Organizational Culture Should Support Patient, Healthcare Worker Safety

By Kelly M. Pyrek

The symbiotic relationship between patient safety and healthcare worker safety and the need for institutional championship of a safety of culture are the focus of a recent monograph released by the Joint Commission in late 2012. The document, "Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation," contends that high rates of injuries and illnesses among healthcare workers serve as a warning that the healthcare environment as a whole must be transformed in order to improve safety.

In healthcare, the primary ethical imperative is First, do no harm. Although we have traditionally applied this obligation to our patients, this monograph helps to establish it also as our obligation to those with whom we workand to all within the healthcare setting, writes Paul M. Schyve, MD, senior advisor for healthcare improvement at the Joint Commission, in a foreword to the monograph.

This organizational culture of safety and the symbiotic nature of patient and healthcare worker safety is something that infection preventionists can help uphold in their daily duties, says Linda Kusek, RN, BSN, MPH, CIC, associate project director of the Department of Health Services Research, Division of Healthcare Quality and Evaluation at the Joint Commission. "Infection prevention and control is actually one of the areas with the most clear-cut symbiotic relationship," says Kusek. "At its core, preventing the transmission of infections directly benefits both patients and workers, since transmission can occur between patients, between workers, and between workers and patients. Infection preventionists often work closely with occupational health staff. Examples of common initiatives include healthcare worker immunization for influenza and other diseases; education and monitoring for proper hand hygiene and the appropriate use of personal protective equipment, such as gloves, masks and respirators; care for occupational exposures, such as sharps injuries; and identification, reporting, prevention and mitigation of potential risks in the environment and in care systems and processes."

The Joint Commission says it hopes the monograph will help "bridge safety-related concepts and topics that are often siloed within the specific disciplines of patient safety/quality improvement and occupational health and safety."  The monograph highlights examples of healthcare organization practices that address patient and worker safety simultaneously and the benefits and potential cost savings attained through collaboration between employee and patient safety departments. The monograph also identifies functional management systems and processes, strategies and tools that have been used to successfully integrate health and safety activities. Using actual case studies, it describes a range of topic areas and settings in which opportunities exist to improve patient safety and worker health and safety activities.

One major step that healthcare institutions can take toward championing patient and healthcare worker safety, according to the monograph, is becoming a high-reliability healthcare organization (HRO) --  described as systems operating in hazardous conditions that have fewer than their fair share of adverse events. (Reason, 2000)

According to Reason (2000), one of the most important distinguishing features of HROs is their intense concern (often referred to in the literature as preoccupation) with the possibility of failure. They recognize the inherent fallibility in humans as well as the risk of system failure associated with equipment and devices used in tightly inter-related (coupled) work processes. HROs strive to create systems and processes that prevent errors or mitigate their impact. They value identifying and reporting potential and actual problems and treat adverse occurrences as opportunities for learning and improvement, according to Hines, et al. (2008). 

Weick, et al. (1999) describe the following five organizational culture characteristics that contribute to a collective mindfulness regarding error prevention: (1) preoccupation with failure, (2) reluctance to simplify interpretations, (3) sensitivity to operations, (4) commitment to resilience, and (5) under-specification of structures. This mindfulness requires both constant awareness and willingness to take action on the part of all staff, according to Weick (1999). In healthcare, the term reliability typically encompasses both getting the same result and getting the correct result. For example, the Institute for Healthcare Improvement (IHI) defines reliability in healthcare as failure-free operation over time.

As the 2001 Institute of Medicine report, "Crossing the Quality Chasm: A New Health System for the 21st Century," explains, "Threats to patient safety are the end result of complex causes such as faulty equipment; system design; and the interplay of human factors, including fatigue, limitations on memory, and distraction. The way to improve safety is to learn about causes of error and use this knowledge to design systems of care so as to prevent error when possible, to make visible those errors that do occur (so they can be intercepted), and to mitigate the harm done when an error does reach the patient." Toward that end, IHI promotes the following three-step model for reducing errors and improving reliability in healthcare systems:
1. Prevent failure (a breakdown in operations or functions).
2. Identify failure when it occurs and mitigate it (intercede) before harm is caused or when failure is not detected.
3. Redesign the process based on the critical failures identified

In order for healthcare organizations to become highly reliable, Chassin and Loeb (2011) say that healthcare facilities must describe embrace three interdependent, essential transformations:
1. Leadership must commit to the goal of high reliability.
2. An organizational culture that supports high reliability must be fully implemented
3. The tools of robust process improvement must be adopted

The concept of a safety culture can be relative to the various stakeholders. According to the Joint Commission monograph, "Safety culture is known to vary widely across organizations, and performance on the specific domains varies within organizations. For example, it is conceivable that hospitals may score high on dimensions related to patient safety but low on worker safety. Similarly, studies have shown that perception of culture varies between departments and units within organizations (for example, ICUs may have a stronger safety culture than medical/surgical floors) and by type of respondent (physicians may have higher perceptions of safety culture than nurses)." (Singer, et al. 2009) Changing an institutional culture can be challenging, as this breadth and depth of change takes time, resources, and stakeholder buy-in.

