Culture Change is at Core of Patient-Safety Improvements

A new study of innovative patient-safety programs found an overriding culture of safety that transcends the six different initiatives analyzed.

Almost everyone that gets into this business comes to believe that a culture of safety is a critical factor in changing organizational performance regarding the safety of patients, said study co-author and health-policy expert David Blumenthal, MD.

The analysis offers health-system managers insight into the triumphs and challenges of colleagues who have tested initiatives to promote patient safety. It appears in the current issue of Milbank Quarterly, which tracks trends in healthcare policy.

Co-author Douglas McCarthy is president of Issues Research, an independent policy research firm based in Durango, Colo. Blumenthal is director of the Institute for Health Policy at Massachusetts GeneralHospital.

In 2000, the Institute of Medicine released the report, To Err Is Human: Building a Safer Health System, which found a substantial body of evidence points to medical errors as a leading cause of death and injury. The report recommended the creation of safety systems in health care organizations.

The Milbank study authors use a definition of safety culture originated by human-error guru James Reason. The hallmarks of a culture of safety include a climate where people are prepared to report their errors and near-misses and a just atmosphere where there is clear line between acceptable and unacceptable behavior. An environment that promotes safety is a flexible culture that emphasizes teamwork.

Outside of healthcare, Reasons safety-culture framework is also used in other high-stakes industries like aviation and nuclear power.

Moving toward a safety culture often requires both revamped clinical practices and social engineering, the authors discovered through their analysis and interviews with patient-safety leaders at the six sites.

The patient-safety innovations included an in-hospital rapid response team at one site, while another health system tested operating-room checklists and simulated crisis events on maternity wards. A Virginia hospital instituted four new strategies, among them a set of safety behavior expectations and high-priority red rules to remind employees of the possible harm of not following certain safety procedures.

When a new intervention encountered resistance, McCarthy said, it was often kept on track by refocusing the staffs attention on the effectiveness of the practice and patient welfare.

Physicians and nurses, all caregivers, are motivated to do whats best for the patient, he said. If they can see that changing the way that they work will accomplish that, theyll be more amenable to making that change.

Blumenthal said the Milbank article offers real-world success stories, not rigorously documented studies. In the absence of hard science, the case studies give health-system managers a body of evidence they can rely on, he added.

At least among these leaders there is progress being made in the healthcare sector, McCarthy said.

All six case studies report positive indicators of success everything from a reduction in harmful medical errors to a drop in the number of hospital-acquired infections in the intensive care unit. But the results arent sufficient to make generalizations about what works to increase patient safety across hospital settings.

Establishing a culture of safety is just one possible lever of change that may result in better care for patients, Blumenthal said.

Reference: McCarthy D, Blumenthal D. Stories from the sharp end: case studies in safety improvement. Milbank Quarterly 84(1), 2006.