Modern Hospitals’ Safety Culture
Dr. Díaz, Carlos Alberto.
Castilla, Rodrigo Alberto. MD.
Patient safety is a key component of healthcare quality in modern hospitals. In order to establish a safety culture, it is essential to implement a patient centred model, based on robust and trustworthy LEAN processes. In this article the previous requirements and the actions needed to create a shared vision and mental model are discussed. The international recommendations include leadership, a group of safety experts, indicators development, monitoring and result assessment, technology investment, improved communication skills, and more. However, the first and probably most important step is to be able to recognize the need and possibility of change, and act upon it, by incorporating patient safety as a strategic priority and assigning resources to achieve continual improvement in the issues it concerns.
Modern hospitals’ care delivery processes must be patient-centred, safe, based on stable procedures, efficient and cost-effective. Their organisation must follow a servuction model and the principles of LEAN management. In order to achieve this makeover, it is necessary to transform the “individual medical deontology” logic, into a new logic, in which multidisciplinary teams are supported by health’s senior managers, whose leadership values include a strategic compromise with patient safety. Furthermore, safety should not be punitive. It should be a culture in which errors are allowed and actions are taken in order to prevent them. This culture, which needs the implementation of a person centred and patient safety programmes, , , , will definitely lead to an improvement of the population’s quality of life , .
The medical profession has undergone, in the last few decades, a remarkable change. It used to be simple, ineffective, and relatively safe. At present, it has become complex, very effective, and potentially dangerous . A zero error health policy is impossible: where there is human participation, there are mistakes. Workplaces are not the exception. However, many of these errors may be prevented by designing systems and processes in which an error is hard to make . These types of systems are usually seen in the aviation industry, especially in the operations area. By comparison, the health industry has led a slower progress in these matters. Virgilio (2011)  pointed out that the death risk in an airline flight is between 1:3,000,000 and 1:10,000,000, while, in medicine is between 1:300 and 1:3,000.
Globally, between 187 and 281 million major surgeries are performed each year. There is a 3-16% complication risk, and 0.4-0.8% of the patients is left with severe sequels. Mortality in patients who have undergone a major surgery is significantly higher than in those of similar age and gender who have not. In a systematic review which included 70,000 medical histories, in-hospitals adverse events constituted 9.2% of the 43.5% which were preventable . At present, the average risk associated with major anaesthesia is between 1.37:100,000 and 4.7:100,000, but its range goes from 0.5:100,000 to 55:100,000 in patients with an ASA 1 and ASA 4 risk classification, respectively . These results lead to the necessity to understand patient safety as the group of tools and actions that are meant to eliminate, reduce or mitigate adverse events caused by healthcare delivery processes .
One of the main developments made by quality of hospital care experts has been the person-centred model, which is based on:
- Individualised care,
- Strong agency relationship between hospitals and its employees, and between them and the patients,
- Top medical and nursing performance,
- Patient safety programmes , ,
- LEAN design of healthcare and administrative processes, with reduced wastes and inefficiencies , , , .
Healthcare quality is presently considered to consist of 4 different logics or perspectives. These are: technique, efficiency, perception and safety. The first two are part of the classic healthcare quality definition. However, the last two are innovative tools which are now being used to enhance hospitals’ performance. The perception logic combines both the patients’ and the employees’ viewpoint. In order to satisfy the patients, an integrated medical assistance, with a close doctor-patient relationship, focus on nursing cares, and a compromised multidisciplinary team, is mandatory. In contrast, employees’ perception is based more on positive, safe workplaces which do not lack the minimum materials, proactive use of technologies, and continuing education, such as classes or even academic courses.
Institutions which have recently started their way towards improvement should focus on establishing a patient safety culture, and on eliminating frequent barriers in change management. A transparent attitude towards errors is needed to discover and repair failures in the processes, whether it is done by remodelling or renovation. All errors must be analysed by proper techniques, and the employees must be trained after the corrections have been made. This way, healthcare quality can be guaranteed and made visible , , .
Transparency and disclosure towards medical errors are relevant components of the new paradigm, which leaves behind the professionals’ conventional individual autonomy. This new paradigm is built upon multidisciplinary teamwork, with increasing participation of patients and their families through an effective communication system. This inclusion enhances the construction of a safer patient environment , .
The previous paragraphs are but a reflection of the current bibliography, and they strengthen the affirmation that patient safety is a pillar of healthcare quality, and must be included in any person-centred model , .
The Lucian Leape  institute proposed five general principles required to transform hospitals and clinics into trustworthy organisations. These are:
- Transparency and disclosure towards medical errors and healthcare quality issues,
- Integrated healthcare in all teams and disciplines,
- Patient inclusion in healthcare teams,
- A positive workplace, which restores the joy of work,
- An education reform in medical sciences, with an innovative approach towards patient safety and healthcare quality.
How to Implement a Safety Culture
Requirements , , .
- A relevant amount of safe practises, precisely done, which do not differ with the variations of time or date.
- Identified high risk activities, and focus on their prevention.
- A shared vision of change and improvement; a general belief of reduced patient injury as a possible achievement.
- A non punitive environment in which individuals are free to report not only their fellow workers’ errors but their own as well.
- Senior managers’ involvement in safety culture: leadership, economical funding, resource assignation, incentives.
- Safe and effective communication between employees.
- Empowerment for the processes’ supervisors.
- Establish patient safety culture as a strategic priority
- Patient safety should be included in a top priority position in the annual strategic plan, framed in a multidisciplinary context with a shared vision .Team members used to collaborate and learn together have a higher impact on patient safety improvement.
- A senior manager ought to be made responsible of safety management, and he should present periodic reports to the executive board.
- Remuneration should be linked to safety objectives’ fulfilment.
- Key programmes should be designed, and should have a close follow-up
- Human resources’ recruitment and selection policies should be adapted to the institution’s patient safety culture. Once hired, new employees should attend a patient safety training session devised for them.
- Time should be spent in workplace inspection and personnel interrogation, in order to detect any safety breach and promote the culture.
- Patient safety successes should be shared with the objective to incentivise other areas to change and improve.
- Encourage a culture which values include: healthcare quality, patient safety, and efficiency .
This is one of the most important steps towards performance enhancing. Furthermore, it creates an institutional trustworthy image, which patients appreciate.
The initial culture ought to be measured before designing any programme. There are many regulations believed to be strictly complied with. However, in reality, these are often bypassed .
Examples of practises that foment the creation of a safety culture are:
- Patient identification.
- Standardised hand-offs .
- Surgical safety checklist .
- Safe sterilisation and preparation of surgical instruments.
- Safe patient logistic.
- Continuity of care programmes based on progressive care units: prehospital, inhospital and posthospital care.
- Pre-operative protocols.
- Electronic clinical history and on-line drug prescription validation.
- Safe medication administration.
- Safety bundles  for central venous accesses , , urinary catheters, mechanical ventilation.
- Falls prevention , .
- Phlebitis and skin ulcers prevention and follow-up.
- Promotion of rational use of medicines .
- Clinical guidelines development.
- Continuous patient education.
- Standardised shift to shift handoffs and sign outs , .
- Infrastructural risk management: security, water treatment, air quality, etc.
- Standardised healthcare providers’ accreditation.
- Safety education teams, with regular and incidental teaching sessions for employees.
- Formalisation of institutional regulations.
- Information access facilitation.
- Build an appropriate organisational infrastructure.
Organisational infrastructure is the collection of procedures that allow the application of knowledge. Modern organisations must be receptive to continuing education and constant innovation, because clear competences are needed to enhance healthcare quality and organisational infrastructure .
Old technology must be replaced for newer, safer technology. This replacement should lead to an improvement in healthcare quality and patient safety. However, this is not always the case. Patient safety can be compromised if there are any weak links in the chain in which the whole professional team plays a vital role. An accurate implementation and integration of new technology must be ensured. This will be determined by the understanding of the new procedures by the operators and the safe application of their knowledge.
Poka-Yoke and Jidoka procedures reduce human error to a minimum rate , , and should be employed as much as possible.
- Set clear roles and responsibilities.
A patient safety team must be developed in order to establish this culture in any organisation. This team should be empowered to work and act upon the strategic lines of action, especially focused on the close monitoring of the indicators which measure the compliance of the institution’s regulations. These, and the organisational policies, should be known by every employee. In addition, patient safety teams should be in charge of the follow-up on specific issues determined by each institution.
- Create a Health and Safety Committee .
A modern hospital should set up a health and safety committee. Its mission ought to be the identification of safety risk patterns and tendencies, in order to efficiently assign priorities and resources. This group of workers should organise periodic presentations to the executive board and senior managers.
The safety committee should include:
- Members with the following qualities and characteristics:
- Leadership and authority, predisposition to change;
- Continuing encouragement of good practises; and
- Other personnel’s support, allowing them to execute the committee’s decisions.
- Multidisciplinary members, who represent each of the hospital’s areas: administrative, medical, nursing, logistics, hospitality, etc.
- A director with a degree in medical sciences or nursing. However, his or hers most important quality should be the personnel’s support.
- Start a Crisis Committee
A Crisis Committee should be started, and reunions organised with a monthly periodicity or immediately, if any crisis should occur. In addition, rapid response teams should be formed. Their members must be continuously supported by external senior managers, lawyers or specialists.
The Rapid Response Team’s functions and responsibilities should be:
- Answering every adverse event call, or any situation which compromises patient safety.
- Encouraging Incident Report Form’s filling to increase the measurement of these situations.
- Continuing education of the hospital’s personnel, guaranteeing an effective response in a crisis situation, 24 hours a day, the seven days of the week.
- Interviewing the patient’s family and explaining to them the holistic work done in the institution.
- Ensuring external medical support, not only within the institution.
