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Singer and Vogus – Interventions That Build Safety Culture (2013)

Piecemeal initiatives to improve a patient safety culture are inadequate; improving a patient safety culture requires sequential, iterative and simultaneous interventions that:

  1. Enable: e.g., "transformational" leadership; critical role of senior leaders; leadership characteristics; human resources; information technology (IT); external regulators
  2. Enact: e.g., teamwork; communication; mindfulness; patient involvement; reporting; coordination between areas /at transitions
  3. Elaborate: e.g., learning (e.g., reports, complaints, morbidity and mortality rounds); education; monitoring (prospective, retrospective, concurrent); operational improvements (industrial techniques, infrastructure).

Baker – Beyond the Quick Fix (2015)

Recommendations: Patient safety /quality improvement strategy; board monitoring of performance; measurement (organizational and microsystem levels); event reporting and analysis (focus on gaps and feasible recommendations); investments in work climate; patients and care givers included in patient safety and quality improvement; investments in patient safety /quality improvement infrastructure; leadership development; collaboration across organizations; pan-Canadian information systems.

Canadian Patient Safety Institute – Patient Safety Culture

Dimensions: informed; reporting; learning; just; flexible.

Contributors: leadership; patient/family engagement; teamwork and communication; openness to reporting; learning; resources; priority of safety versus production; education and training.

British Columbia – Culture Change Toolbox: Components of Patient Safety Culture (2013)

Teamwork and communication; safety climate; psychological safety; organizational fairness; just culture; stress recognition; working conditions; leadership; learning and improvement; patients as partners; transparency.

American College of Healthcare Executives (ACHE) / Institute for Healthcare Improvement (IHI) / National Patient Safety Foundation (NPSF) – Leadership Blueprint for Culture of Safety (2017)

Six leadership domains: vision; trust, respect and inclusion; board engagement; leadership development; just culture; behaviour expectations.

IHI Whitepaper – Patient Safety (2006)

Patient safety strategy/aims; senior leader communication and awareness building (e.g., walk-rounds); engage stakeholders (board, leaders, physicians, staff, patients/families) in patient safety; implement "just" culture; focus on process redesign/improved reliability (e.g., evidence-based standardization, human factors); leader/ manager/staff accountability  (e.g., for safety reporting, reliable processes/"daily work") and aligned incentives for patient safety; patient safety infrastructure (staff and committees); assess patient safety  culture; measure/track patient safety (e.g. mortality, trigger tool); support patients/families impacted by errors.

IHI Whitepaper – 7 Leadership Leverage Points (2008)

System-level aims; executable strategy; leadership attention; patients /families; Chief Financial Officer (CFO) as quality champion; engage physicians; improvement capability.

IHI Whitepaper – High-Impact Leadership (2013)

Person-centredness (e.g., patient involvement/stories); front-line engagement (e.g., regular presence at frontlines, visible champion, lead projects); relentless focus (e.g., talk about vision every day, align schedule with high-priority initiatives; designate resources); transparency; build will to improve (e.g., communicate and model desired behaviours, openness, swift action against undesired behaviour); boundary-lessness (e.g., systems thinking, harvest ideas from and partner with other organizations).

IHI Whitepaper – Sustaining Improvement (2016)

Quality control, improvement, culture; standardization; accountability (standard work); visual management; problem solving; escalation; integration; prioritization; daily work; policy; transparency; trust.

IHI Whitepaper – Safe, Reliable and Effective Care (2017)

Leadership; psychological safety; accountability (act in safe and respectful manner); teamwork and communication; negotiation; continuous learning; improvement and measurement; reliability; transparency.

Key Concepts

  • Safety science – focusses on contributing factors and underlying causes of risk and harm, including errors and human factors. It includes many disciplines not typically considered part of healthcare. Recognizes the fundamental importance of system design in driving workforce behaviour. In other industries, such as aviation, safety experts accept that human error must be expected, anticipated, and its effects mitigated. Safety science and human factors engineering is used to design systems to prevent errors, and to mitigate harm when errors occur. (Berwick et al., 2015).
  • Implementation science – supplements patient safety science; focusses on identifying and implementing valuable practices and lessons learned, and scaling up/translation across the organization and system. (Berwick et al., 2015).
  • Just culture – a culture that recognizes that individual practitioners should not be held accountable for system failings over which they have no control. A just culture recognizes many individual or "active" errors represent predictable interactions between humans and the systems in which they work. A just culture also does not tolerate conscious disregard of clear risks to patients or gross misconduct. (Berwick et al., 2015).
  • Psychological safety – an environment where: anyone can ask questions without looking stupid; anyone can ask for feedback without looking incompetent; anyone can be respectfully critical without appearing negative; anyone can suggest innovative ideas without being perceived as disruptive. (Frankel, 2017).
  • Staff safety/health – A precursor to providing high quality care are staff that are free from physical harm during daily work. (Perlo, 2017)
  • Patient and family engagement – recognized as a primary area of focus in patient safety and quality; includes engagement at three levels: direct care (diagnosis, treatment decisions, monitoring), organizational design and governance (planning, patient advisory councils, quality improvement projects), policy making (public health, research priorities, resource allocation). (Carman, 2013).
  • Disruptive behaviour – any behaviour that shows disrespect for others or any interpersonal interactions that impede the delivery of patient care; this behaviour poses a threat to patient safety. (AHRQ PS Net, 2017).
  • High reliability/resilience – reliable/mindful organizations are:  preoccupied with failure (look for small signals of failure vs. preoccupation with success); reluctant to simplify interpretations (acknowledge complexity); sensitive to operations (aware of what is happening at frontlines); committed to resilience (acting quickly when things go wrong, e.g., patient deterioration); and defer to experts (vs. authority). (Weick & Sutcliffe, 2015).
  • Patient safety measurement – five dimensions: past harm (incidents, mortality); reliability (compliance); sensitivity to operations (walk-rounds, staffing levels, escalation); anticipation and preparedness (risk registers, safety culture scores, absenteeism); integration and learning (automated alerts, board dashboards). (Vincent, 2016).
  • Frontline leadership/distributed leadership – recognized as a key driver for change in healthcare; local leaders translate senior leader priorities/values into action at the microsystem level; they have great impact on unit cultures and learning processes. (IHI, 2016).
  • Physician leadership – recognized as a key driver for change in healthcare; six strategies for engaging physicians: discover common purpose; reframe values and beliefs; segment the engagement plan; use engaging improvement methods; show courage; adopt an engaging style. (Reinertsen, 2007).
  • Staff engagement – A joyful, engaged workforce will have: physical and psychological safety; meaning and purpose; choice and autonomy; recognition and rewards; participative management; camaraderie and teamwork; daily improvement; wellness and resilience; real-time measurement. (Perlo, 2017)
  • Teamwork/communication – gaps in communication and/or poor teamwork are frequently noted as contributing factors to many patient safety events. Strong teams which train together and have established and reliable communication practices will have superior patient safety performance. (Baker, 2015).
  • Industry-wide standardization/alignment – A key feature in other high-risk industries is alignment across the sector related to key priorities, national/international standards and regulation of safety-critical practices and technologies. (Dixon-Woods, 2016, Berwick et al., 2015).

