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Creating a safety culture

Doucette, Jeffrey N. DNP, RN, NEA-BC, FAAN, FACHE

doi: 10.1097/01.NUMA.0000602836.74593.96
Department: Leadership Q&A
Free

Senior Vice President and CNO, Thomas Jefferson University Hospitals, Philadelphia, Pa.

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Q I'm struggling to increase the number of reported safety events and near-misses at my organization. What ideas do you have for how we can boost reporting?

This is an area in which many organizations are struggling, and the approaches to improving reporting are as unique as the organizations themselves. Creating a culture of safety requires a multifaceted approach. In my experience, increased reporting is one of the last indicators that you've achieved a strong safety culture on your team. When reporting goes up, it's an indicator that there's a significant amount of trust and respect—the foundational elements of a safe, team-oriented, and highly reliable practice environment.

Building trust on your team begins with you. As a leader, it's imperative to foster a culture of open, honest, direct, and transparent communication and role model these behaviors. Trust also requires a substantial investment in acknowledging the positive attributes of your employees in at least a 5:1 ratio to the negative. In other words, you should be telling staff members what they're doing right five times more than pointing out what they're doing wrong. Trust can be complex and mean different things to different people, but the key features are competence, integrity, honesty, and reliability. In general, this includes possessing the right skill set, having each other's backs, and always doing the right thing, especially when no one is looking.

Establishing psychological safety is another main component of increasing event reporting. Harvard Business School professor Amy Edmondson describes a psychologically safe workplace culture as “one where people are not full of fear, and not trying to cover their tracks to avoid being embarrassed or pushed.” This is a particularly poignant definition when you consider the complex and ever-evolving environment in which care takes place. Interventions to enhance psychological safety include having leaders who admit to and own their own mistakes, as well as forgive team members' mistakes. Although this isn't always easy to do, it's essential for a team focused on safe and reliable practices. Encouraging questions and responding favorably to even the most seemingly impossible suggestions and ideas also helps inspire psychological safety. When staff members feel like their voices are heard, they're far more likely to speak up in the spirit of safe patient care.

Implementing highly reliable processes also contributes to an environment that supports reporting. When processes are reliable, they're consistent, well understood, enculturated, and executed consistently regardless of who's performing the task. This makes it easier to identify deviations from accepted practices, as well as hold employees accountable for performance expectations. Although it's important to focus on processes, you must also balance this with a significant focus on people. Leaders and organizations who try to divorce the two are almost certain to never achieve positive safety outcomes. When people and/or processes fail, using a just culture framework to evaluate the root cause of problems and to take appropriate corrective actions is the most appropriate approach.

Finally, celebrate the opportunities and ideas that encourage reporting and identifying potential process failure points. A strong “good catch” program provides a forum for generating ideas, reporting events, and recognizing employees who bring these issues forward. For example, my current organization has a committee that reviews monthly submissions and chooses the “best catch,” rewarding the employee and/or team with recognition at the monthly leadership team meeting, a certificate, and a write-up in employee-facing communications.

Increasing event reporting can be a challenge on many levels. Creating a culture that promotes reporting intensifies the reliability of your processes and reduces the risk associated with errors. At the end of the day, the most important piece of a strong reporting program is your responsibility as the leader to follow through on the events and ideas that are shared with you.

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