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    10 Elements of A Just Patient Safety Culture Whitepaper

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    Sema Sadullayeva02
    The document outlines 10 elements of a just patient safety culture: 1) use a transparent approach to adverse events, 2) define clear processes for distinguishing errors, 3) have leaders who lead by example, 4) put policies in place to support the culture, 5) focus on a just culture that recognizes reporting, 6) use validated tools to measure safety culture, 7) act on data from surveys, 8) commit necessary resources to address issues, 9) provide training to strengthen systems, and 10) regularly evaluate the culture. Establishing such a culture across a healthcare organization can improve patient outcomes and reduce costs.

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    © All Rights Reserved
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    10 Elements of A Just Patient Safety Culture Whitepaper

    Uploaded by

    Sema Sadullayeva02
    18 views8 pages
    The document outlines 10 elements of a just patient safety culture: 1) use a transparent approach to adverse events, 2) define clear processes for distinguishing errors, 3) have leaders who lead by example, 4) put policies in place to support the culture, 5) focus on a just culture that recognizes reporting, 6) use validated tools to measure safety culture, 7) act on data from surveys, 8) commit necessary resources to address issues, 9) provide training to strengthen systems, and 10) regularly evaluate the culture. Establishing such a culture across a healthcare organization can improve patient outcomes and reduce costs.

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    10 Elements of a Just Patient Safety Culture Whitepaper

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    The document outlines 10 elements of a just patient safety culture: 1) use a transparent approach to adverse events, 2) define clear processes for distinguishing errors, 3) have leaders who lead by example, 4) put policies in place to support the culture, 5) focus on a just culture that recognizes reporting, 6) use validated tools to measure safety culture, 7) act on data from surveys, 8) commit necessary resources to address issues, 9) provide training to strengthen systems, and 10) regularly evaluate the culture. Establishing such a culture across a healthcare organization can improve patient outcomes and reduce costs.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    18 views8 pages

    10 Elements of A Just Patient Safety Culture Whitepaper

    Uploaded by

    Sema Sadullayeva02
    The document outlines 10 elements of a just patient safety culture: 1) use a transparent approach to adverse events, 2) define clear processes for distinguishing errors, 3) have leaders who lead by example, 4) put policies in place to support the culture, 5) focus on a just culture that recognizes reporting, 6) use validated tools to measure safety culture, 7) act on data from surveys, 8) commit necessary resources to address issues, 9) provide training to strengthen systems, and 10) regularly evaluate the culture. Establishing such a culture across a healthcare organization can improve patient outcomes and reduce costs.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 8

    10 Elements of a Just Patient Safety Culture

    What is Patient Safety?

    Patient Safety refers to:

    “how healthcare organizations protect their patients from errors,


    injuries, accidents, and infections.” (1)

    Effective Patient Safety programs can improve patient outcomes and reduce
    costs at the same time. In 2015, due to an increased focus on patient safety, it is
    estimated that 125,000 fewer patients died in the hospital as a result of hospital-
    acquired infections (HACs). Not only that– approximately $28 billion in health
    care costs were saved, as well. (Graph 1) (2)

    There are 134


    million patient
    safety events that
    occur each year,
    resulting in $20B in
    annual costs. (3)

    Studies have shown that establishing a patient safety culture can improve patient
    safety outcomes. With that in mind, establishing a culture of patient safety is
    every healthcare professional’s responsibility. (1) Patient safety culture is defined
    as the culmination:
    “of individual and group beliefs, values, attitudes, perceptions,
    competencies, and patterns of behavior that determine the
    organization’s commitment to quality and patient safety.” (1)

    In a culture of patient safety, every member of a healthcare team is equally


    committed to putting patient safety first, and they continuously engage in actions
    that reflect that commitment.
    1- What is Patient Safety. Leapfrog Hospital Safety Grade. Retrieved on August 3, 2019 at https://www.hospitalsafetygrade.org/what-is-patient-safety
    2- Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer.Agency for Healthcare Research and
    Quality. Retrieved on August 4, 2019 at https://www.ahrq.gov/professionals/quality-patient-safety/pfp/2015-interim.html?
    utm_source=AHRQ&utm_medium=PR&utm_term=&utm_content=6&utm_campaign=AHRQ_NSOHAC_2016#exhibit1
    Graph 1- Source: AHRQ National Scorecard Estimates from Medicare Patient Safety Monitoring System, National Healthcare Safety Network, and
    Healthcare Cost and Utilization Project.
    3- https://www.who.int/features/factfiles/patient_safety/en/
    2
    10 Key Elements of a Patient Safety Culture

