safety is our joint effort! · 2018-06-11 · safety is our joint effort! how do you create a...

Safety is our joint effort! How do you create healthcare safety culture?

https://www.patientsafety.com/

Safety is our joint effort! How do you create a healthcare safety culture? |The Patient Safety Company

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This e-book has been written with the help of Wendy Rientjes. From 2006-2012, as a Safety &

Quality Advisor of a Dutch healthcare institution, she was responsible for the implementation

of the Safety Management System and Integral Risk Management. Since 2012 she has been

working as an independent consultant in the field of patient safety and safety culture under the

name of Rientjes Training Coaching & Consultancy. See www.rientjesadvies.nl

http://www.rientjesadvies.nl


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ContentsIntroduction ........................................................................................................................................4

Safety Culture .....................................................................................................................................4

International cultural differences ...................................................................................................5

The four dimensions of culture ...................................................................................................... 5

Organisational culture ......................................................................................................................6

Types of orgisational culture .......................................................................................................... 6

The soft side of safety culture ..........................................................................................................7

Which interventions contribute to desired culture change? .......................................................8

From old to new behaviour ............................................................................................................ 8

Changing the mindset ..................................................................................................................... 9

Role of management ..................................................................................................................... 10

Multidisciplinary team training .................................................................................................... 11

Case study “That’s how we do it here!” ........................................................................................ 12

An example from day-to-day reality ............................................................................................ 13

How can The Patient Safety Company provide support? .......................................................... 14

Culture survey ............................................................................................................................... 14

Incident reporting, analysis and the initiation of improvement measures ........................... 15

Talking safety ................................................................................................................................. 15

The benefits in a nutshell ............................................................................................................. 15

Sources ............................................................................................................................................ 16


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IntroductionIn the aftermath of a calamity we are often told that the root cause was the culture of the

institution in question. The word culture in this respect reflects the degree to which the care

professional feels comfortable about reporting an incident, or dares to confront a colleague

with what is perceived as unsafe behaviour. In an ideal world, we would call this a blame-free

culture. Or perhaps an open culture, a just culture in which it is generally accepted that you can

learn from mistakes by discussing them. This boosts improvements in the healthcare sector,

leading to more incident disclosure for the benefit of both patient and public. We discussed this

theme at length in our previous e-book.

In this e-book, we explore the characteristics of hospital culture in general and the interventions

that can contribute to a just culture.

Safety cultureWhen safety culture in hospitals is compared in international surveys, the United States tends

to be the focal point. The US has been working on the improvement of patient safety for at

least 10 years longer than in Europe. This has everything to do with the period within which a

country actively pays attention to a safety culture. Nationwide attention for patient safety can

influence the experienced safety culture. Like in 1999, for example, when a federal report was

published – ‘To Err is Human’ (Kohn, Corrigan & Donaldson) – that put patient safety in the United

States centre stage. Or after Rein Willems (SHELL) in 2004 published a report entitled ‘Hier werk

je veilig of je werkt hier niet’ (‘Here you work safely or you don’t work here at all’), welcoming the

advent of patient safety in the Netherlands. There are however more reasons that can explain

the international distinctions in safety culture.

Download our Just-culture e-book

http://info.patientsafety.com/download-the-just-culture-ebook

http://info.patientsafety.com/just-culture-ebook


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International cultural differencesMultiyear research into cultural differences indicates that each and every society, modern or

traditional, is confronted with issues that have consequences for functioning within that society

in a group or as an individual (Hofstede, Hofstede and Minkov, 2010). A clear illustration of this is

the survey conducted amongst IBM-employees from more than 50 countries (Hofstede, 1974).

In each of the varying cultures, the common problems experienced by these employees could

be classified in one of four themes:

• Distance from true power: social inequality, including the attitude towards authority.

• Individualism versus collectivism: the relationship between individual and group.

• Masculine versus feminine: the desired role allocation between men and women.

• Insecurity avoidance: the way mixed messages and uncertainty is treated and how they are

connected to anger control and emotional outpouring.

The four dimensions of cultureHofstede refers to the above mentioned themes as the four dimensions of culture that

distinguish the national culture of countries from one another (Hofstede, Hofstede and Minkov,

2010). These four dimensions can be applied within the hospital culture – particularly the

professional culture – and go some way to explaining the international distinctions in safety

culture at hospitals.