A conceptual model developed by a team of interdisciplinary scholars as part of the Agency for Healthcare Research and Quality (AHRQ) research portfolio, The Effect of Health Care Working Conditions on the Quality of Care shows the structural and process factors that affect outcomes for both workers and patients. Some of the relationships are direct, while others are indirect. For example, leaders have a direct effect on work design and quality emphasis, which in turn indirectly affects patient outcomes. Leaders also have a direct effect on worker outcomes, such as satisfaction and intention to leave; workers then have a direct effect on patient outcomes. As the Joint Commission monograph says, "Given that poorer safety culture and working conditions are associated with undesirable outcomes for workers, and undesirable worker outcomes are associated with poorer patient outcomes, it stands to reason that healthcare organizations preoccupied with safety should not focus on patient safety alone. HROs must recognize the inseparable integration of worker safety and patient safety and address worker health and safety as well as patient safety."

An increasing number of hospitals are discovering that they can demonstrate return on investment (ROI) for implementing quality improvement strategies, and that it is cost-effective to invest in capital equipment and/or lengthy employee-driven process improvement initiatives. According to the Joint Commission monograph, there are many concrete ways to demonstrate ROI of a safety culture, including:

1. Sharps injury prevention
- Examples of strategies: Sharps with engineered sharps injury protections; blunt suture needles to prevent needlesticks, surgical
injuries; minimize hand transfers of surgical instruments in the operating room
- The potential benefit to patients: Decreased exposure to bloodborne pathogens
- The potential benefit to healthcare workers: Decreased exposure to bloodborne pathogens
- The potential benefit to the healthcare organization: Decreased worker compensation claims, insurance costs; decreased litigation; improved safety culture

2. Infection prevention
- Examples of strategies: Healthcare worker immunization; hand hygiene; standard precautions; personal protective equipment
- The potential benefit to patients: Decreased transmission of pathogenic organisms from workers to patients and patients to patients
- The potential benefit to healthcare workers: Decreased transmission of pathogenic organisms from patients to workers
- The potential benefit to the healthcare organization: Increased adherence to guidelines; fewer sick days; lower externally reported infection rates; less risk of financial penalties in pay-for-performance initiatives

3. Active surveillance, analysis and feedback of adverse events, environmental hazards and risks
- Examples of strategies: Reporting near misses; safety rounds; periodic health and safety inspections
- The potential benefit to patients: Fewer hazards and adverse events in patients
- The potential benefit to healthcare workers: Fewer injuries and illness; increased satisfaction
- The potential benefit to the healthcare organization: Increased opportunities to intervene before harm occurs; better
quality data; improved compliance with regulatory and oversight bodies; improved safety culture

4. Appropriate staffing levels, mix and workload assignments
- Examples of strategies: Work-hour restrictions, evidence-based shift length, rotation, rest periods
- The potential benefit to patients: Lower mortality (failure to rescue); fewer fatigue-related adverse events; increased patient satisfaction
- The potential benefit to healthcare workers: Decreased stress and burnout; enhanced morale, quality of work life
- The potential benefit to the healthcare organization: Decreased turnover; decreased absenteeism, work-related illnesses; improved publicly-reported patient satisfaction; increased market share; improved safety culture

5. Improving safety culture/climate and teamwork
- Examples of strategies: Engaging workers and engaging patients in safety activities; leadership rounds; daily huddles
- The potential benefit to patients: Fewer adverse events; increased satisfaction
- The potential benefit to healthcare workers: Enhanced morale, employee satisfaction; decreased fatigue and burnout
- The potential benefit to the healthcare organization: Improved patient and worker outcomes; decreased litigation; improved reputation; decreased turnover

The monograph explores certain healthcare hazards that are appropriate for the infection control community; let's take a closer look:

