1) The document discusses changing the safety culture of a hospital by focusing efforts on enhancing staff awareness of patient and staff safety and quality from 2008 to 2011. 2) Key elements in changing culture included setting direction by establishing a vision and values, implementing policies and infrastructure like a patient safety program, and engaging staff through workshops and leadership. 3) Data shows improvements in reported safety incidents from 2007 to 2011 and increases in teamwork and safety climate survey scores, indicating progress in changing the hospital's safety culture over time.

1. Changing the safety culture
of a hospital
CT Hung 25th May 2012

2. Queen Elizabeth Hospital
Since 1963
Largest acute hosp in HK,
Hong Kong 1800 beds, 5400+ staff
7 Million population
Highly subsidized health
service
5% GDP on healthcare

3. Changing hospital’s culture
• Culture change
– Leads to sustainable quality improvements
– 10-32% successful, 19% breakthroughs (Smith 2003)
– Cause or effect of improved performance?
– Changing culture alongside structural reforms to improve hospital
performance
• Negative connotations about change management
• Adding to complexity
– Hospital: complicated by presence of different professionals
– failures not tolerated

4. The Change Journey: Reasons
• Patient safety: a global concern
• NHS: “building a safety culture” as the
first step
• Public expectations & transparency
• Disconfirming data
– Sentinel events reported on media
– Safety Climate Survey

5. Sexton Rudman
Hung et al et al et al
(2006) (2006)
Safety Climate
2007 Total Agree
Mean (SD) Agree (%)
Mean
(SD)
(%)
I would feel safe being treated in this hospital as a 2.94
31.7 75
patient. (1.082)
I am encouraged by my colleagues to report any 3.7 4.30
62.4 78
patient safety concerns that I have. (0.939) (0.962)
The culture in my work-place makes it easy to learn 3.47 3.67
55.1 72
from the errors of others. (0.961) (1.028)
Medical errors are handled appropriately in my work- 3.61 3.75
57.8 51
place. (0.971) (1.082)

6. Years of Safety
Focus efforts to enhance
staff’s awareness on
patient / staff safety &
quality
2008-09: Year of Patient
Safety
2009-10: Year of Staff
Safety
2010-11: Year of Quality

7. Five elements in changing culture
• Setting the direction
• Laying down policies and infrastructures
• Engaging staff and those being changed
• Using other external forces
• Showing sustainable results.

8. Setting Direction &
Aligning Values
Vision, Mission,
Values 2007

9. Policies & Infrastructures
• Promulgate Patient Safety Programme
• Align
– quality and safety infrastructure for hospitals /
departments
– Reporting / monitoring lines and create network of
stakeholders
– language to facilitate communication
• New culture needs to be
– Seen, and
– Perceived readily by staff, e.g. regular safety rounds

10. EPS: Electronic Patient Safety Newsletter

11. Staff engagement
• Involves everyone in the organization
– Create a common burning platform
– Strategic workshops, Forums, Road-shows
• Manage expectation
– Change spans over several years
• Leadership at every level
– lead the show, walk the talk
– staff looks up to see how they actualize the
vision / values and deal with their own errors
– Enabling / creating champions at middle
manager levels

12. Staff engagement 2
• Engaging physicians
– Leader of clinical teams, adds weight and speeds
up changes
• Once staff members are engaged
– they will lead the show
• Find & empower Right people
– Difficult but possible

13. Internal Harmony
• Conflicts
unavoidable
• Less energy
wasted at
non-
productive
activities

14. External and other forces
• Corporate governance
• WISER (We Innovate, Services Excel
Regularly)/ LEAN movement
• Hospital accreditation
• Patient & Community Engagement

15. WISER Movement
• Burning platform: heavy
workload, inadequate staff
• Bring material changes to the
workflow, helping staff to
manage their work
• Engaging staff during the AFTER !
change process
• “feel good” factor
• Once tipping point reached,
moves with great speed
BEFORE !

