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Quality and Patient Safety Culture


Board Commitment to Transparency and Accountability

Involve Patients and their Families

  • Open meetings with a short narrative of an actual patient event, illustrating the type or pattern of harm. Include lessons learned, and specific actions being asked of the board based upon this event (IHI How to Guide, p. 22). Videos entitled “The Patient and the Anesthesiologist” detail a patient safety incident, and show physicians, patient and other providers discussing this incident.
  • Guidelines for Patient Safety Stories with the Board (Available at
  • The Institute for Healthcare Improvement (IHI), in conjunction with the National Initiative for Children’s Healthcare Quality (NICHQ) developed an organizational self-assessment tool around elements of patient and family-centred care. This tool allows organizations to understand the range and breadth of elements under patient- and family-centred care and to assess where they are against the leading edge of practice.

Organizational Journey to a Just Culture

 The Canadian Medical Protective Association (CMPA) has produced a publication entitled “Learning from Adverse Events: Fostering a Just Culture of Safety in Canadian Hospitals and Health Care Institutions” which explains how healthcare providers can foster a just culture of safety within a hospital/institution, whether they are in a leadership/management role or a participant in the reporting and review process.

The Dana Farber Cancer Institute in Boston, MA has principles of a fair and just culture listed on their website with associated explanation

 Fleming (2005) describes a Ten-Step Process to Successful Safety Culture Measurement and Improvement:

  1. Build capacity
  2. Select an appropriate survey instrument
  3. Obtain informed leadership support
  4. Involve healthcare staff
  5. Survey distribution and collection
  6. Data analysis and interpretation
  7. Feedback results
  8. Agree upon interventions via consultation
  9. Implement interventions
  10. Track changes

 Patient Safety Culture Improvement Tool (Fleming & Wentzell, 2008)

5 Actions to Improve Patient Safety Reporting. This tool from the UK found that trusts reporting high levels of patient safety incidents suggest a stronger organizational culture of safety because staff take incidents seriously and associate reporting with learning.

Manchester Patient Safety Framework (MaPSaF) is a tool developed to help NHS organizations assess their progress in developing a safety culture. The framework has been adapted to Acute, Ambulance, Mental Health and Primary Care.

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