    Is your healthcare organization committed to establishing a patient safety


    culture? If so, here are ten key elements of a patient safety culture that you and
    your team should be aware of:

    1. Use a Transparent Approach


    Use a transparent, non-punitive approach to report and learn from adverse
    events, close calls, and unsafe conditions. (4) An increase in the number of
    adverse events reported and effective reporting by all team members leads
    to improved patient outcomes and helps drive overall organizational change.

    This approach includes encouragement of collaboration across all ranks


    and disciplines to seek solutions to patient safety problems.

    2. Define Set Processes


    Use clear, just, and transparent risk-based processes for recognizing and
    distinguishing human errors and system errors from unsafe actions. The goal
    of every team member is zero harm to patients. "Zero harm" refers to the
    concept of not having any patients harmed as a result of their interactions with
    a healthcare system (4). In order to achieve zero harm, patient safety must be
    embedded into the organizational culture. (5, 6)

    Establishing a Culture of Safety

    Establishing a culture of safety is the responsibility


    of all members of a care team - not just the Risk
    Manager.

    4- Karren Appold; MDedge News, "Aim to Achieve 'zero harm'. https://www.the-hospitalist.org/hospitalist/article/162595/antimicrobial-resistance.


    5- 11 Tenets of a Safety Culture, The Joint Commission. Retrieved on August 3, 2019
    at https://www.jointcommission.org/assets/1/6/SEA_57_infographic_11_tenets_safety_culture.pdf
    6- Halverson, Eunice. (June 7, 2017) Zero Harm. Center for Patient Safety. Retrieved on August 3, 2019 3
    at https://www.centerforpatientsafety.org/2017/06/07/zero-harm/
    3. Lead by Example
    In a true patient safety culture, all organizational leaders are expected to adopt
    and lead by example.

    When leaders display the appropriate behaviors, they can decrease


    feelings of intimidation and increase the probability of their staff
    reporting errors and safety concerns. (5)

    Promoting a culture of safety is the responsibility of everyone in the organization,


    whether they are leaders, frontline staff, or volunteers.

    4. Put Policies in Place

    Organizations are expected to create and adhere to policies that support their
    safety culture. This means setting up systems and policies around the reporting
    of adverse events, near misses, and unsafe conditions that can lead to further
    patient injuries. Policies must be enforced, communicated, and made easily
    accessible to all team members within the organization. (5)

    5. Focus on a Just Culture

    The patient safety culture should also be a Just Culture, one which recognizes all
    team members who report adverse events and near misses. A Just Culture is
    defined as:

    "a culture that holds organizations accountable for the systems they
    design and for how they respond to staff behaviors fairly and justly. In
    turn, staff members are accountable for the quality of their choices and
    for reporting both their errors and system vulnerabilities." (7)

    A Just Culture also recognizes those who identify unsafe conditions, or who have
    good suggestions for safety improvements.

    It is important that leadership shares information brought forward regarding


    these adverse events, near misses, and recommendations for safety
    improvements with all team members so all can learn from these “free lessons.”
    (5, 8)
    5- 11 Tenets of a Safety Culture, The Joint Commission. Retrieved on August 3, 2019
    at https://www.jointcommission.org/assets/1/6/SEA_57_infographic_11_tenets_safety_culture.pdf
    7- Griffith, K.S. (2009). "Column: The Growth of a Just Culture."The Joint Commission Perspectives on Patient Safety 9 (12): 8–9.
    8- Joint Commission Outlines 11 Tenets of a Safety Culture, Risk Management News. Retrieved on August 3, 2019
    at https://www.ecri.org/components/HRCAlerts/Pages/HRCAlerts030817_Joint.aspx
    4
    6. Use Validated Tools

    The next important element to improve patient safety culture is to use validated
    tools to measure patient safety. An organization is expected to determine a
    baseline measurement on their safety culture performance using a validated
    tool. Two commonly used tools are the Agency for Healthcare Research and
    Quality (AHRQ)'s Patient Safety Culture Surveys and the Safety Attitudes
    Questionnaire. AHRQ provides annual updated benchmarking data from the
    hospital survey.

