Health system leaders often hear that it's their responsibility to champion a culture of patient safety, but what does that require?
Since the 1999 publication of the seminal report To Err is Human, healthcare organizations have pursued strategies to reduce their adverse event rates. Ultimately, industry leaders have asserted that a just culture of patient safety is necessary to support staff and improve outcomes, and that those changes must come from the top.
But following a long history of power hierarchies and punitive responses to errors and patient safety events, shifting to a just culture of patient safety will require actionable changes. After all, a just culture is characterized by a fair, non-punitive approach to accountability that foremost acknowledges that most medical errors occur because of system flaws, not personal negligence.
"Leadership has to be visible and committed to this shift, and it has to be a core value for them -- it can't be delegated to others," according to Tejal Gandhi, M.D., the chief safety and transformation officer at Press Ganey. "And when I say leadership, I mean every leader in the organization, from the C-suite to the local nurse manager. This has to be a focus for all leaders in the organization because there's such an ingrained culture that we're trying to change."
But what does that commitment actually look like? What specific steps can health system leadership take to drive an organization's shift toward a just patient safety culture?
According to Gandhi, health system leaders can't just say they're committed to patient safety -- they must demonstrate their commitment. By integrating more robust patient safety reporting systems, communicating corrective action plans and engaging frontline staff in patient safety efforts, leaders can authentically lead the charge on patient safety.
Enable effective patient safety reporting systems
In order to detect medical errors and prevent them from becoming adverse events, health systems need to make it easier for staff members to report them.
But those patient safety reporting systems are among the biggest challenges to overhauling the patient safety culture. In the past, these systems have been clunky, and overly manual processes have made it difficult for staff to flag and mitigate patient safety events.
"I'll take you back 20 years to when I ran a safety program at a large academic medical center. We were using spreadsheets and other tools to try to track events and then follow up with people, and it was very cumbersome," Gandhi recalled. "Now, AI can help with reporting a safety concern by making it quick and easy to do."
AI has the ability to streamline the reporting process, getting rid of the friction that might have previously discouraged staff from flagging an incident.
Pairing technology capabilities with a non-punitive, just culture of patient safety can create a more effective mechanism for patient safety reporting, which, in turn, can enable better mitigation and system overhauls.
Follow through on patient safety reports
It's not enough to solicit adverse event reporting. There also needs to be corrective action and follow-up with those reporting issues and with other relevant teams.
Many health systems get bogged down by outdated tools or manual systems, keeping patient safety experts from identifying trends and using that information to redesign processes and achieve better outcomes.
"A big hospital could get up to 10,000 reports a year. This is not an easy amount of information to manage," Gandhi explained.
Tools that integrate AI make it easy to parse through insights and lead to system improvements.
"We're leveraging AI to help make that analysis piece far more robust," Gandhi said of Press Ganey's own priorities. "We're trying to shift analysis from just the safety leaders in the organization to nurse managers and so on. We're trying to shift them from just managing the data to getting good insights out of the data in an easier way. That can lead to strong actions, and then that feedback piece."
That feedback part is integral, Gandhi stressed. Staff members want to know that their report went somewhere, and in fact, failing to follow up with them can erode trust with leadership, she said.
But yet again, AI can support this process.
"When you close out the exploration and figure out what the improvement's going to be, you could use AI, for example, to draft the note back to the reporter to explain what the status is, as opposed to a person having to do that manually," Gandhi said. "AI could also automate where the follow-up note goes."
Connect with frontline staff about patient safety
Of course, technology is not a panacea, especially for a transition as complex as this one.
"It is hard to change culture and drive a culture of safety," Gandhi remarked. "For decades, we have not had very strong cultures of safety. We've had punitive cultures, and people didn't feel psychologically safe to speak up."
Technology isn't going to fix healthcare's psychological safety problem, Gandhi continued. Instead, health system leaders will need to connect with staff personally to foster more open discussions about the specific system failures that drive the most patient safety events.
"If your leaders don't demonstrate that this is a core value for the organization, be visible about that and be engaged in it, then change is going to be very difficult," she stated.
This can't happen if leaders stay closed off in their offices all day. Instead, Gandhi recommended that health system leaders participate in staff meetings on patient safety and join patient safety huddles.
Leaders should avoid trite messaging about patient safety or only talking about it occasionally. Instead, consistent discussions about patient safety and the health system's priority of non-punitive corrective action will be key.
"Then you have to do something about the things you're hearing about. The risk of inauthenticity occurs if you hear about these issues and nothing changes; that actually is worse for your culture," Gandhi stressed. "The critical piece is that follow-up and feedback because there have been studies that have shown that if you do these rounds poorly, it actually can worsen your culture."
Failure to connect authentically with staff can have serious consequences, Gandhi added, particularly around staff retention.
If an organizations' safety culture and engagement are low, staff members are more likely to leave, she continued.
"There are ROI conversations about how we pay for certain safety interventions, but I constantly say you're paying for your people, and you want to retain your people. One of the best ways to do that is to make staff believe that the organization and the leaders care about safety. That will have your folks want to stay on."
Sara Heath has reported news related to patient engagement and health equity since 2015.