Environmental Scan

ACHE, NPSF Lucian Leape Institute. (2017). Leading a culture of safety: a blueprint for success.

AHRQ PS Net. (2017). Disruptive and unprofessional behavior.

Baker R. (2010). Effective governance of quality and patient safety: a toolkit for healthcare board members and senior leaders.

Baker R.  (2015). Beyond the quick fix strategies for improving patient safety . Institute of Health Policy, Management and Evaluation at the University of Toronto.

Baker R, Norton P, et al. (2004). The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 170(11):1678-86.

BC Patient Safety and Quality Council. (2013). Culture change toolbox.

Berwick D, Shojania K, et al. (2015). Free from harm: accelerating patient safety improvement fifteen years after To Err Is Human. National Patient Safety Foundation.

Berwick D, Feely D. (2017). WIHI: the next wave of patient safety. Institute for Healthcare Improvement (IHI) webinar.

Botwinick L, Bisognano M, Haraden C. (2006). Leadership guide to patient safety. IHI White Paper.

Canadian Institute for Health Information, Canadian Patient Safety Institute (2016). Measuring patient harm in Canadian hospitals.

Canadian Patient Safety Institute (CPSI). (Date unknown). Patient safety culture.

Carman L, Dardess P, Maurer M, et al. (2013). Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Affairs. 32(2):223-231.

CPSI, AHQPSC, HQO, PFPSC. (2017). Engaging patients in patient safety: a Canadian guide.

CPSI. (2012). The economics of patient safety in acute care: technical report.

Dixon-Woods M, Pronovost P. (2016). Patient safety and the problem of many hands. BMJ Qual Saf. 25(7):485-488.

Frankel A, et al. (2017). A framework for safe, reliable, and effective care. IHI White Paper.

IHI. (Date unknown). What is a bundle?

IOM. (2001). Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press.

The Joint Commission. (2017). The essential role of leadership in developing a safety culture. Sentinel event alert.

Kizer, K. (1999). Large system change and a culture of safety. In: Enhancing patient safety and reducing errors in health care. Chicago, IL: National Patient Safety Foundation.

Kristensen S, Christensen K, Jaquet A, Beck C, Sabroe S, Bartels P, Mainz, J. (2016). Strengthening leadership as a catalyst for enhanced patient safety culture: a repeated cross-sectional experimental study. BMJ Open. 1-10.

National Patient Safety Foundation. (2017). Call to action: preventable health care harm is a public health crisis and patient safety requires a coordianted public health response.

Perlo J, Balik B, Swensen S, et al. (2017). IHI framework for improving joy in work. IHI White Paper.

Reinertsen J, Bisognano M, Pugh M. (2008) Seven leadership leverage points for organization-level improvement in health care (second edition). IHI White Paper.

Reinertsen J, Gosfield A, Rupp W, et al. (2007). Engaging physicians in a shared quality agenda. IHI White Paper.

Sammer C, et al. (2010). What is patient safety culture? A review of the literature. J Nur Schol. 42:2;156-165.

Scoville R, Little K, Rakover J, Luther K, Mate K. (2016). Sustaining improvement. IHI White Paper.

Singer S, Vogus T. (2013). Reducing hospital errors: interventions that build safety culture. Annu Rev Public Health. 34:373-396.

Swensen S, et al. (2013). High-impact leadership: improve care, improve the health of populations, and reduce costs. IHI White Paper.

Vincent C, et al. (2016). A framework for measuring and monitoring safety: a practical guide to using a new framework for measuring and monitoring safety in the NHS. The Health Foundation Quick Guide.

Weick, K, Sutcliffe, K. (2015). Managing the unexpected: sustained performance in a complex world. Hoboken, NJ: John Wiley & Sons.