    There is an expectation that healthcare institutions repeat organizational


    assessment of their safety culture every 18 to 24 months in order to
    review progress and sustain improvements. (5, 9)

    7. Act on the Data

    Safety culture survey results are to be analyzed from all departments to find
    opportunities for quality and safety improvement. Across the country, there is
    documented evidence of considerable variation in perceptions of safety
    culture across organizations and job descriptions. Understanding these
    variations in perceptions is valuable to the organization in developing and
    implementing interventions to comprehensibly address safety concerns. (5, 9)

    8. Commit the Necessary Resources

    Organizations must commit resources to address any safety concerns that arise
    from analysis of safety culture surveys. These resources might take the form of
    personnel, additional training, or increased funding.

    Funding is often necessary in order to develop and implement


    interventions that increase patient safety at the site of care. (5, 9)

    4- 11 Tenets of a Safety Culture, The Joint Commission. Retrieved on August 3, 2019


    at https://www.jointcommission.org/assets/1/6/SEA_57_infographic_11_tenets_safety_culture.pdf
    9- Culture of Safety. Patient Safety Network. Agency for Healthcare Research and Quality. Retrieved on August 2, 2019
    at https://psnet.ahrq.gov/primers/primer/5/Culture-of-Safety

    5
    9. Train your Team
    Safety culture team training is embedded into quality improvement projects
    and organizational processes to strengthen safety systems. An effective patient
    safety culture encourages collaboration across ranks and disciplines to seek
    solutions to patient safety problems. (5, 10)

    10. Regularly Assess Strengths and Weaknesses

    Organizations must proactively assess system strengths and vulnerabilities, and


    prioritize them for enhancement or improvement.

    Historically, healthcare organizations have approached patient safety as


    a reaction to an event that harmed a patient. A proactive system
    approach is to search for potential breakdowns in safety and address
    those potential breakdowns in order to consistently ensure patient
    safety. (5, 10)

    By establishing a just patient safety culture with the elements outlined above,
    healthcare organizations can ensure that patients, physicians, and staff all
    achieve the highest quality outcomes possible.

    5- 11 Tenets of a Safety Culture, The Joint Commission. Retrieved on August 3, 2019


    at https://www.jointcommission.org/assets/1/6/SEA_57_infographic_11_tenets_safety_culture.pdf
    9- Culture of Safety. Patient Safety Network. Agency for Healthcare Research and Quality. Retrieved on August 2, 2019
    at https://psnet.ahrq.gov/primers/primer/5/Culture-of-Safety
    10- Safer Clinical Systems: A new, proactive approach to building safe healthcare systems. Warwick Medical School. Retrieved on August 3, 2019
    at http://patientsafety.health.org.uk/sites/default/files/resources/hf_safer_clinical_systems_reference_guide_final_1.pdf 6
    Performance Health Partners Incident Reporting Solution

    Performance Health Partners incident reporting software helps healthcare


    organizations:

    Eliminate the risk of inconsistent or incomplete data entry


    Effectively synthesize patient safety data
    Provide a central channel for team communication
    Get real time notifications and alerts
    Analyze custom dashboards to track trends over time

    For more information on how a software solution can help improve patient
    safety outcomes, visit www.performancehealthus.com or click the button below
    to schedule a demo:

    Schedule a Demo View Resources

    4
    Client Experience

    “By implementing PHP’s solutions, we were able


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    — Jessica Booth, RN Risk Manager — Mona Daigle, Compliance and Risk Manager

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    — Karen Wyble, RN, MSN, Chief Executive
    Officer
    — Taylor Allen, Director of Infection Control

    info@performancehealthUS.com
    1-877-264-0399

    www.PerformanceHealthUS.com

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