How to Create a
Culture of Safety
Michael Leonard, M.D. – Expert
Faculty for the Institute for
Healthcare Improvement (IHI) and
Adjunct Professor of Medicine,
Duke University School of Medicine
Creating a Culture of Safety
Michael Leonard, MD,
Pascal Metrics
Adjunct Professor of Medicine, Duke University
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 Safety is a characteristic of a sociotechnical system
 System-level failures occur almost always because of
unforeseen combinations of component failures
©2012-13 Developed cooperatively by Mayo Clinic and Pascal Metrics, Inc.
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Evolution of A Culture of Safety
GENERATIVE
Organizational Culture “Genetically-wired” to
produce safety
PROACTIVE
“We methodically anticipate”— prevent
problems before they occur
SYSTEMATIC
Systems being put into place
to manage most hazards
REACTIVE
“Safety is important. We do a lot every
time we have an accident”
UNMINDFUL
“We show up, don’t we?”
Chronically Complacent
WHERE ARE YOU?
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Patient & Family Centered Care
GENERATIVE
Organizational Culture “Genetically-wired” to
produce safety
PROACTIVE
“We methodically anticipate”— prevent problems before
they occur
SYSTEMATIC
Systems being put into place to manage most
hazards
REACTIVE
“Safety is important. We do a lot every time we have
an accident”
UNMINDFUL
Chronically Complacent
• Truly patient-centered care,
it’s all about them, a true
partnership
• Structured process for patient
& family at the table, input is
valued, results visible
• Care process visible to the
patient, learning and feedback
process is sporadic
• Customer service is a focus,
PFCC is not incorporated in a
meaningful way
• Care process built around the
convenience of the providers,
not patients and families
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Putting Patients and Families First
Anthony Digioia - Total Joint Program - UPMC
Patient centered, reliable care process with teamwork and
safety
Seeing the process through the patient’s eyes
Standardization and continual learning
Workgroup involves all involved in the care of the patient –
weekly, multidisciplinary meetings
Teamwork and safety principles key components – huddle
around every patient to plan individualized care
HCAPS – 91 overall, 99% antibiotics admin, D/C within 24
hrs. Infection rate 0.3 % ( aver. 0.8-2.5% )
High functional status at D/C, 93% walking without handheld
assistance; LOS 2.8 TKR, 2.7 THR, 91% D/C home
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Senior Leadership
GENERATIVE
Organizational Culture “Genetically-wired” to
produce safety
PROACTIVE
“We methodically anticipate”— prevent problems before
they occur
SYSTEMATIC
Systems being put into place to manage most
hazards
REACTIVE
“Safety is important. We do a lot every time we have
an accident”
UNMINDFUL
Chronically Complacent
• Systematic, structured, cyclic
flow of information with
feedback and learning
• Methodical engagement with
dialogue and learning
• In the conversation with front
• line
In the
conversation with
staff
front line staff
• The suits are here – something
bad must have happened
• Where are they? Who are
they?
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CLINICAL UNITS WITHIN THE SAME HOSPITAL
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Culture Matters
9
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High
Low
Psychological Safety
Characteristics of High Performing Cultures
Comfort Zone
Learning Zone
Everyone works well together,
but assumes good care is
delivered, no need to waste
time insuring safety and
quality
Optimal, safe care is a team
effort, all mistakes are
reported so they can be
discussed & new ways are
identified to avoid future
problems
Apathy Zone
Anxiety Zone
No one is interested or willing
to coming up with more
efficient & safe ways to work
or learning from mistakesthat’s managements job
Mistakes are a sign of
personal weakness and will
be punished so they are
covered up and go
unreported
Low
High
Accountability
©2012 Developed cooperatively by Mayo Clinic and Pascal Metrics, Inc.
