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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Sara J. Singer, Harvard University
Anita L. Tucker, University of Pennsylvania
Academy of Management—August 9, 2005
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
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 NurseValuing and empowering front line staff
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
“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 DirectorEngaging in the patient safety effort
“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
“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 CareImproving systems rather than blaming individuals
Difference from hospital 7 significant at ** p<.01 , * p<.05