Sharps Injuries and Infection Transmission
Sharps injuries and bloodborne pathogen exposures present a serious concern for healthcare workers and patients. Data from the World Health Organization (WHO) indicates that worldwide, 2 million out of 35 million healthcare workers experience percutaneous exposure to infectious diseases each year while the Centers for Disease Control and Prevention (CDC) estimates as many as 385,000 sharps injuries are incurred by hospital-based personnel each year in the United States. Evidence shows that there are successful strategies and interventions that dramatically reduce the risk of a sharps injury. A range of safety-equipped injection devices have been developed over the past 20 years. Coupled with ongoing educational efforts, there has been a reduction in injury rates. Frontline staff should be involved in the evaluation and selection of specific products. However, introducing safety devices alone is not enough. When possible, other methods of medication administration should be substituted. Healthcare organizations should provide administrative structures such as policies and procedures to support the consistent and effective use of selected safety devices.

Examples of interventions that successfully reduce the risk and incidence of sharps injuries and bloodborne pathogen exposures across health care settings are well documented. Administrative actions include the following:
Institute a systematic approach to bloodborne pathogen exposure prevention including: employee education programs, policies, and procedures to support injury prevention, reporting, and postexposure protocols.
Assess the organizations risks and injury experience through a review of available reports, injury surveillance, and staff survey.
Eliminate unnecessary invasive procedures in favor of safer alternatives when appropriate.
Organize a multidisciplinary quality improvement team, conduct a baseline assessment, set priorities of an action plan, and implement improvement interventions.
Assess the impact of prevention activities through feedback, data collection, and analysis, and modify activities as needed.
Offer vaccine to persons with the potential for exposure to HBV and other bloodborne pathogens.
Provide easy access to efficient systems for post-exposure prophylaxis to prevent HIV transmission. Examples of behavioral controls include the following: avoid recapping needles using two hands; use safe needle disposal methods and materials; use blunt suture needles instead of sharp ones; and use safety-engineered instruments when available and feasible.
Avoid hand-to-hand passing of instruments in the surgical settingcreate neutral zones or designated fields for instrument transfers to avoid simultaneous handling by personnel.

Safe Injection Practices are paramount to patient and healthcare worker safety.  As Perz, et al. (2010) observe, Preventing the spread of bloodborne pathogens, particularly hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), represents a basic expectation anywhere healthcare is provided. This is true both in terms of patient and provider protections. Healthcare should provide no avenue for the transmission of these potentially life-threatening infections; yet, unsafe medical practices continue to contribute to much of the worldwide disease burden that is associated with HBV and HCV.

As described by CDC, unsafe injection practices put patients and healthcare providers at risk of infectious and noninfectious adverse events and have been associated with a wide variety of procedures and settings. Investigations by state and local health departments and the CDC have identified improper use of syringes, needles, and medication vials when administering routine injections.

These practices have resulted in:
Transmission of bloodborne viruses, including HCV to patients
Notification of thousands of patients of possible exposure to bloodborne pathogens and recommendation that they be tested for HCV, HBV, and HIV
Referral of providers to licensing boards for disciplinary action
Malpractice suits filed by patients

The One & Only campaign, led by the Centers for Disease Control and Prevention (CDC) and the Safe Injection Practices Coalition (SIPC), focuses on educating healthcare workers about the following basic safety messages:
Do not use needles and syringes for more than one patient or reuse to draw up additional medication.
Do not administer medications from a single-dose vial or IV bag to multiple patients.
Limit the use of multi-dose vials and dedicate them to a single patient whenever possible.

Preventing Transmission of Infectious Diseases
As the monograph explains, "Infectious disease transmission by direct and indirect exposure is perhaps the most visible health risk underscoring the connection between healthcare workers and patients. Occupational health and infection preventionists (IPs) have traditionally worked toward shared goals of preventing, tracking, recording, and reporting (where indicated) the occurrence of infectious diseases in healthcare organizations. Epidemics, especially recent influenza outbreaks, have increasingly drawn these professionals together across healthcare organizations and settings. In fact, in a few organizations, these roles may even be combined, making a strong case example for the synergy between healthcare worker and patient health interventions. The increasing complexity of the healthcare environment has expanded the scope of work for IPs to include oversight of employee health services related to infection prevention. However, significant opportunities exist to enhance collaboration in preventing infection among healthcare workers, patients, and the community at large."

