In recent years, healthcare reform has placed greater emphasis on promoting patient safety and quality improvements in healthcare organizations across the US. Starting in 2013, under the Affordable Care Act, healthcare providers' reimbursements are now linked to the quality of healthcare services that they provide which also encompasses patients' experiences. A recent Johns Hopkins study indicates that medical errors are the third leading cause of death in the United States, resulting in at least 250,000 deaths every year. Due to these factors, it has become increasingly important for healthcare organizations to adopt a patient safety culture. When organizations foster a culture that seeks to put patient safety first, they not only learn how to provide safer care for patients, they also have the opportunity to drive proactive risk prevention efforts.
What does an organization gain by continuously striving for an improved patient safety culture? According to the Institute for Healthcare Improvement (IHI), when a healthcare institution does not have this culture in place, staff can be hesitant to report adverse events due to fear that they will be punished or belief that reporting an event will not result in meaningful change. To help you in your journey, we are highlighting key components of adopting and effectively implementing a patient safety culture at your organization.
Gain organization-wide support for your patient safety culture
A patient safety culture should start at the highest level of a healthcare organization. Becker’s Hospital Review discusses this in, “6 Elements of a True Patient Safety Culture,” highlighting Matthew Lambert, MD, and the two key components he believes contribute to an organization embracing a patient safety culture. First, visibility to staff. When frontline staff see that health care leadership are interacting with physicians, nurses and patients, beyond traditional boardroom or C-suite settings, this shows a clear commitment to patient safety. Additionally, Dr. Lambert says that visibility to other members of a healthcare leadership team is also a critical part of a true patient safety culture. Leadership can convey this importance by requesting that patient safety is the first topic of discussion at board meetings. Taking this simple action emphasizes members of the leadership team’s commitment to prioritizing the discussion around patient safety.
When leadership demonstrates the importance of and their commitment to patient safety, staff are better positioned to follow by example. Achieving a patient safety culture is only possible when it is embraced by all levels of the organization. The Joint Commission defines a safety culture as “... the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety.” As valuable as it is for an organization to emphasize the importance of patient safety through discussion, it’s also important that all levels of the organization take daily actions to help support a culture of safety. To help care teams across the organization embrace a patient safety culture, leadership should strive to encourage staff to speak up about any safety concerns, so all members of the organization can work to foster a safe environment of fair accountability.
Adopt an effective reporting system
A patient safety culture means that staff have clearly defined opportunities to report safety issues that could lead to a near miss or adverse event. To empower staff to report, i healthcare leadership teams need to adopt a non-punitive response to these reports. Historically, frontline staff have feared punishment following a harmful event, which has led to a lack of reporting. Leadership should work to reward staff for speaking up and avoid punishing staff when errors or adverse events can be contributed to system failures.
The IHI suggests several ways that healthcare leadership can encourage staff to report including creating a non-punitive reporting policy, training managers to identify the difference between human and system failures and asking staff to share with others how leadership supported them following a safety issue. The next step is to equip staff members with easy to use tools that capture event data directly in the system. RLDatix software supports a patient safety culture by helping staff capture adverse events, near misses and good catches with customizable forms tailored to an organization’s unique specifications. A safety culture doesn’t stop after recording an event. RLDatix supports continued tracking of an incident with predefined workflows and allows providers to identify incidents that require further investigation.
Promote transparency and openness
The Patient Safety Movement created the Actionable Patient Safety Solutions guide to help organizations prioritize their safety actions and measure their progress in each area. One of the checklist categories, “Ensure Transparency,” highlights the importance of transparency and openness when cultivating a patient safety culture. Some of the checklist items include emphasizing teamwork, accountability, encouraging staff to speak up when they perceive a problem and creating an environment where providers, patients and family members can actively engage in communication, accountability and support. Staff, patients and families are uniquely impacted by an organization’s safety culture, which requires that it put an emphasis on transparent and open communication with each person involved in a safety event.
The Communication and Optimal Resolution (CANDOR) toolkit combines proven methodologies and best practices to help organizations proactively offer support when an unintended harm event occurs. This approach seeks to equip institutions with tools to deliver compassionate communication and provide guidance for hospitals and healthcare systems to respond in a principled way following a harm event. Dr. Tim McDonald, Chief Patient Safety & Risk Officer at RLDatix, writes, “Support is crucial, and when it’s offered with compassion and sincerity—supported by the institution—we strengthen organizational cultures and optimize their capacities to learn from patient harm in order to reduce the instances in the future.”
In light of COVID-19 and its impact on patients, staff and families, an organization’s communication efforts have never been more important. The CANDOR toolkit encompasses engaging in honest communication with patients and families, providing care for the caregivers and learning from incidents, so the organization can revise its processes to benefit everyone involved.
Develop a safety huddle program
Adopting a safety huddle program allows members from teams across your organization to share input from their unique perspective and gather insights from other providers. Manual forms of safety huddle management put critical patient information at risk of getting lost which can ultimately impact an organization’s pursuit of a patient safety culture. RLDatix’s safety huddle module serves as a robust electronic system that supports an organization’s safety culture by recording huddle notes, concerns and follow up pending actions in a centralized, secure and easily accessible system. Whether you have implemented a safety huddle program, or you are launching one for the first time, your care teams’ daily huddle contributions play an important role in fostering your organization’s patient safety culture.
Involve patients in safety initiatives
Patients’ input on an organization’s safety initiatives plays a crucial role in developing and maintaining a patient safety culture. To help patients and families feel included throughout the care process, consider practicing these tips: invite them to take part in multidisciplinary rounds to provide comments, ask them to participate in your patient safety committees or include patients and families as partners to help ensure compliance with safe practices such as ensuring staff are verifying patient identification before administering medication.
While patients can serve as a supporting defense of an organization’s safety culture, it is important to keep in mind that some patients might have apprehension around providing input. To help them overcome this challenge, it’s the responsibility of the healthcare organization to create a strong patient safety culture that emphasizes the valuable role patients play in improving care efforts.
Resources exist to help organizations encourage patients to serve as an active role in their patient safety culture. In 2010, The Joint Commission developed the “Speak Up Initiative” which included videos and infographics to encourage patients to speak up for their safety. Additionally, the ARQH Patient Safety Network created a list of questions that patients should ask before, during and after a healthcare experience. The RLDatix safety management software helps organizations make their patient safety culture a priority by capturing feedback from patients directly in the system. This allows providers to inform critical decisions surrounding patient safety initiatives and identify what safety efforts can be improved.
Your next steps to achieve a patient safety culture
As healthcare faces new challenges and opportunities, one aspect remains consistent: achieving a culture that puts patient safety first should remain top of mind. From the corporate level to departmental care teams, each member of a healthcare institution can actively contribute to pursuing a culture that prioritizes the care and safety of patients, families and frontline staff. Adopting an effective reporting system, promoting transparent communication, developing a safety huddle program and involving patients and families in your organization’s patient safety initiatives are just a few ways that you can actively pursue a patient safety culture at your organization. RLDatix is here to support your efforts with comprehensive patient safety tools that drives lasting change and performance across each area of your organization.
Discover how RLDatix can help your organization achieve a patient safety culture