Challenge 1

Creating a Culture of Safety

Executive Summary Checklist

Implementing a culture of safety will require an implementation plan to complete the following actionable steps:

  • Achieving a culture of safety in a healthcare requires transformational change which is owned and led by the top leaders of the organization, including the board.
  • Transparency, both within and outside of the organization, drives improvement across the continuum of care.
  • Understanding and implementing Just Culture is essential for transitioning from a culture of shame and blame to one of trust and respect, but with accountability.
  • If patient harm results from a medical error: apologize in 30 minutes, pay for all care, seek a just resolution; provide a credit card for future care of survivor of harm.
  • Creation of a reliable means to capture and analyze good catches/near-miss is the key to identifying and addressing unstable processes and systems.
  • Both safety culture and patient outcomes require continual assessment: “What is measured gets managed.”
  • Hospital governance and senior administrative leadership must commit to the major performance gap. Leaders cannot simply be “on board” with patient safety – they must own it.
  • Create and maintain five components of a safety culture to achieve a high-reliability organization:
    • Establish Trust
    • Establish Accountability
    • Identify unsafe conditions
    • Strengthen Systems
    • Assess and Continuously Improve the Safety Culture
  • Develop a strong infrastructure ensuring:
    • Budgets allow for an adequate number of quality and patient safety professionals
    • Implementation and ongoing monitoring of a comprehensive patient safety program that is approved by the Board of Trustees.
    • Create an internal working group made up of quality department, nursing, risk management, patient safety, patient advocacy and regulatory leaders.
    • Develop a ‘Good Catch’ Program to recognize and reward staff for reporting near misses or system issues.
  • Implement an electronic adverse event reporting system that allows for anonymous reporting, tracking, trending and response to aggregate safety data.

Between the 2017 World Patient Safety, Science & Technology Summit and the 2017 Midyear Planning Meeting a workgroup comprised of experts representing administrators, clinicians, technologists and patient advocates will meet to update this APSS. If you are interested in joining this workgroup, please email us.