The monograph endeavors to recognize the shared goals and interventions that protect employees and patients from disease transmission and infection.
A consensus panel (Scheckler, et al. 1998) convened to develop recommendations for the infrastructure and essential activities for infection control in hospitals, identified the following goals of an infection control and prevention program:
Protect the patient.
Protect the healthcare worker, visitors and others in the healthcare environment.
Accomplish the previous two goals in a cost-effective manner, whenever possible.

The Joint Commission emphasizes that "These goals can be applied in any setting where patients and healthcare workers interact. Preventing the transmission of disease to individuals requires attention to the various modes of transmission. These modes include contact (direct and indirect), droplet and airborne. Infection control guidelines recommend implementation of infection control practices that have shown to decrease the transmission of infectious agents. However, several observational studies have revealed that adherence to these recommendations by healthcare personnel ranges from 43 percent to 89 percent, depending on the circumstance in which they were used. The CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings46 has noted that health care workers often perceive their compliance to be higher than actual observed performance. Traditional interventions that are used to increase compliance, such as education, enhance knowledge levels but may not change behaviors. Multifaceted approaches that combine new elements, such as engineering controls, facility design concepts, or the use of electronic monitoring and voice prompts for hand hygiene, are being explored." (Siegel, et al. 2007)

While there are numerous evidence-based resources related to HAI prevention, the Joint Commission monograph emphasizes the organizational safety culture as the platform upon which all interventions stand.  Siegel, et al. (2007) say that an organizational safety culture with a shared commitment to infection prevention for the safety of patients and workers is created through the following:

1. The actions management takes to improve patient and worker safety,
2. Worker participation in safety planning
3. The availability of appropriate protective equipment
4. Influence of group norms regarding acceptable safety practices
5. The organizations socialization process for new personnel

According to the Joint Commission monograph, interventions to prevent transmission of infectious diseases are often identified within a hierarchy of controls:

Administrative controls are directed at the early detection of infectious diseases in workers or patients and include screening mechanisms (such as medical histories), testing (such as a TB skin test), and policies and procedures detailing referral and treatment protocols.

Engineering controls include special building design (for example, isolation rooms) and mechanical systems\ such as high-efficiency particulate air (HEPA) filters and ventilation systems. Personal protective equipment (PPE) is sometimes the most practical means of preventing infectious disease transmission. The CDC emphasizes that the use of standard precautions is based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. These precautions include infection prevention practices that apply to all patients and all settings in which healthcare is delivered. Prevention practices include hand hygiene; use of gloves, gown, respirators, masks, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Hand hygiene is often noted as the most important practice to reduce the transmission of infectious agents in health care settings as well as being an essential component of standard precautions. Hand hygiene includes both handwashing with either plain or antiseptic-containing soap and water, and the use of alcohol-based products (gels, rinses, foams) that do not require the use of water. Hand hygiene is a critical activity for healthcare personnel, but it is also important for patients and visitors. Using physical barriers and PPE protects workers and patients from exposure and possible disease transmission. A robust infection prevention and control program is built on coordination between occupational and infection preventionists and deploys multiple strategies within a hierarchy of controls.

The monograph describes barriers to recognizing and addressing patient and worker safety issues and suggests strategies to overcome them and make safety a priority. In addition, the monograph recommends action steps that healthcare organizations can take to improve safety for both patients and workers, as well as topics for future research. Work on the monograph, which was supported in part by the National Institute for Occupational Safety and Health (NIOSH), National Occupational Research Agenda (NORA) Healthcare and Social Assistance Sector Council, began with a national call soliciting effective  or innovative safety practices from a wide range of settings that address both patients and workers. These practices were related to topics such as worker and patient safety culture, worker and patient satisfaction, injury prevention, infection prevention, performance improvement and individual engagement in safety activities.

The breakdowns that put both patients and workers at risk are often the same. In order to truly improve healthcare, organizations must implement a system-wide culture of safety, says Jerod M. Loeb, PhD, executive vice president of the Division of Healthcare Quality Evaluation at the Joint Commission. By identifying the causes of breakdowns and near misses, we can learn how to make a real difference.

The monograph, Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation can be downloaded at: http://www.jointcommission.org/improving_Patient_Worker_Safety/.

References

Chassin MR, Loeb JM. The ongoing quality improvement journey: Next stop, high reliability. Health Aff (Millwood). 2011 Apr;30(4):559-568.

Hines S, Luna K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Rockville
(MD): AHRQ Publication. 2008 Apr; No. 08-0022. Contract No.: 290-04-0011. Available from: http://www.ahrq.gov/qual/hroadvice/.