Source: Edmonson, A.C. “The Competitive Imperative of Learning,” HBS Centennial Issue. Harvard Business Review 86, nos. 7/8 (2008)
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360-degree View: Identify and Prioritize Highest
Risk Units
Geriat
Target
L&D
Prioritize
Safety Climate Score
Admin
ORs
Lab
PACU
Med Unit
Peds
Cardiopulm
Surg Unit
Teamwork Climate Score
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CULTURE
IS RELATED TO…
Teamwork Climate Scores Across Facility
98
CCU
REHAB
OR
EMERG
5 WEST
6 WEST
PEDS
GERI
DIALYSIS
PERIOP
PHARM
3WEST
ICU
NICU
SICU
PEDS
OB
100
73 75 80
80
62 62
55
52
51
60
45 45 49 49
41
36
40 28 33
20
0
HCAHPS
50
92
Medication Errors per Month
6.1
2.0
Days between C Diff Infections
40
121
Days between Stage 3 Pressure Ulcers
18
52
Illustrative Data:
Extracted from
Blinded Client Data
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AND
UNFAVORABLE EMPLOYEE OUTCOMES
Teamwork Climate Scores Across Facility
100
80
75
73
80
62 62
55
52
51
60
45 45 49 49
41
36
40 28 33
20
0
98
<60% Score =
Danger Zone
CCU
REHAB
OR
EMERG
5 WEST
6 WEST
PEDS
GERI
DIALYSIS
PERIOP
PHARM
3WEST
ICU
NICU
SICU
PEDS
OB
…
Employee Satisfaction
55
91
Employee Injury per 1000 days
16
0.1
Employee Absenteeism per 1000 days
15
10
RN Vacancy Rate
9
1
Illustrative Data:
Extracted from
Blinded Client Data
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Using Cultural Data and Teamwork to
Drive Improvement
2009 Percent Favorable
2010 Percent Favorable
2010 Hospital Partner
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Areas of Clear Focus and Action
Effective Clinical Leadership
Psychological Safety
Comfort Learning from Errors
Teamwork Behaviors
Continual Learning and Improvement
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Socio-Technical Framework:
Clinical Leadership
GENERATIVE
Organizational Culture “Genetically-wired” to
produce safety
PROACTIVE
“We methodically anticipate”— prevent
problems before they occur
SYSTEMATIC
Systems being put into place
to manage most hazards
Team leaders create high
degrees of psych safety and
accountability
Leaders consistently model and teach
effective behaviors
Leadership training available, taught
and a priority
REACTIVE
“Safety is important. We do a lot every
time we have an accident”
UNMINDFUL
“We show up, don’t we?”
Chronically Complacent
Sporadic, based on individuals
Noticeably absent
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Surg Tech
Support
Staff
Surgeon
OR Nurse
Anesth MD
Anesth Tech
< 5 Respond
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Leaders
The associated behaviors:
GENERATE TRUST
Open; Honest; Approachable
PROMOTE RESPECT
Non-negotiable; Non-hierarchical
PSYCHOLOGICAL SAFETY
Responsive to team members speaking
up about concerns and ideas
JUST CULTURE
Clear policy and practice of fair
treatment and accountability
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Socio-Technical Framework:
Psychological Safety
GENERATIVE
Organizational Culture “Genetically-wired” to
produce safety
PROACTIVE
“We methodically anticipate”— prevent
problems before they occur
SYSTEMATIC
Systems being put into place
to manage most hazards
REACTIVE
“Safety is important. We do a lot every
time we have an accident”
UNMINDFUL
“We show up, don’t we?”
Chronically Complacent
Primary function of leaders –
continuously modeled throughout the
organization
Leaders model and expect behaviors
promoting psychological safety
Awareness that speaking up, voicing
concerns is important
Personality dependent – depends who
I’m
working with
Fear based – keep your head down –
Don’t speak up
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In virtually every episode of serious
avoidable harm or death, someone knew
there was a problem and was unable to get
the team to respond appropriately in a
timely manner.
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Psychological Safety Is Local
© 2012 Pascal Metrics
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Psychological Safety
Psychological safety is a belief that one will not be
punished or humiliated for speaking up with ideas,
questions, concerns, or mistakes.
A shared sense of psychological safety is a critical
input to an effective learning system.
Psychological Safety and Learning Behavior in Work Teams. Administrative Science Quarterly, Vol. 44,
No. 2 (Jun., 1999), pp. 350-383
Amy Edmondson
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Psychological Safety
We are our own image
consultants and best
image protectors
To protect one’s image, if you don’t want to look
STUPID
Don’t ask questions
INCOMPETENT
Don’t ask for feedback
NEGATIVE
Don’t be doubtful or criticize
DISRUPTIVE
Don’t suggest anything innovative
PSYCHOLOGICAL SAFETY CHANGES THIS PARADIGM
Source: Amy Edmondson
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Psychological Safety
We are our own image
consultants and best
image protectors
To protect one’s image, if you don’t want to look
STUPID
Don’t
Ask questions
ask questions
INCOMPETENT
PSYCHOLOGICAL
NEGATIVE
SAFETY
Don’t
Ask for
ask
feedback
for feedback
DISRUPTIVE
Don’t
Be innovative
suggest anything innovative
Don’t
Be doubtful
be doubtful or criticize
Source: Amy Edmondson
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Socio-Technical Framework:
Organizational Fairness / Just Culture
GENERATIVE
Organizational Culture “Genetically-wired” to
produce safety
PROACTIVE
“We methodically anticipate”— prevent
problems before they occur
SYSTEMATIC
Systems being put into place
to manage most hazards
REACTIVE
“Safety is important. We do a lot every
time we have an accident”
UNMINDFUL
“We show up, don’t we?”