It goes without saying that in countries where authority and social status are seen as important

values (such as in Asian and South American nations and Russia), it is a giant step for a nurse to

confront a medical specialist on the grounds of perceived unsafe behaviour. Contact typically

takes place on the initiative of the medical specialist or a superior, and a subordinate is not so

likely to take the first step. It is therefore logical that it is easier to confront each other on the

issue of safety in countries with a less pronounced power hierarchy, such as is often the case

in large parts of Europe and the United States. There, subordinates expect to be consulted by

their superiors or by the medical specialist. In a similar vein, the dimensions of individualism

and collectivism, uncertainty avoidance and role allocation between men and women have

considerable influence on a hospital’s organisational culture.


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Organisational cultureThe culture within an organisation consists of

various layers (Fig. 1). The deeper the layer,

the more difficult it is to change the culture.

The values are enshrined within the cultural

heart of the organisation. These radiate the

characteristics of the organisation (Hofstede,

Hofstede and Minkov, 2010). Although

they are rarely discussed explicitly, these

values indicate what behaviour should be

perceived as normal or abnormal within the

organisation. The next layer contains the

rituals of social and behavioural patterns

that have crept into an organisation. These

are the written and unwritten rules expressed in statements like: “This is how we have always

done it here.” This kind of behaviour shows the true colours of an organisational culture. This is

followed by the heroes, those who are crucially important to the culture of an organisation and

the ones who set the right example by behaving properly at all times. The founding father of a

business, for example, who is respected by one and all. The symbols comprise the outermost

layer. It is the language – the institutional jargon – the gestures, the clothing or the flags that

can only be comprehended by those who buy into that culture: the military or the police, for

example.

Types of organisational cultureCameron & Quinn (2012) developed the Organizational Culture Assessment Instrument to

determine the culture of an organisation. The model identifies four dominant organisational

cultures that themselves form the characteristics of the family culture, hierarchical culture, market

culture and adhocratic culture (Fig. 2). The various values, assumptions and interpretations that

are the essence of that culture can be found within these organisational cultures.

The family culture• friendly work environment

• leaders are mentors• loyality & tradition• great commitment

• flexibility• concern for people

• teamwork

The hierarchy culture• formalized and structured• leaders are coordinators• formal rules and policies

• need for stability and predictability

The adhocracy culture• creative work environment

• leaders are innovators• experimenting & innovating

• leading edge• flexible & individualistic

The market culture• results oriented

• competitive• leaders are hunters

• reputation & success• external positioning

• need for stability and predictability

Flexibility and discretion

Stability and control

Inte

rnal

focu

s an

d in

tegr

atio

n

External focus and differentiationValues Practices

Rituals

Heroes

Symbols

Figure 1 The onion as metaphor for culture

Figure 2 Competing values framework of Cameron & Quinn


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Type of culture in the healthcare sectorHealthcare is characterised by the standards and values suited to the family culture: collectivism,

loyalty, tradition, modesty and consensus. These values can be amplified or restrained,

depending on the national culture.

Culture is a collective phenomenon whereby the same standards and values are shared within

a particular social environment. Doctors therefore belong to a group of people who live in the

same social environment but have also followed a similar educational track during which the

standards and values of their mentors have been passed on. Values, standards and rules-to-

live-by can be taught and are not predetermined at birth. This is the reason why many doctors

and nurses or care professionals believe they may make no mistakes at all (Leistikow et al,

2009). This is regarded as a sign of incompetence or personal failure. From this point of view, the

care professional involved is unlikely to discuss an error so readily, leading to a situation where

a third party is unable to learn from the ensuing situation (Powel and Hill, 2006).

The soft side of safety cultureChanges to the organisational culture, distribution of resources or rules, protocols, guidelines

and risk analyses – the so-called hard factors – are of the essence in order to ensure the provision

of good patient care. It is the employees who determine organisational culture. They form the

collective values expressed in the way of thinking, feeling and acting. Attention for the soft side

of an organisational culture is crucially important for understanding the values and standards

that underpin that culture.

