Creating a Culture of Safety

1
Creating a Culture of Safety

• Sara J. Singer, Harvard University
• Anita L. Tucker, University of Pennsylvania
• Academy of ManagementAugust 9, 2005

2
Research objective

• How do senior hospital leaders contribute to
  creating a strong culture of safety?

3
Motivation

• Creating a strong safety culture is a critical
  task of senior leaders in hazardous industries,
  such as healthcare (Roberts Rousseau, 1989)
• Few hospital CEOs devote sufficient time or
  resources to patient safety (Leape Berwick,
  2005)
• Variation exists across hospitals in leaderships
  awareness of safety risks and mistakes
• Senior leaders have a more optimistic view of
  safety culture than other personnel (Singer et
  al., 2003)

4
Methods

• Qualitative and quantitative methods at 8
  hospitals
• 26 semi-structured interviews of 51 senior
  leaders and front line workers
• 7 site visits to observe leaders conducting an
  intervention to improve safety culture
• Survey items on safety leadership
• 7 items, alpha 0.89

5
Safety leadership survey items

• Senior management provides a climate that
  promotes patient safety.
• Senior management has a clear picture of the risk
  associated with patient care.
• Patient safety decisions are made at the proper
  level by the most qualified people.
• Overall, the level of patient safety at this
  facility is improving.
• Senior management considers patient safety when
  program changes are discussed.
• Senior management has a good idea of the kinds of
  mistakes that actually occur in this facility.
• I am provided with adequate resources (personnel,
  budget, and equipment) to provide safe patient
  care.

6
Analysis of qualitative data

• Line-by-line review by 2 researchers
• Inductive coding, independently then jointly,
  negotiating differences and refining the coding
  scheme guided by comparison with literature
• Use of software (Atlas TI) to record codes and
  facilitate analysis and reporting

7
Qualitative results 6 dimensions

• Create a compelling safety vision
• Value and empower personnel
• Leader engagement in patient safety improvement
  efforts
• Lead by example
• Focus on system issues rather than on individual
  error
• Quest for improvement (even if already good)

8
Hospital ratings on 6 safety leadership dimensions

• Stronger leadership in hospitals 6 and 3 v. 7

9
Valuing and empowering front line staff

• Hospital 6
• 26 bed hospital in rural, mid-America
• There was a lot of consensus building about the
  new computer system. A lot of evaluation. We
  have let management and staff chose the system.
  We have done a ton of training. Our own staff
  built the internal menus Michelle Paulson, CEO

• Hospital 7
• 300 bed hospital in urban Southwest
• They Senior managers don't want to hear it,
  they don't want to know it, they don't care.
  Denise, RN Emergency Room Nurse

10
Engaging in the patient safety effort

• Hospital 3
• 5 hospital system in a midsize Midwestern city
• Our CEO, he is constantly out and about, walking
  around, checking on things. Ed, Cath Lab
  Technician, Hosp 3
• I worked on a board presentation wrestling
  with How do we present to board of directors
  this analysis of an error in a meaningful but
  actionable direction, such that the governing
  body understands? Alan Eberhardt, Network CMO

• Hospital 7
• When people feel like they have one shot at
  being heard by senior management, they want
  tomake sure they get their issues raised.
  Because who knows if they ever get another
  chance. Viola Flynn, Outgoing QI Director

11
Improving systems rather than blaming individuals

• Hospital 6
• We treated that mistake that caused no harm as
  a sentinel event When we did the root cause
  analysis, we realized that the process in the lab
  left a single tech, any tech, vulnerable
  Initially the staff wanted to point to the
  techWe had to back them up and actually protect
  the employee from that type of reaction.
  Michelle Paulson, CEO

• Hospital 7
• You quickly identify who you think caused the
  problem and you deal with them in a not-so
  educational way. Senior Mid-level Manager of
  Emergency Care

12
Survey results Average problematic response

• Hosp 6 and 3 have stronger safety leadership than
  hosp 7
• Difference from hospital 7 significant at
  plt.01 , plt.05

13
Survey Results

• Large differences in views of senior leaders
  between Hospitals 6 and 7
• 10 v. 26 believed senior managers did not have
  a good idea of the mistakes that occur in their
  facility
• 4 v. 24 felt senior managers failed to provide
  a climate that promoted patient safety

14
Conclusions

• Quantitative results support our categorization
  of hospitals on the 6 dimensions
• Though many hospital leaders created a vision for
  safety, what distinguished strong leadership from
  weak was
• Extensive engagement of senior leaders
• Systems focus
• Valuing and empowering employees to act on behalf
  of patient safety
• Dissatisfaction with current safety performance