How To Develop a Patient Safety Culture in a Healthcare Organization

1. STRENGTH THROUGH
ADVERSITY
“BAD THINGS DO HAPPEN. HOW I RESPOND TO THEM DEFINES MY CHARACTER AND
THE QUALITY OF MY LIFE.”
WALTER ANDERSON
EDITOR OF PARADE MAGAZINE
AUTHOR, COURAGE IS A THREE LETTER WORD; MEANT TO BE

2. 10 STEPS TO BUILDING A PATIENT SAFETY CULTURE
1. Senior Leader Commitment
2. Metrics/Data and Analytics
3. Messaging
4. Performance Improvement Methodology
5. Leadership Development/Training

3. 10 STEPS TO BUILDING A PATIENT SAFETY CULTURE
6. “Teamness”/Engagement of Staff
7. Just Culture/Learning Culture Philosophy
8. Learning from Failures
9. Celebration of Successes
10. Quest for Zero

4. 1. SENIOR LEADER COMMITMENT
• Governance
• Executive Team Must “Walk the Talk”
• Must be institution-wide, not just Nursing and Clinical Leaders
• Integration into Strategic Plan
• Inclusion in Organizational Pillars

5. PILLARS OF SUCCESS
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Organizational
Pillars

6. 2. METRICS/DATA AND ANALYTICS
• Adopt metrics to track performance
• Share at all departmental meetings, medical staff meetings
• Allow for discussion on modifying or changing metrics based on organizational
priorities
• Concurrent and retrospective analytics should be embedded in healthcare
delivery
• A shift is occurring as descriptive analytics (what happened, where and why) shifts
to predictive analytics (what will happen next) to prescriptive analytics (what’s the
best that can happen)

7. PATIENT SAFETY METRICS
• Critical Care/ICU Measures
o ICU Admissions, Readmissions, Deaths
o Unintended Extubations
o Timeliness of Antibiotic Administration
o Code Blue Response/Rapid
Response
• Radiology Specific Measures
o Radiation Exposure Threshold
o Accuracy of Radiopharmaceutical
Administration
• Blood & Blood Product Use
o Crossmatch to Transfusion Ratio
o Transfusion Reactions
o Accuracy of Blood Bank Specimens
• Patient Identification Measures
o Inaccurate Patient identification Rate
o Medical Record Overlays/Duplicates
o Specimen/Labeling Errors
• Influenza Immunization Rate
NIH Clinical Center

8. PATIENT SAFETY METRICS
• Patient Experience Measures
o HCAHPS Overall
o HCAHPS Composite
• Nursing Quality Indicators
o Inpatient Fall Rate
o Pressure Ulcer Prevalence
• Infection Prevention & Control
o Hand Hygiene Adherence
o CLABSI Rate
o CAUTI Rate
• Medication Management
o Medication Events
o Adverse Drug Reactions
o Barcode Utilization
• Clinical Documentation
o Delinquent Records Rate
o Coding Accuracy
o Unacceptable Abbreviation Use
• Surgery Specific Measures
o Days Between Surgical Count Discrepancies
o Surgical Site Infection (SSI) Rate NIH Clinical Center

9. CONSIDER A “TOTAL PATIENT HARM” RATE
Adverse drug events
+
Catheter-associated urinary tract infections
+
Central line-associated bloodstream infections
+
Injuries from falls
+
Obstetrical adverse events
+
Early elective deliveries
+
Pressure ulcers
+
Surgical site infections
+
Venus thromboembolisms
+
Ventilator-associated pneumonias
=
TOTAL PATIENT HARM RATE

10. STAFF SAFETY METRICS
• Annualized Rate of Employee Injuries/TCIR: Total Case Incidence Rate
• Severity of Employee Injuries/DART case incident rate (Days Away, Restricted, and/or
Transferred)
• Source of Employee Injuries
o Patient Handling
o Needle Stick
o Exposure to Hazardous Substances
o Fatigue/Emotional Distress
o Workplace Violence
• Percent Executive Safety Rounds Completed