Every modern hospital employee should be prepared and encouraged to report incidents, whether it is because of their own error or not. This is a crucial aspect, because the prevention of future errors depends exclusively on the knowledge gained from past errors. Employees must feel they will not be reprimanded for their reports but, on the contrary, congratulated for their contribution. Continuous education must be offered to them, with classes, training and the application of information technology .
- Design trustworthy, robust and controllable healthcare processes
Every healthcare process must be trustworthy, robust, and controllable . Safety checkpoints must be placed in each of the hospital’s areas , whose members must be committed to the compliance with the rules , . This way, it is easier to ensure the effectiveness of risk reduction policies in every aspect of the clinical management . The involvement of the patient’s family in this aspect is mandatory to continue the development of safety culture in an out-hospital environment.
The following processes must be monitored with specific indicators periodically updated, in order to continuously try to improve the result:
- Electronic, standardised, shift to shit hand-offs , ;
- On-line drug prescription validation;
- Healthcare assistance peer control;
- Patient identification;
- Predesigned bundles according to each organisation’s requirements;
- Surgical safety checklist;
- Healthcare associated infections;
- Pre-discharge patient education: medication administration, nutritional processes, mobilisation techniques, etc.
- Develop safe and effective communication skills , .
Communication is one of the main healthcare quality and patient safety competences the providers must have. Communication must be complete, clear, concise and opportune. Complete means that it must contain all the relevant information, including any questions that need to be made and their answers. Clear, because simple and direct language must be used, without abbreviations, or expressions that would lead to confusion. Also, the interlocutor’s comprehension must be checked. Concise, for it should avoid unnecessary information and possible wastes of time. Finally, it must be opportune, delivering the right information at the right time.
The barriers to effective and safe communication in healthcare are:
- Interruptions, which bias the interpretation and comprehension.
- Restricted or secretive conversations, in which key aspects are left out.
- Verbal hostility, which creates a negative work environment and discourages incident reporting. Besides, it can create conflicts between team members.
- Personnel’s fatigue, which reduces healthcare quality. This is especially often in nurses, who frequently have more than one job.
- Unclear roles and responsibilities in a multidisciplinary team.
- Frequent changes in a team’s structure, which bias team members’ relationships.
- Excessive workloads.
- Working conditions, which have a notorious relevance in the employees’ attitude.
- Technological problems, in written communication.
Fluid, safe and effective communication skills must be used in every hospital area: operating theatre, emergency rooms, diagnostic imaging rooms, ambulatory consulting rooms, etc . Communication skills should be focused on patient safety issues, which should be discussed in the committees. In addition, all available data must be gathered before these sessions, such as: patients’ and their family’s testimony, clinical history, surgery report, even video records if it is necessary.
Communication skills must be used to attend the causal factors of healthcare errors, which are :
- Inconsistent information transmission.
- Lack or inadequate healthcare planning.
- Non-compliance with the safety rules.
- Excessive workload.
- Lack of personnel.
- Multicultural healthcare providers.
- Damaged or worn healthcare technology.
Instances in which safe and effective communication skills urgently need to be applied in modern hospitals are:
- Development of a shared mental model and vision, both of which must be patient-centred.
- Strategic planning in clinical management.
- Discussion and setting of patients’ daily goals between team members and the patient and his or her family.
- Setting an objective observer in shift to shift and other hand-offs, who analyses not only communication skills but also group dynamics between team members
Lastly, the transition between levels of care should be improved, especially the responsibility over the patient hand-off. The consequences of an inadequate transition, which is caused in most cases by a communication failure between different healthcares team members, may lead to prolonged hospital stay or even unplanned readmissions. These healthcare inefficiencies endanger patient safety, diminishing healthcare quality and increasing hospital costs .
- Implement adverse events’ simulations for training teamwork skills , , .
Any organisation can benefit from different simulation of crisis situations because managers can appreciate how developed the members‘ shared vision and teamwork skills are. Possible simulations could be: hand-offs, patients’ falls, burns, medication administration errors, etc. The results observed in the simulations will enable the trainers to design specific programmes to strengthen the employee´s qualities and characteristics. These simulations should be recorded for academic purposes and kept under strict vigilance.
Healthcare quality is a combination of top medical and nursing performance, economic efficiency, patient safety, within a patient-centred model with increased customer satisfaction. Many have been the achievements and hard are the challenges that lie ahead of us. It will be impossible to move further on this path without appropriate organisational infrastructure , technology investment, continuing education, trustworthy processes, positive working environment, and inclusion of the patient and their families in healthcare programmes . Finally, senior managers and board directors will need to support this strategic plan through their leadership, and making decisions according to the reports made by patient safety experts.
 Physician. Public health specialist. Director of the Health Economics and Management specialisation, Universidad ISALUD, Buenos Aires, Argentina. Medical manager at Sanatorio Sagrado Corazón, Buenos Aires, Argentina.
 Physician. Health economics and management resident at Sanatorio Sagrado Corazón, Buenos Aires, Argentina.