What Is Your Patient Safety Culture?
The links between organizational culture, safety, and quality are nothing new. Many industries have generated high-reliability outcomes by addressing culture change.
By controlling an EMS organization’s ability to change and respond, culture has an incredible impact on organizational success. As management expert Edgar Schein wrote, “Culture determines and limits strategy.” This article will explore how measurement and assessment of the cultural climate should be part of your patient safety plan and strategy.
Across the healthcare continuum, measurement provides data. Historically EMS has lacked helpful safety data, instead just emphasizing doing the “right thing” for the patient. However, without measurement and the resulting data, it is difficult to assess progress in important areas such as quality and safety. Today EMS is using data in many new and innovative ways to improve the quality of care and strengthen organizational sustainability.
One approach to understanding an organization’s current state of patient safety is to collect data around specific adverse events, near-misses, and unsafe conditions. This data reflects a reality that’s known by frontline staff but is often difficult to fully capture. Challenges in collecting this information include:
- Lack of education about what to report;
- Lack of education about how to report, including inefficient reporting processes;
- Lack of prioritization to report a mistake, near-miss, or unsafe condition;
- Staff members who are fearful to report a mistake.
An artificially low number of reports can be interpreted several ways. Most often it generates a false sense of security for leaders who assume all is well. The Institute of Medicine’s report To Err is Human addressed this false reality and led a paradigm shift by encouraging leaders to study mistakes and respond to them proactively rather than reactively. This encouraged the development of safety science and corresponding changes in culture.
“Culture,” in its simplest form, consists of the attitudes, beliefs, and perceptions of a collective group of people. It shapes their behaviors, decisions, and choices and is therefore a complicated but highly influential component of the safety equation.
Culture is local. Many organizations have seen how subcultures can develop with their own identity or values. Shift teams or locations often develop their own unique subcultures. This can result from distance, unique shared experiences, or just variations in local management. Unfortunately these variations can lead to the breakdown of the organization’s overall mission, vision, and values.
Understanding employees’ attitudes and perceptions helps leaders as they seek new talent and work to retain talented staff. Candidates are attracted to work environments that demonstrate shared accountability, trust, and transparency. Safety programs based on the science of safety, data-driven outcomes, strong leadership, and a supportive culture will move EMS organizations forward in the 21st century medical environment.
Defining Safety Culture
Patient safety culture is the extent to which an organization’s culture supports and promotes patient safety. It refers to the beliefs, values, and norms shared by healthcare practitioners and other staff throughout the organization that influence their actions and behaviors.
Patient safety culture can be measured by determining what is rewarded, supported, expected, and accepted in an organization as it relates to patient safety. (As an example, find the AHRQ’s patient safety culture assessment tool at www.ahrq.gov/sops/quality-patient-safety/patientsafetyculture/index.html.)
Several key elements, or domains, have been identified that correlate to improved patient safety. Through validated testing, organizations can evaluate their strengths and weaknesses in areas such as:
- Compliance with procedures
- Training and skills
- Nonpunitive response to errors
- Feedback and communication
- Communication openness
- Supervisor expectations about safety
- Management support for safety
- Organizational learning
Surveying these areas allows organizational leaders and managers to develop a much stronger picture of life on the front lines. For example, nine EMS organizations recently completed a patient safety culture assessment.
Of 670 respondents, 60% indicated they felt the person was being written up, in instances of violation, rather than the problem. Only 45% expressed their ability to openly talk about problems in their service.
These findings, while limited, reflect cultures that are strongly punitive and reactive, rather than proactive. Additionally, 53% indicated upper management seemed interested in patient safety only after an adverse incident happened. Just 67% felt staff members were treated fairly when they made a mistake.
Culture change is a transformative process. Just as sailors would not begin a voyage without a map and navigation tools, culture change requires planning and direction. A survey provides a snapshot of the current cultural climate and allows comparison to other EMS provider organizations. It helps leaders know where they need to go.
A culture survey can provide these benefits:
- A baseline against which to measure improvement;
- Measurement of the impact of programs such as Just Culture/shared accountability;
- Identification and leveraging of organizational strengths;
- Assessment and improvement of employee retention strategies;
- Identification of opportunities for improvement;
- Repeat assessments to provide directional trends and patterns;
- Data to support focused projects or initiatives;
- Internal and external benchmarking to compare against other EMS services.
Provider and patient safety is an important part of the new medical landscape. To achieve patient safety goals, EMS leaders must proactively engage with a wide-ranging variety of improvements, but it begins with measurement. A patient safety culture assessment is the first step in the journey to improve culture and reduce preventable patient harm.
Sidebar: When a Mistake Happens
As a leader, how do you respond when a mistake happens?
- A culture of fear and punishment—A paramedic makes a medication mistake but doesn’t tell anyone or report it out of fear of being fired. The provider feels responsible and shoulders fear and embarrassment, becoming a second victim.
- A culture of learning and improvement—A paramedic makes a medication mistake and reports it to the on-duty supervisor. The paramedic knows this will maximize optimal care for the patient and learning to prevent any similar events.
In collaboration with the Center for Patient Safety, EMS World is launching a new online series focusing on safety, Just Culture, and the power of survey data in guiding improvement in EMS. Visit www.emsworld.com/operations to learn more.
EMSForward is an ongoing campaign to drive awareness, conversation, and action to improve patient safety. EMSForward 360 is a supplemental campaign using a new assessment that amplifies the voices of leaders and staff. This data-driven program provides a deeper understanding to guide culture change initiatives at the agency level.
More information on the patient safety culture in EMS will be available next month in the EMSForward 360 booklet, available for download from the Center for Patient Safety at www.centerforpatientsafety.org or
The Center for Patient Safety has been working with EMS since 2009 to offer innovative and proactive solutions to reduce preventable harm. It would like to acknowledge and recognize the National Registry of EMTs for the collaboration and codevelopment of the survey instrument.
Lee Varner, MSEMS, CPPS, EMT-P, is patient safety director of EMS services at the Center for Patient Safety, Jefferson City, Mo.