Only very little research has been undertaken into culture-changing interventions aimed at

improving healthcare. But we can use examples from management and organizational sciences

that emphasise the importance of seeing healthcare in the proper context.


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Which interventions contribute to desired culture change?In order to create the desired safety culture within the healthcare sector, attention must first

be paid to the current culture within a hospital. Look at the shared self-evident attitude of

care professionals to get a better understanding of collective behaviour. How do they react to

incidents and calamities, for example?

Managers who engage in conversation with subordinates discovered that the care professionals

experience their working environment from the perspective of one big family. This makes it

more than tricky to confront colleagues with instances of unsafe behaviour. And don’t even

think about reporting an incident: care professionals regard that as a direct assault on the

relationship with a family member. That’s not the way we treat family: “You don’t betray your

nearest and dearest, right?”

From old to new behaviourIt is important to take these values into account during the development of the reporting

process in order to create the desired culture. When care professionals notice that the mutual

relationship is not impacted after reporting an incident, this facilitates future incident reporting.

New behaviour demands a climate in which employees feel safe enough to discuss values

and standards and ask critical questions. The clearest example of this is incident reporting.

Employees must experience that this attitude is valued and rewarded in the organisation in

order to buy into it. It is important that employees can be part of discussions where they can

learn about safety in healthcare, without experiencing loss of face. This is also the place to

discuss shared values about “how do we treat each other in our one big family?”.


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Managers and superiors play a crucial role in this process by talking with care professionals

about the core values and by showing exemplary behaviour.

Education, primarily the intensive and lengthy path that medical specialists need to follow, also

plays a major role in the development of shared values. Fortunately, an increasing number of

care professionals in both basic training and further education are instructed about patient

safety, based on the just culture principle: being open with each other and feeling safe enough to

confront one another on issues such as professional behaviour. In this way, the next generation

of care professionals is trained to communicate transparently.

Practical examples of new behaviour

• Openly discuss incidents, calamities and near-misses.

• Report incidents, calamities and near-misses.

• Demonstrate that incident reports are handled confidentially.

• Discuss the shared values of the organisational culture: what is regarded as acceptable

behaviour?

• Tell about the incidents that you caused/happened to yourself (at all levels).

• Write about incidents, for example in the staff newspaper.

• Confront each other with respect to (unsafe) behaviour.

• Organise special meetings with ‘safety’ as the theme, in which open and honest

disclosure is fostered.

• Hang dashboards with management reports in a visible location, presenting/showing

the number of reported incidents, types of incidents, root causes, etc.

Changing the mindsetIn the current medical culture, care professionals proceed from the mindset, the subconscious conviction, that they may not make mistakes. Mistakes could imply that patient safety is compromised (Powel and Hill, 2006).It is also important that caregivers learn how the human brain works and why people tend

to deny their own mistakes. “People overestimate their own competence when they make

mistakes, and that is typically caused by external factors”, according to Roos Vonk in ‘Menselijke

gebreken voor gevorderden’ (“Human shortcomings for cognoscenti” (2011). If a doctor with a

positive self-image makes a mistake, he/she could attribute this to the sloppy instructions of a

colleague. This is also known as cognitive dissonance.

More research needs to be undertaken into human limitations (from a cognitive, physical and

emotional perspective) that can explain the origin of errors (and incidents). A caregiver learns

that there are potential risks attached to a particular care task, that colleagues have the same

limitations and that making mistakes is not ‘stupid’. This new mindset helps them to understand

themselves as well as others.


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Situational awareness is another example of this. Care professionals are trained to recognise

risk, but when a professional is no longer alert due to stress, fatigue or the pressure of work, this

can cause a lack of situational awareness. Caregivers are then no longer aware of what is going

on around them. But with renewed mindset, thanks to acquired know-how about the origin of

error due to human limitations, caregivers will be able to indicate or recognise that they are

tired. Without feeling that they have failed.

Analysing and discussing incidents with colleagues can improve the situational awareness of

caregivers, because they acknowledge the root cause of the incident: at the end of a night shift,

for example. Moreover, situational awareness can:

• teach employees to see how an incident, such as the one described above, can originate

• and what could have been done better or more efficiently in the course of the day;

• teach employees the continuous improvement initiatives that can be achieved;

• contribute to safeguarding patient safety without unsettling caregivers to the extent that

they develop doubts about their own ability to perform. Or even fear of failure.

