Healthcare organisations around the world work hard to ensure that patient safety is a strategic imperative. Yet, despite healthcare’s collective best efforts, significant patient safety improvements have been difficult to achieve. In 1999, the Institute of Medicine reported that at least 44,000 people, and perhaps as many as 98,000 people, die in U.S. hospitals each year because of preventable medical errors. By 2016, a study by Johns Hopkins revised that number to more than 250,000 people, making medical errors the third-leading cause of death after heart disease and cancer. In Ireland, data reported in 2017 indicates that an estimated 1,000 preventable deaths caused by medical harm occur every year, with 160,000 patients experiencing injuries due to human error. In response to the staggering statistics surrounding patient harm around the world, the World Health Organization (WHO) designated 17th September 2019 the first-ever World Patient Safety Day.
You might be wondering what factors have contributed to these unfortunate medical errors.
Despite intermittent improvements, all-too often we still read about patient harm events. Certainly, hospitals where these events take place have well-designed policies, procedures, pathways and workflows that are in place to help prevent these types of events from occurring. If so, then what went wrong? Often, these events have something to do with understanding safety culture.
Research has shown that the three major components of a safety culture are:
1. A just culture,
2. A reporting culture and
3. A learning culture
While it might be easy to think of this as a three-legged stool, a better model might be to consider these three elements as interconnected spokes on a wheel. Here’s why. First, a just culture is the key ingredient in a reporting culture, because staff who are fearful of repercussions when reporting errors, mistakes, and other adverse events will be unlikely to report at all. Second, a reporting culture – fueled by a just culture – is the key ingredient in a learning culture, because if nothing is being reported, learning simply cannot exist.
Let’s explore each of these three elements in a little more detail.
The Five Essential Elements of a Just Culture
Just culture is the process of attempting to manage human fallibility through system design and behavioural choices that we have within our organisations. Unfortunately, in healthcare, culture has largely consisted of punishing people for mistakes. When that happens, we don’t have the ability to learn from it, and we lose the opportunity to improve.
To ensure your culture is “just,” focus on these five elements and ask yourself the five corresponding questions:
1. Values and Expectations: Do we recognise that we are all imperfect and that it is nobler to continuously work toward improved reliability?
2. System Design: Have we designed our systems to anticipate human error, capture errors before they reach the patient and permit recovery when harm occurs?
3. Human Behaviour: Have we anticipated that we will make mistakes, no matter how skilled and have we recognised the difference between human error, at-risk behaviour and reckless behaviour?
4. Learning Systems: Can we identify risk by observing the design of the systems in which we work, our behaviours and the behaviours of those around us?
5. Justice and Accountability: Do we hold one another accountable for the quality of our systems and our choices?
Following a harm event, it’s beneficial for healthcare organisations to have tools in place that promote effective communication with patients, families and caregivers. The Communication and Optimal Resolution Toolkit (CANDOR) combines a “head & heart” approach when engaging in these conversations. Implementing this approach supports healthcare organisations in their efforts to provide compassionate communication through a fair and accountable culture.
Tips for Creating a Proactive Reporting Culture
In 2013, Airways New Zealand CEO Ed Sims authored an article for Business Leaders’ Health & Safety Forum entitled, “Building a Reporting Culture.” Airways runs New Zealand’s air traffic control operations and has 750 staff; zero harm is as important to Airways as it is to any hospital around the world. In that article, Sims offered three tips for creating a reporting culture:
- Always provide positive feedback to the person submitting the incident report.
- Congratulate staff for making the effort to report a concern or for taking ownership of a mistake.
- Let staff see that something happens as a result of their report and that their concerns don’t just disappear into the ether.
In addition, The Joint Comission has created a guide outlining “The 4 E’s of a Reporting Culture” to help care teams across an organisation identify how they can contribute to a strong reporting culture:
1. Establish Trust
2. Encourage reporting
3. Eliminate fear of punishment
4. Eliminate errors, close calls and hazardous conditions
To encourage frontline staff to report safety concerns, it is important to be equipped with a tool that makes it easy to capture events and near misses. The RLDatix software is built with customisable and dynamic forms, so organisations can tailor them to their unique requirements. The data recorded in RLDatix serves as a valuable resource for organisations to identify areas of improvement and continue to build a safety culture. When staff are equipped with tools to quickly and effectively capture safety data, providers are better positioned to protect patients from harm.
Four Ways to Create a Learning Culture
Much has been written about learning organisations and how companies that promote continuous learning are able to accelerate the success curve. In 2018, management gurus Tomas Chamorro-Premuzic and Josh Bersin co-authored, “4 Ways to Create a Learning Culture on Your Team,” for Harvard Business Review, where they revealed these four science-based recommendations for creating a learning culture:
1. Reward continuous learning, which includes “creating a climate that nurtures critical thinking, where challenging authority and speaking up are encouraged, even if it means creating discord.”
2. Give meaningful and constructive feedback, including feedback that is both positive and negative. “However,” the authors wrote, “negative feedback must be provided in a constructive and delicate way – it is a true art – as people are generally less receptive of it than of praise and appreciation.
3. Lead by example. If you want your staff to take on new challenges, volunteer for something outside their comfort zone, or tackle a project that requires a new skill, then you must do the same.
4. Hire curious people. People who are curious are natural learners and are more suitable for a learning culture.
Once an organisation has cultivated a learning culture, how do they maintain it? The RLDatix Safety Learnings module provides organisations with a tool to share and engage with safety information and learnings to drive quality improvement across every care team. Using RLDatix, staff can easily generate a safety learning from within any incident or feedback record, supporting triangulation of learnings and other data. Additionally, the module serves as a community hub for good practice learnings, allowing users to interact and vote on the most useful shared learnings.
As the healthcare industry relentlessly pursues zero preventable harm, it is, of course, important that the right systems are in place. Equally important, is that the right culture is in place, too. In light of COVID-19, frontline staff continue to confront daily challenges surrounding the unfolding global pandemic. As staff navigate industry uncertainties and added stress, it’s increasingly important for healthcare organisations to be educated on the key components of a just, learning and proactive reporting culture, and how these components can help cultivate a culture of safety for patients, families and care teams.