16. Hospital Accreditation
• Important in building sustainable system
• Change from project-based into system-based
• Systematic, holistic, credible and robust
• Prestige / pride factor
• Projects by itself: can engage, motivate and
transform staff
• Continuously giving challenges to tackle
through 4 yearly cycle

17. Patient & Community Engagement
• Patients as Partners
• Communication projects
– CARPS, various books
• Patient Forum
• Public Advisory Group
Public Advisory Group

18. Successes for sustainability
• Successes have to be
seen & celebrated
• Delight / surprise
factor for
celebrations
• Pride and identity in
the organization
• Keeps momentum
going on
• Annual conventions

19. Some Obvious Changes
• Commitment to Safety / AIRS
2007 2011
quality incidents
• Reporting culture QEH 1359 1555
• Positive attitude towards
KH 651 392
errors
BH 62 63
• Acknowledging the problem and solving it
• Solution can be found if we work together
• Enhanced transparency
• Hardware changes related to hospital accreditation
• Care of dying: AED bereavement room

20. 2011 Vs 2007
O v er all M ean S c or e for Team w or k and S afety C lim ates 2007 2011
2.0 2.5 3.0 3.5 4.0
3.59
Teamwork Overall
3.64 *
3.29
Safety Overall
3.38
*
Overall M ean Score for Teamwork and Safety Climate by Hospitals 2007 2011
4.5
4.0 *
3.56 3.66 3.68 3.66 3.63 3.53
*
3.27 3.36
*
3.33 3.44 3.48 3.38
3.5
3.0
2.5
2.0
Teamwork Safety Overall Teamwork Safety Overall Teamwork Safety Overall
Overall Overall Overall
Queen Elizabeth Hospital Kowloon Hospital Buddhist Hospital
*: p < 0.05

21. 2011 Vs 2007 2
Ov e rall M e an Score for Te amwork and Safe ty Climate s by Discipline 2007 2011
4.5
* *
4.0 3.67 3.75 3.57 3.64 3.67 3.67
3.31 3.44 3.43 3.48
3.5 3.27 3.36
3.0
2.5
2.0
Teamwork Safety Overall Teamwork Safety Overall Teamwork Safety Overall
Overall Overall Overall
Medical Nurse Allied Health
Ov e rall M e an Score for Te amwork and Safe ty Climate s by Se niority 2007 2011
4.5
* * 3.77 3.76
4.10 4.08
4.0 3.67 3.73
3.49 3.59 3.47 3.48
3.5 3.21 3.33
3.0
2.5
2.0
Teamwork Safety Overall Teamwork Safety Overall Teamwork Safety Overall
Overall Overall Overall
Junior Middle Senior
* : p < 0.05

22. 2011
Safety Climate 2007
Mean
2007
Total
2011
Mean
Total
Agree
Agree
Questions (SD)
(%)
(SD) (%)
I would feel safe being treated in this hospital as a 2.94
31.7 3.10* 36.2
patient. (1.082)
I am encouraged by my colleagues to report any 3.7
62.4 3.76 66.5
patient safety concerns that I have. (0.939)
The culture in my work-place makes it easy to learn 3.47
55.1 3.52 56.8
from the errors of others. (0.961)
Medical errors are handled appropriately in my work- 3.61
57.8 3.71* 64.5
place. (0.971)
*: p < 0.05

23. Discussion
• Success Factors
– Culture change rooted in stated business strategy
– Change / innovation rewarded
– Change effort small / manageable
– Dedicated capable project team
– Role of middle managers
– Visible support from sponsor
– Project tracked & publicized
• Failure Factors
– Ineffective missing conflicting leadership
– Clash with existing culture
Smith ME (2003),"Changing an organisation's culture: correlates of success and failure",Leadership
& Organization Development Journal, Vol. 24 Iss: 5 pp. 249 - 261

24. Reflections
• Complacency is enemy
• How to catch attention
• Don’t do it for sake of doing
• 3 years too short for results
• Manpower deficiencies must be addressed
• Should do more in
– Speak up culture
– Research (Parmelli et al, Cochrane Library 2011) esp role of
cognitive errors
– Accountability

25. Conclusion
• Culture change part of the multi-prong
approach to enhance performance
– One size does not fit all
• Change rooted in core business
• Clear vision
• Staff engagement, esp middle
management
• Evaluation: see the results
• Reward & recognition

26. Acknowledgements
Thank you