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Learning Session Abstract

Identification of Leadership Tactics to Improve Safety Culture

Hochberg, Evan M. MBA, RN, CPN; Merkeley, Kathryn A. MHSA, RN; Fahey, Lisbeth MSN, RN; Shah, Rahul K. MD, MBA

Author Information
Pediatric Quality and Safety: March/April 2019 - Volume 4 - Issue - p e133
doi: 10.1097/pq9.0000000000000133
  • Open


A strong safety culture plays a critical role in a health system’s ability to provide safe, high-quality care. Leadership behavior and expectations are primary drivers in the development and modification of a system’s culture. In 2004, the Agency for Healthcare Research and Quality developed the first broadly adopted healthcare safety culture measurement tool. Additional tools have been developed since this time, and safety culture measurement has become a foundational component of patient safety programs across the country. Despite the popularity of these measurement tools, limited resources are available to provide practical improvement tactics for leaders. Without practical tactics, leaders face difficulty in responding to survey results with reliable interventions. This initiative aimed to identify microsystem leadership interventions that drive improvements in safety culture.


The Safety Attitudes Questionnaire safety culture survey was administered to 3,379 respondents in 2017. The safety team analyzed Safety Attitudes Questionnaire results and identified microsystems whose improvements surpassed the organization’s average from 2015, coupled with overall scores exceeding industry benchmarks. Using the survey item scores, the safety staff developed structured interviews to elicit leadership best practices within the organization. Local leaders and direct care staff were interviewed about structural or process changes implemented in those areas between the 2015 and 2017 surveys, which may have contributed to cultural improvement. These interventions were described and assembled into a toolkit in the form of a paper-bound document (Fig. 1) for dissemination to local microsystem leaders.

Fig. 1.
Fig. 1.:
BMT indicates blood and marrow transplant.


This initiative identified 34 primary transferable interventions used in high-performing departments. Several leadership themes emerged from these interventions. These themes include the following:

  • - Teamwork can be facilitated through the use of standardized tools to guide communication through critical operational and administrative functions.
  • - Working conditions improved when line staff felt ownership in operational changes. Direct care staff involvement in decision making and improvement initiatives provided autonomy over the work environment and encouraged dialog between employees and supervisors.
  • - Interprofessional integration into traditionally unilateral administrative responsibilities (eg, hiring process) improved working conditions and teamwork climate through collective ownership of department functions.
  • - Transparency about changes in operations, business strategy, and administrative spheres influenced perceptions of local and senior management. When front-line requests for departmental changes were not completed, communication of the reasoning behind these difficult decisions positively impacted staff perceptions.
  • - Safety climate was enhanced through onboarding processes focused on early development of manager–employee relationships. Early development of these relationships made it easier for staff to speak up when identifying events or unsafe situations.


By looking internally for methods of improvement, the safety team identified best practices for leaders to execute in the pursuit of a strong culture of safety. The toolkit describing these best practices has become a crucial resource in the development of action plans for leaders in units across the organization. The process described herein is suitable for identifying local improvements transferable within a macrosystem.


safety culture; safety culture measurement; leadership methods; safety attitudes; questionnaire

Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc.