RN, MPH, CIC, vice president for quality and patient safety at Main Line Health System in suburban Philadelphia, says culture our values, beliefs and norms is responsible for 70% of system failures resulting in a patient-safety event.
The culture work is the most important, but its what we tend to go to last or not at all, Murphy says, adding that every unit will have a different culture, but a leader can intentionally shape a different common culture of reliability, where people have the knowledge and tools to do their work reliably.
Leaders must set the expectations, provide the resources to deliver safe care and then build and reinforce accountability, she adds.
Making Safety Personal and Transparent
Performance improvement initiatives, typically, revolve around statistics comparing a facilitys own data across time and using numbers to benchmark against similar organizations. Murphy recommends nurse leaders learn how patient safety events are defined, collected and reported back.
Although quantifiable metrics enable participants to determine trends, what really promotes ownership and builds momentum, says Sue Gullo, RN, BSN, MS, a director at the Institute for Healthcare Improvement in Cambridge, Mass., are personal stories good and bad about patients.
Translating the data into patients has changed the way people think, Gullo says. Stories about how [something] has made a difference is key to getting buy-in and spreading it within a department.
For instance, rather than simply reporting that two falls occurred last week, the nurse leader might let staff know a patient fell while trying to get to the bathroom and broke her hip, which resulted in the need for surgery, and another patients fall, while not resulting in an injury, caused him to be afraid to ambulate, which can hamper a speedy recovery. The stories hammer home the consequences for patients.
Being transparent about errors helps everyone understand the root cause of the problem. Murphy urges nurse leaders to learn more about how accidents happen and uses the Swiss cheese and blunt-end/sharp-end models as examples of how patient safety mechanisms can fail even with the best intentions. In the Swiss cheese model, developed by James Reason, a psychology professor at the University of Manchester in the United Kingdom, multiple barriers are put in place to prevent errors. When the holes line up, the mistake happens, and the patient may be harmed.
In the blunt end/sharp end model, developed by Richard Cook, MD, an assistant professor at the University of Chicago department of anesthesia and critical care, and David Woods, PhD, professor of industrial and system engineering at Ohio State University in Columbus, decisions and policy set at the blunt end, including administrative calls and support services, result in errors at the sharp end where patient care is delivered.
Once [nurses] have a broad understanding of accident causation, at the fundamental level, [they need to] understand the events in their area, under their watch, Murphy says.
An end to Finger-Pointing
A huge component of establishing a safety culture involves removing the tradition of blame and replacing it with a review of system errors that contributed to the adverse event. That requires transparency and reporting incidents and near misses. Staff need to feel free to report issues that may cause harm, Gelinas says. That may be as simple as speaking up when a doctor skips hand washing, but staff will be less likely to bring issues forward when nurse leaders condone or turn a blind eye to disruptive behavior.
Dealing with behavior is the hardest thing to do and has the greatest yield, Gelinas adds.
Murphy also promotes a just environment, not focusing on firing or punishing when a patient-safety event happens. We, as humans, will make errors, but when you look at the system side of error, we have often surrounded brilliant people with poorly designed systems in healthcare, Murphy says. That includes infrastructure, reporting structures, technology, equipment and communication.
In many events, it was easier for a person to make a mistake than it was for them to be forced to do the right thing, Murphy says. Studying the system, rather than looking for the bad apple, is a culture change in healthcare.
Then leaders must hold people accountable within the system, Murphy adds.
The aviation and nuclear power industries have invested in creating cultures of reliability. Now its time for healthcare to put similar measures in place. We do so many things very well, but inconsistently, Murphy says.
Reliability depends on following what she describes as clinical bundles and people bundles, which include teamwork, communication, peer checking, reminding each other to follow policies or stopping a mistake.
Gary L. Sculli, RN, a safety program manager for the U.S. Department of Veterans Affairs National Center for Patient Safety in Ann Arbor, Mich., is leading implementation of the Nursing Crew Resource Management program throughout the VA system. NCRM encourages nurses to speak up and bring information forward in a timely fashion. The training program includes graded assertiveness, tools for relaying information, use of checklists and closed-loop communication.
We go at it from a teamwork perspective, says Sculli, the lead author of Soaring to Success: Taking Crew Resource Management from the Cockpit to the Nursing Unit. We take CRM-based strategies and use them to manage human error.
Sculli conducts the training and, for one year, the unit undertakes a CRM project, such as reducing distractions, developing and implementing checklists, monitoring fellow team members and recognizing red flags to support situational awareness and clinical decision-making. Sculli conducts monthly coaching calls to give direction and support and later returns to the unit for refresher training.
Nurse leaders cannot change the culture on their own. It requires a collaborative model with physicians and the entire organization, Gullo says. Peter J. Pronovost, MD, PhD, medical director of the Johns Hopkins Quality and Safety Research Group and a professor at Johns Hopkins University, pioneered the comprehensive unit-level safety program, which involves physicians and nurses working together to identify hazards and their solutions.
We feel we are advocating for the patient but often [nurses, administrators and physicians] do battle rather than realize we are working for the same goal, Pronovost says. What is more joyful and effective is organizing those efforts around the patient. Each of the professions brings something to the table.
Pronovost, lead author of Safe Patients, Smart Hospitals: How One Doctors Checklist Can Help Us Change Health Care from the Inside Out, advocates in a January Journal of the American Medical Association commentary that hospitals must involve and support physicians in process improvement efforts instead of segregating nursing and physician quality initiatives.
To be effective, it needs to be a collaborative model with physicians, Gullo agrees. If nurses are alone in this, it can be a really big uphill battle. If nurses embrace one philosophy and physicians another, its difficult. It has to be embraced by the whole organization.