11. FACILITIES SAFETY REPORTING
• Fire and Life Safety
• Utilities and Medical Equipment
• Engineering Safety
o MEP Risk
o Energy Optimization
o HVAC
• Occupational/Workers Comp Claims
Percent
• HIPAA Risk Assessment
• Construction Risk Assessments
• Laboratory Biosafety
• Indoor Environmental Quality
o Mold & Moisture
o Legionella
o LEED Readiness
• Disaster/Emergency Response Readiness
• Cybersecurity

12. 3. ADOPT AN INSTITUTIONAL MESSAGE
• Select a Theme
• Create a Slogan
• Develop an internal campaign
• Engage internal and external constituents
• Safety Awareness

13. RULES OF THUMB FOR DEVELOPING A
SLOGAN/TAGLINE
• Use Poetry and Meter so it “Rolls off the Tongue” easily
• Start with what your audience (in this case, your workforce) already knows, then twist
it
• Be bold
• Involve and empower the customer (employee); invite him/her to a better experience
• Don’t mistake values or descriptors for slogans
David Bohan, Bohan Advertising/Marketing

14. 4. SELECT A PERFORMANCE IMPROVEMENT METHODOLOGY

15. SO WHAT TO MAKE OF ALL THIS?
• Select a methodology
• Train your workforce
• Stick with it
• Seek broad representation on your teams
• Report your results
• Adjust as necessary to make further improvements

16. 5. LEADERSHIP DEVELOPMENT
• Regular Leadership Training Sessions
• Incorporate Performance Improvement Methodology Training
• Teach Coaching of Subordinates
• Develop Accountability Processes, Reports
• Incorporate Team Training

17. GOAL:
SUSTAINING A PATIENT SAFETY CULTURE
TeamSTEPPS

18. 6. PROMOTE “TEAMNESS”/ENGAGEMENT OF STAFF
(INCLUDE PHYSICIANS, NURSES AND OTHER MEMBERS OF THE CARE DELIVERY TEAM)
• Team Orientation
• May require physician training/leadership development
• Inclusiveness of PI teams
• Physician engagement achieved through formal committee involvement and informal
settings
• Include quality measure in physician contracts
• Consequences for lack of engagement, poor performance

19. COMPONENTS OF TEAM TRAINING
• Assertiveness Training
• Cross-training
• Error Management Training
• Guided Team Self-correction
• Metacognition Training
• TACT: Team Adaptation and Coordination Training (also known as Crew Resource
Training)
Carayon P, Salas E, Weaver SJ, Gregory ME. Team training for patient safety
In: Carayon P. ed Handbook of human factors and ergonomics in health care and patient safety

20. 7. JUST CULTURE/LEARNING CULTURE PHILOSOPHY
• People within the organization must believe that they are obligated to report
errors
• “Just” does not mean “blame-free”: Some errors warrant disciplinary action
• Foster “mindfulness”
• Objective analysis of error
• Use tools to enhance patient safety: Team STEPPS
• Outcome engineering

21. DEVELOPING A LEARNING CULTURE DEPENDS ON
3 FACTORS:
• Detecting and consistently reporting failures
• Systematically analyzing failures
• Proactively searching for opportunities for experimentation and innovation

22. 9. CELEBRATION OF SUCCESSES
• Individual recognition
o Include peers, family whenever possible
o Verbal acknowledgement and written thank-you’s
• Team recognition
• “Managing up” other caregivers, departments
• Institutional Celebrations (include all shifts)
• Seek external institutional recognition

23. EXTERNAL RECOGNITION FOSTERS TEAM
PRIDE

24. 10. RELENTLESSLY PURSUE THE “QUEST FOR ZERO”
• Zero tolerance for preventable harm
• Don’t get discouraged
• A journey, not a destination

25. FINAL THOUGHTS
• Make patient safety the founding pillar of your organization
• Don’t seek just clinical and financial compliance; seek total transparency
• Be mindful of errors
• Aggressively seek opportunities for improvement
• Recognize that healthcare delivery is the ultimate team sport
• Get involved
o In leadership training
o In performance improvement teams
• Promote nursing involvement in governance forums