Creating a culture of safety
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Creating a Culture of Safety. Sara J. Singer, Harvard University Anita L. Tucker, University of Pennsylvania Academy of Management—August 9, 2005. Research objective. How do senior hospital leaders contribute to creating a strong culture of safety? . Motivation.

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Creating a culture of safety l.jpg

Creating a Culture of Safety

Sara J. Singer, Harvard University

Anita L. Tucker, University of Pennsylvania

Academy of Management—August 9, 2005

Research objective l.jpg
Research objective

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

Motivation l.jpg

  • 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 leadership’s awareness of safety risks and mistakes

    • Senior leaders have a more optimistic view of safety culture than other personnel (Singer et al., 2003)

Methods l.jpg

  • 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

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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.

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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

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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)

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Hospital ratings on 6 safety leadership dimensions

  • Stronger leadership in hospitals 6 and 3 v. 7

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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

Valuing and empowering front line staff

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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 to…make sure they get their… issues raised. Because who knows if they ever get another chance.” –Viola Flynn, Outgoing QI Director

Engaging in the patient safety effort

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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 tech…We 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

Improving systems rather than blaming individuals

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Survey results: Average % problematic response

  • Hosp 6 and 3 have stronger safety leadership than hosp 7

    Difference from hospital 7 significant at ** p<.01 , * p<.05

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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

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  • 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