Practical examples of how to change mindset

• Organise workshops about safe healthcare to improve the culture of reporting incidents.

• Provide training about the working of the human brain / create situational awareness.

• Conduct safety rounds or audits and explain to others what you’re doing and why

you’re doing it.

• Make photos of unsafe situations and discuss these as a team.

• Before the start of every shift, discuss departmental risks (for example a patient with

high-risk medication or a tricky operation).

Role of managementIn order to understand why caregivers hold back from reporting incidents, it is important that

management is abreast of the cultural values and standards in their hospital. In the complexity

of a hospital culture, it is crucial to be able to understand caregiver reaction or behaviour.

Management have to take certain specific cultural values in the hospital into account, during the

process of culture change.

Moreover, hospital management can focus on its own behaviour. By continually setting the

right example and expressing that talking openly about mistakes is okay, desirable and even

essential. Personal behaviour is a little easier to influence than organisational culture.

Appoint a medical specialist as ambassador for quality and patient safety towards other medical

specialists. This can have a tremendously unifying outcome and provides management insight

into the cultural aspects, values and standards of medical specialists


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Practical examples of management tasks

• Appoint a medical specialist who will act as an ambassador for quality and safety.

• Behave in an exemplary fashion.

• Develop insight into the values and standards of the organisational culture.

• Discuss safety during periodic assessments: What are you going to do to boost safety this

year? How did you approach this issue? Do you report incidents? Do you confront colleagues

when necessary?

• Make safety part of the annual planning: What are you going to do to boost safety next

year?

• Make sure that blame-free reporting really is blame free. Research the consequences of

reporting an incident and find out if they are, or are not, perceived as punitive.

• Demonstrate that each incident reported is handled confidentiallyn.

• Discuss the shared values of the organizational culture: What is regarded as acceptable

behaviour?

Multidisciplinary team trainingA medical team consists of various care professionals who typically share skills, know-how and

attitude. A surgical team, for example, comprises surgeons, nursing staff and assistants. Team

members understand their responsibilities and those of their colleagues. In order to dare to

confront another team member with a case of unsafe behaviour, it is important that openness

and psychological security are embedded in the organisation. It is important that caregivers dare

to provide feedback, dare to ask for help from colleagues and dare to exchange information

amongst one another.


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Lessons learned in the airline business can be transferred to the healthcare sector. During team

training, there is plenty of attention for the effect of certain pilot attitude and behaviour, safe and

unsafe. It appeared that a hierarchical division of tasks in the industry promoted an everybody-

for-himself attitude, with the result that the captain did not take ground staff seriously. The

result was poor communication and poor cooperation. This can have a devastating effect in

an emergency. Expressing instead of repressing a deviating opinion could have prevented

many incidents. Healthcare is a comparable sector, with specialist know-how and a high-tech

environment.

Practical examples of multidisciplinary team training

• Provide training about the working of the human brain / create situational awareness.

• Organise intervision meetings during which colleagues discuss problems in the same

area of expertise.

• Discuss case studies.

• Provide feedback training.

Case study: “That’s how we do it here!”There are various ways to work together to change the collective values of a hospital. The day-

to-day reality is that simply implementing incident reporting is no guarantee for a safe hospital

culture. Incident reporting is primarily regarded as an extra task “that needs to be done in

addition to all the rest”. Caregivers occasionally have insufficient insight into the importance

of incident reporting, due to their conviction that nothing will be done with the notification. Or:

employees do not have the guts to report an incident, because last time they were confronted

with their action by another colleague.

In order to gain insight into the conviction and collective values in a hospital, it is important

to enter into discussion with one another. This helps one to understand how new directives

concerning safety come across on staff and how one can ensure that caregivers report incidents.

To implement permanent change in an organisation, it is crucial that management demonstrates

inspirational leadership by being involved in word and deed and by showing exemplary

behaviour. Visibility is the pre-eminent condition to generate a strong safety culture.