Institute of Medicine, Committee on Quality of Health Care in America. National Academy Press; 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Available from: http://www.nap.edu/catalog.php?record_id=10027.

Perz JF, Thompson ND, Schaeger MK, Patel PR. US outbreak investigations highlight the needs for safe injection practices and basic infection control. Clin Liver Dis. 14 (2010) 137-151. Page 137.

Reason J. Human error: Models and management. BMJ. 2000;320:768-770.

Scheckler WE, Brimhall D, Buck AS, Farr BM, Friedman C, Garibaldi RA. Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: A consensus panel report. Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol. 1998 Feb;19(2):114-124.

Siegel JD, Rhinehart E, Jackson M, Chiarello L; Health Care Infection Control Practices Advisory Committee. 2007 Guideline for isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control. 2007 Dec; 35(10 Suppl 2):S65-164.

Singer SJ, et al. Patient safety climate in 92 hospitals differences by work area and discipline. Med Care. 2009;47(1):2331.
 
Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: Processes of collective mindfulness. Res Organizational Behav. 1999;21:81-123.

Infection Preventionists Can Cultivate a Safety Culture: A Q&A with Barbara Braun

Barbara I. Braun, PhD, project director of the Department of Health Services Research, Division of  Healthcare Quality Evaluation at the Joint Commission, shares her perspectives about

Q: What do you believe are the critical gaps in knowledge pertaining to patient and worker safety and infection control?

A: Many healthcare organizations not just hospitals, but all settings and services may not have considered the potential synergies and value of investing in improvements that address both worker and patient safety in important areas like infection control. In The Joint Commissions new monograph, Improving Patient and Worker Safety:  Opportunities for Synergy, Collaboration and Innovation, specific examples of where patient and worker safety can be improved are highlighted in table 1-3, on page 13. These examples include fall prevention, safe patient handling, infection prevention, sharps injury prevention, active surveillance for environmental hazards, and improving civility, respect and teamwork. Regarding infection prevention, the monograph discusses improvement strategies for worker immunization, hand hygiene and personal protective equipment, just to name a few.

Q: How does the monograph help address these gaps?

A: The monograph helps raise awareness in the healthcare industry about common health and safety risks that are shared by patients and healthcare workers. Through its literature references and links to effective resources, readers can learn more about the synergies in health care between worker and patient safety in specific topic areas and about making safety a core organizational value, which is characteristic of highly reliable industries. The monograph highlights case studies from healthcare organizations that have successfully implemented initiatives to reduce their injuries and increase patient and worker safety.

Q: How can infection preventionists educate their peers and colleagues so that more than just lip service is paid to an organizational safety culture?

A: Infection preventionists and others can also use this monograph to review their functional management systems and processes, strategies, and implement tools for improvement that have already been used to successfully integrate health and safety activities at other organizations. The monograph not only provides recommendations for improved safety using the principles of a safety culture, but provides proven solutions and improvement results at healthcare organizations who strengthen their safety culture.  Additionally, the Joint Commission has several free resources on its website (http://www.jointcommission.org/highreliability.aspx) that address the important role of leadership in improving safety culture. Experts recommend that culture change be approached both top-down and bottom-up. Infection prevention and employee health staff can help drive measurable improvements by employing safety culture methods. The monograph itself includes examples of tools that are available for healthcare professionals to measure these improvements.

Q: How critical is risk management to infection control and patient safety? How can it be integrated into daily practice?

A: An effective surveillance system for identifying adverse events is an essential function for risk management, quality improvement and patient safety.  The field of infection control is fortunate to have a validated event reporting system the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) that facilitates comparative reporting of patient infection-related rates and process information using standardized methodologies. Many are not aware that the NHSN also has modules for monitoring healthcare worker safety that can assist healthcare facilities with monitoring and reporting trends in body fluid exposures; assessing the impact of preventive measures; categorizing antiviral medication use for exposures to influenza, monitoring influenza vaccination percentages among health care personal; and generating exposure reports for individual medical records and OSHA-300 or equivalent reports. (Visit: http://www.cdc.gov/nhsn/hps.html/)

Q: Quality improvement, value-based purchasing, pay-for-performance are these economic concepts driving patient safety efforts in the right direction and can they co-exist with clinical imperatives?

A: The focus of the monograph is to provide health care organizations with information and resources that address safety and quality improvement for both health care workers and patients through safety culture and high reliability methods. The information it provides is not meant to address compliance strategies for value-based purchasing or pay-for-performance.