Creating a Culture of Safety Takes Time
Accreditation Monthly
April 11, 2008
The new Joint Commission standard calling on hospitals to create a culture of safety will not take effect until 2009. However, organizations that want to shine during survey time should get moving now. “It takes years,” says Ken Rohde, a senior consultant with The Greeley Company, a division of HCPro in Marblehead, MA. “It doesn’t take months. It takes years to turn these things into habits.”
The Joint Commission (formerly JCAHO) has revised the leadership standard of its manual. Beginning in January 2009, standard LD.3.10 will require organizations to create a culture of safety. “A culture of safety is difficult to define and even harder to measure,” says Richard A. Sheff, MD, chair and executive director of The Greeley Company. The new standard, he adds, will force the field to focus on safety but is, so far, short on details.
“What The Joint Commission has a history of doing, particularly when it creates new standards, is setting generalized standards,” Sheff says. “They say, ‘This is the right thing to do,’ but frankly, The Joint Commission doesn’t know the best way to do it. It creates a lot of ferment in the field. And then a lot of experiments happen and best practices begin to emerge and [the] standard becomes more standardized, if you will.”
Conducting a culture assessment
Rohde, who has years of experience working for high-risk businesses, including several in the nuclear power industry, says hospitals should begin by assessing their current culture of safety. “The first thing you need to do is understand what your existing shared beliefs and values are,” Rohde says. “And the first step is diagnosis, and that’s doing an assessment of where you are.”
An effective assessment, Rohde explains, will examine five key areas, including:
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Self-reporting and improvement. “Do we believe in reporting things?” Rohde asks. “Is that a shared value? Or is our shared value, ‘Don’t report anything, or you’ll get into trouble.’ That’s a negative shared value or belief. It’s part of the culture, but it’s not necessarily a good part of the culture.”
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Working together toward a common goal. “Are we a bunch of individual people, or do we work together as a team?” Rohde says. “Do we share equipment, or do we hoard equipment?”
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Accepting responsibility and accountability. “Can we count on each other?” Rohde says. “Can they count on me, if I say I’m going to do something? Or in our culture, do things slip off?”
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Risk-balanced decision-making. “Do we make decisions based on not spending any money, because our culture says making sure we don’t spend money is a good thing, even if the equipment is falling apart?” Rohde says. “Or is our culture, ‘We’re going to buy the latest and greatest cool piece of equipment, even though in the long run, we may not be able to sustain it.’”
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Medical staff engagement. In regard to the medical staff and the hospital staff, Rohde asks: “Do we see them as two separate entities, or do we see them working together toward a common goal? Do we share issues? Are we willing to coach each other?”
Responses from staff members to questions that explore those five key attributes should give hospitals a pretty clear view of where their culture is heading. Organizations can then use the assessment to benchmark against another facility’s culture of safety. Or they can compare where their hospital is today to two years from now to see if it improves. “To benchmark your culture against other cultures is really pretty difficult,” Rohde says. “It’s easier to benchmark yourself this year and compare the results to two years from now to see if the culture has changed.”
Deciding what to keep, ditch
The assessment, Rohde adds, will allow hospitals to diagnose where they want to make interventions, which parts of the culture they want to keep, and which areas they want to change.
The next step is to communicate specifically which parts of the culture the organization wants to change, Rohde says. “We need to clearly set the expectations for what is safe behavior,” Rohde explains. “If we don’t, then everybody is going to be doing their own thing, and we’re not going to have shared values and beliefs that are consistent and congruent with our overall organizational approach.”
After setting expectations, hospitals need to provide easy-to-use error reduction tools and train staff how to use them. Continuous monitoring is critical. “If we back off, then it doesn’t become part of our shared culture and beliefs and we slide back into our previous culture, which we weren’t happy with,” Rohde says.
Turning behaviors into habits
The ultimate goal is to turn behaviors that promote safety into habits. Rohde cites the increasing use of seat belts as an analogy. “At first, we used them because someone said they were a good idea to prevent injuries,” Rohde says. “Later on, people used them because maybe the policemen were watching to see they were wearing them. Now, we put seat belts on because it’s become a habit. It has become such a part of our culture, our daily shared values and beliefs, that often we’re unwilling to drive unless everybody in our car has their seat belt buckled.”
But how do you get a young nurse to challenge an experienced, and perhaps irritable, physician who is not following proper protocols? “That’s always a difficult thing to get people to do whenever there is a power gradient, such as a new employee as opposed to a seasoned department head,” Rohde says. “That same problem was seen in the aviation industry, where copilots did not feel free to challenge the pilots because of a similar gradation in perceived power.”
Making staff members feel safe to challenge
The aviation industry, which has seen tremendous strides in safety in the last two decades, developed a method to help the entire crew work together and solve problems as they came up.
Staff members shouldn’t immediately jump into a face-to-face confrontation if they see someone breaking the rules, Rohde says. Instead, he suggests following the three levels of escalation of concern used in the crew resource management methods developed in the aviation industry.
“The first part is to give a gentle nudge,” Rohde says. “You say, ‘Excuse me, can I get you some gloves?’ if you see a practitioner not using gloves when they should be. You ask that gentle question. That allows the other person to change their behavior without it becoming a big issue.”
The second step, he explains, is to ask the clinician to change his or her behavior by saying something such as: “Excuse me, can I ask you to put on some gloves? You know it’s an important part of our safety process to protect both you and the patient.”
If that still doesn’t work and there’s imminent danger to either the patient or the practitioner, it’s time to draw the line. At the third step, Rohde says, the clinician might say: “Our policy requires we wear protective equipment, including gloves, when we’re working with a MRSA patient. You don’t have gloves on now, and I can’t continue to allow us to go further without getting management involved. To do so would result in harm to you, the patient, and the organization as a whole, and I just can’t allow that to happen.”
Applying lessons from high-risk industries
Some in the healthcare field charge that lessons from the aviation industry and other high-risk fields can’t be applied to hospitals, since they see different patients with different problems every single day.
Rohde disagrees. “Not right. Healthcare needs to learn from other high-risk industries,” he says. “These are not new concepts. These are concepts that are really quite well-developed, and that’s a real benefit to healthcare.” Hospitals, Rohde adds, should take policies from high-risk industries that apply to them and then modify the policies to suit their organizations.
“Once they are appropriately modified, most of the methods work very effectively within healthcare,” Rohde says.
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Question of the Month | Expert Advice & Guidance
- Are there specific requirements for governing board members, as leadership, to receive education related to the 2009 TJC standards?
Yes. Specifically under the 2009 standard LD.01.07.01, governing board members are to be oriented to the hospital's:
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