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An example from day-to-day realityA hospital executive assumed the leadership role by being both visible and accessible. She was

actively involved and a powerful promoter of more organisational transparency. She did this

by making regular rounds for the sole purpose of discussing safety with the staff. This was the

perfect moment for her – as a hospital executive – to engage in conversation about safety and

shared values on a given department. With the threshold at rock-bottom, she illustrated how

accessible managers can be by inviting staff to talk about safety. She also confronted medical

specialists on the subject of unsafe behaviour: entering the staff canteen in operating gowns,

for example.

When executives realise the degree to which they must set the right example throughout

the organisation, they can apply this knowledge by openly talking about mistakes made. An

executive who shows that mistakes can be made every day and thereby creates a new culture of

“that’s how we do it here” is refreshing. Confronting each other with unsafe behaviour is also a

good example of this. Also medical specialists must know that setting the right example induces

others to follow suit. “If the doctor doesn’t play according to the rules, why should I?” – as a nurse

might well think.

But more initiatives are taken at other levels within the organisation with respect to the

disclosure of incidents and risks. Managers, medical specialists and quality assurance managers

play an important role in putting safety on the agenda as a recurring item for discussion. In this

way, the importance of speaking out about incidents becomes second nature to team members.

This is a wonderful opportunity to discuss amongst one another the root cause of the origin, the

nature and the severity of the incident or incidents. Not only does this boost awareness, it also

helps employees to understand that being transparent about incidents is not only good for the

team but for the organisation at large.


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Creating risk awareness can be promoted during the change of shifts by handing over the

incidents that took place on the prior shift to the caregivers on the consecutive shift. Not only

does this create a moment for sharing lessons learned, but it boosts awareness amongst

caregivers of the imperative of being aware of the risks that could confront them during their

shift. For example: high-risk medication, drips, or patients with high-risk medical issues.

Moreover, joint lunches and themed meetings can be organised every month with a specific

issue centre stage, so that caregivers can engage in relevant conversation with one another.

These are outstanding opportunities for a hospital executive to engage in conversation with

staff with respect to safety and to “walk the talk” throughout the hospital.

It is therefore of crucial importance that executives and management show leadership by

sharing a common vision that engages employees and sets their intrinsic motivation into

motion. Employees learn from this experience that they too can contribute to the future of

safety. It is so important that they assume responsibility and truly feel that they have a stake in

the safety of the healthcare sector.

How can The Patient Safety Company provide support?The TPSC software solutions support both the hard and the soft sides of the safety culture. Both

are inextricably linked to one another. Data and information with respect to risks within an

institution is collected, but doing something with that information is people business. However,

TPSC provides various tools that encourage discussion about the true culture of the department.

Culture survey To start, TPSC can measure the degree to which an open (or closed) culture prevails in an

institution or a department with the help of a culture survey. The survey results determine the

interventions that can be undertaken to improve the safety culture of a department.


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Incident reporting, analysis and the initiation of improvement measuresTPSC software supports the hard sides of the safety culture by implementing tools for incident

reporting, the execution of risk analyses and the safeguarding of improvements. These solutions

provide input for dashboard reporting and enable possession of real-time information (the

number of incidents, the type of incident, the root causes, etc.).

Talking safetyExecutives, team leaders, quality managers or safety commissions can use real-time information

to highlight the soft sides of safety as well. Real-time information can be used as an instrument

to introduce new behavioural patterns within a department or an institution, such as openly

disclosing management reports related to incidents. This creates awareness and a culture in

which safety discussions are open, reflecting the values and the standards of the institution.

The benefits in a nutshell• Culture survey to measure hospital culture.

• Real-time reporting tool, so that incidents can be discussed during departmental team

meetings.

• Analysis tool supporting the discussion, transparency and acknowledgement of the root

causes of an incident, thereby boosting awareness.

• Dashboards; to be visible on departmental notice boards with information about incident

numbers, root causes, type and nature: supports an open culture and creates awareness.

• Use incidents to jointly discuss values shared within the organisational culture: what is seen

as acceptable behaviour?

http://www.patientsafety.com


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http://qualitysafety.bmj.com/content/early/2016/04/01/bmjqs-2015-004853.full

http://qualitysafety.bmj.com/content/early/2016/04/01/bmjqs-2015-004853.full

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