Chronically Complacent
Leaders share events, model a culture
of accountability, learning is the
priority
Safe to discuss error, individual v.
system error clear
Algorithm present and used, learning
more important
than blame
Depends on who I’m working with,
errors usually lead to blame and
punishment
Nothing good will come from talking
about mistakes, somebody’s in trouble
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SURGICAL SERVICE LINES WITHIN THE SAME ORGANIZATION
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Perspectives on Human Error – Sidney Dekker
Old View
New View
• Human error is a cause
of trouble
• Human error is a symptom
of deeper system trouble
• You need to find people’s
mistakes, bad judgments and
inaccurate assessments
• Instead, understand how their
assessments and actions made
sense at the time — context
• Complex systems are
basically safe
• Complex systems are basically
unsafe
• Unreliable, erratic humans
undermine system safety
• Complex systems are tradeoffs
between competing goals —
safety v. efficiency
• Make systems safer by
restricting the human
contribution
• People must create safety
through practice at all levels
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VERY UNSAFE SPACE
100%
Agreement
Non acceptable
Usual Space
Of Action
Expected safe
space of action
as defined by
professional
standards
Real Life standards
60-90%
Safety Reg’s &
good practices,
accreditation
standards
ACCIDENT
LOW
100%
‘Illegal normal’
Individual Benefits
HIGH
Systemic Migration of Boundaries:
Deviation is Normal
HIGH
Production Performance
LOW
Rene Amalberti, MD, PhD
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Little Things Can Cause Big Problems
Room 20
Look out the window
A simple knee scope
He’s OK – he’s not too sedated - you go home
What it says on the box is not what’s in the box
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Drawing the Bright Line
Repeat
Events
Malicious
Substance Use
Remediate /
replace
Conscious unsafe act
Substitution Test could 2-3
others make the same mistake
in similar circumstances?
Reason, James
Safe Harbor –
Systems
Approach
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Socio-Technical Framework:
Effective Teamwork
GENERATIVE
Organizational Culture “Genetically-wired” to
produce safety
PROACTIVE
“We methodically anticipate”— prevent
problems before they occur
SYSTEMATIC
Systems being put into place
to manage most hazards
REACTIVE
“Safety is important. We do a lot every
time we have an accident”
UNMINDFUL
“We show up, don’t we?”
Chronically Complacent
Highly functional teams with
systematic, continuous learning
Methodical implementation and
reinforcement of team behaviors
Teamwork tools and training available,
partial adoption
Awareness and teamwork training
after adverse events is the norm
Individual expert model – “Just do
your job and everything will be fine”
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TEM Teams
The associated behaviors:
PLAN FORWARD
Brief (rounding, huddle, pause,
timeout, check-in)
REFLECT BACK
Debrief
COMMUNICATE CLEARLY
Structured Communication
SBAR and Repeat-Back
MANAGE CONFLICT
Structured Critical Language
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Repeat Back
Ensuring transmission
and reception of information
is clear and accurate
• All drug names
• All numbers
(patient ID, dosages,
etc.)
• Clinical histories
• Handoff information
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Critical Language
A PHRASE THAT STOPS THE WORK
“I need a little clarity.”
“I am concerned or unclear. This is unsafe.”
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Debriefing
Ask three questions:
What did we do well?
What did we learn?
What do we want to
do differently tomorrow or next
time?
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THE IMPACT OF ACTING ON SAFETY CULTURE
DATA IN RHODE ISLAND ICUS
ICUs that DEBRIEFED
ICUs that did not DEBRIEF
Change in survey scores
Reflected on culture scores and took
action
1. >15% culture score increase in 5/7
domains
2. >10% BSI reduction
3. >15% VAP reduction
*
*
Did not reflect on SAQ scores nor take
action
1. 5% culture score drop in 5/7
domains
2. No reduction in BSIs
3. 5% increase in VAPs
*
*
Vigorito-Cornell
et al.
©2012 DevelopedAttribution:
cooperatively byM.
Mayo
Clinic and Pascal Metrics,
Inc.Improving
*
safety culture results in Rhode Island ICUs: lessons
learned from the development of action-oriented plans. Jt Comm J Qual Patient Saf. 2011 Nov;37(11):50937
Socio-Technical Framework:
Process Improvement
GENERATIVE
Organizational Culture “Genetically-wired” to
produce safety
PROACTIVE
“We methodically anticipate”— prevent
problems before they occur
SYSTEMATIC
Systems being put into place
to manage most hazards
REACTIVE
“Safety is important. We do a lot every
time we have an accident”
UNMINDFUL
“We show up, don’t we?”
Chronically Complacent
Unit level continuous learning,
improvement, org. alignment
Robust unit level learning and
improvement the norm, linking
opportunities to action
Knowledge of process improvement,
testing, collaborative work
We try harder when faced with
performance gaps or adverse events
Simple things don’t get fixed, lots of first
order problem solving
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Learning is Visible in Healthy Work Areas
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Acute Medicines Unit, Ninewells Hospital, Dundee,
Scotland - Arun Chaudhuri, Medical Director
Hand Hygiene
DVT Prescribing
Compliance
Bld Culture
Contamination
Compliance with
Med. Reconciliation
Early Warning
Scores Bundle
O2 Prescribing
Pressure Ulcer
Prevention Bundle
?
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The Learning Board
© 2012; Mercy Medical Center, Cincinnati, OH
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