Transcript Slide 1

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

 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

 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

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.

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

Qualitative results: 6 dimensions

      Create a compelling safety vision Value and empower personnel Leader engagement improvement efforts in patient safety Lead by example Focus on system issues individual error rather than on Quest for improvement (even if already good)

Hospital ratings on 6 safety leadership dimensions

Behavior 1. Vision 2. Value and empowerment 3. Engagement

Hospital Hospital Hospital Hospital Hospital Hospital Hospital 6

Strong Strong Strong 4. Leadership by Example 5. Systems focus Strong Strong 6. Dissatisfaction with status quo Strong

3

Strong Strong Strong Strong Strong Strong

4

Strong Strong Strong Strong Strong

8

Strong Strong

Ambiguous 2 Ambiguous Ambiguous Ambiguous Unknown Ambiguous Ambiguous Weak

Strong

5 Weak Ambiguous Ambiguous Ambiguous Ambiguous Ambiguous Ambiguous Ambiguous Ambiguous Ambiguous Ambiguous Ambiguous Ambiguous 1 Weak Weak Weak 7 Weak Weak Weak Weak  Stronger leadership in hospitals 6 and 3 v. 7

Valuing and empowering front line staff

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

Engaging in the patient safety effort

Hospital 3    5 hospital system in a midsize Midwestern city “Our CEO, he is constantly out and about Hosp 3 , walking around, checking on things.” – Ed, Cath Lab Technician, “I… worked on a board presentation an error] in a understands [wrestling with] How do we present to board of directors this [analysis of meaningful but actionable direction, such that the governing body ?” Alan Eberhardt, Network CMO Hospital 7  “When people feel like they have one shot Because at [being heard by senior management], they want to…make sure they get their… issues raised. who knows if they ever get another chance.” – Viola Flynn, Outgoing QI Director

Improving systems rather than blaming individuals

Hospital 6  “We we treated that [mistake that caused no harm] as a sentinel event… When we did the root cause analysis, realized that the process in the lab left a single tech, any tech, vulnerable to back them up and actually protect the employee reaction.” —Michelle Paulson, CEO … Initially the staff wanted to point to the tech…We had from that type of Hospital 7  “You quickly identify who you think caused the problem and you deal with them in a not-so educational way.” Emergency Care – Senior Mid-level Manager of

Survey results: Average % problematic response

 Hosp 6 and 3 have stronger safety leadership than hosp 7 Hsp LDRSHP items (7) 6 5.0** 3 9.3** 4 8 11.4** 10.7** 2 12.8

5 12.8

1 12.5** 7 21.4

All safety climate items 12.0* 15.9* 16.2

18.5

17.0

16.5

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

16.6

21.9

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

Conclusions

 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