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Joint Commission: Leadership key in push for culture of safety


April 13, 2017

Solid leadership is central to promoting and sustaining a culture of safety in any healthcare organization, The Joint Commission said in its latest Sentinel Event Alert, published in March to remind leaders that it’s their job to identify and mitigate potential pitfalls on an organizational level.

People will err, and equipment will misfire, but a systemic approach to safety will aim to catch mistakes before they harm patients and, in the event of a negative outcome or a close call, see the situation as a learning opportunity, the alert states.

“Although this latest alert was in regard to patient safety, I do absolutely believe that leadership is central to developing a safety culture for patients, visitors, and staff,” says Cindy Taylor, ARM, CSPHP, director of Workers’ Compensation and Ergonomics for UNC Health Care in Chapel Hill, North Carolina. “If you do not have the support of leadership, you will not be able to create a safety culture.”

The alert, which updates and replaces a previous version issued in 2009, outlines actions leaders should take within their organizations to build trust, accountability, an eye for safety hazards, stronger systems, and means of assessment. First on the list is ensuring that the adverse-event reporting process is neither opaque nor focused solely on doling out punishments. This nonpunitive approach can increase error reporting, giving organizations more data points to analyze in the never-ending search for weak spots to be patched.

The alert calls for organizations to root out any intimidating behaviors that might discourage workers from reporting problems, and it encourages them to give special recognition to those who spot and report unsafe conditions. The document urges leaders to quantify the health of their safety culture and track it over time.

Steve MacArthur, a safety consultant for The Greeley Company in Danvers, Massachusetts, who co-authored The Hospital Safety Professional’s Handbook with Taylor, says he doesn’t see anything particularly novel in the latest alert.

“I guess it’s possible that this might light a fire under folks to move the ball forward with a little more quickness, but organizational culture does not turn on a dime,” MacArthur says. “The real focus of this is that it puts organizational leadership on the hook for making this happen.”

The paradox of strong leadership in this case is that you cannot force a cultural change. Leaders can explain and model safety procedures, but they cannot mandate safety culture, says Ken Weinberg, BA, MSc, PhD, consultant in environmental health, safety, and toxicology for SafDoc Systems LLC in Stoughton, Massachusetts.

“What develops a safety culture is getting people to understand how they can create a safe working environment for themselves,” Weinberg says.

Suggested actions

The Joint Commission outlined 11 recommended actions and related resources in SEA 57, noting that the recommendations are designed to be implemented simultaneously, not in a particular order. They are as follows:

  1. Reporting systems should avoid secrecy and obsession with punishment. Anyone within your organization should be able to report any mishap, near miss, or unsafe situation without fearing reprisal or penalty for an honest error.
  2. Distinguish between mistakes made by individuals and those stemming from flawed systems. Treat individual errors as learning opportunities, while using tools like the Incident Decision Tree published by the UK’s National Patient Safety Agency to promote transparency in your accountability process.
  3. Model good behavior from the top. Organizational leaders must embody the respectful and engaged demeanor they expect from their staff.
  4. Communicate expectations. Every team member should be made aware of the safety policies that have been established and enforced.
  5. Praise those who speak up. To help dismantle the culture of fear that discourages staffers from reporting safety concerns, actively encourage those who spot problems and report them.
  6. Quantify your safety culture. Measure the health of an organization’s current safety culture using the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture.
  7. Study your own data. Survey results regarding safety culture within your organization could contain clues on where you might improve safety and/or quality. Break the data down unit by unit, and share what you find.
  8. Create a plan, and test it. Based on your unit-level data, devise and implement one or more efforts to improve safety culture.
  9. Marry safety culture training with broader projects. Incorporate safety-related team training as you pursue initiatives to improve overall quality.
  10. Foster an enterprising spirit. Encourage go-getters to identify strengths and weaknesses of drug-management, electronic health records, and other systems, in order to pursue possible improvements.
  11. Review progress regularly. Conduct another safety culture review every 18–24 months. Break the data down to the unit level. Share the results.

The Joint Commission’s standards include specific requirements that leaders establish and sustain safety and quality organizationwide. (See LD.03.01.01, EPs 1, 4, and 5.)

The full SEA is available online at www.jointcommission.org/sea_issue_57/.

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