Michael Leonard and Allan Frankel discuss how leaders can influence their organisations to help create a robust safety culture.

High reliability environments deal with risk and hazard on a daily basis, yet maintain impressive levels of safety by building a safety culture and continuous learning.

The fundamental difference is that such environments relentlessly assure safety while, in medicine, safety is often assumed. This assumption leads to a dangerous mindset and often results in serious, avoidable injury.

The systematic delivery of safe and reliable care requires a safety culture, continuous learning and improvement. The role of leaders is to support this work

by defining the goals and values of the organisation as well as relentlessly communicating that safe care is a primary goal. Leaders need to be able to clearly articulate the behavioural norms and address those that create unacceptable risk, ensuring consistency in holding people accountable - this lays the foundation for a strong safety culture.  

Psychological safety

Psychological safety is an environment where no one is hesitant to voice a concern about anything that puts the organisation at risk. If you always go to the same people when you have a concern, it is because it is psychologically safe to do so; in the same vein, the individuals you are hesitant to approach because it will be unpleasant personify a lack of psychological safety. Within a hospital setting, this could lead to avoidable harm or death.

Leaders can contribute to psychological safety and a collaborative care environment in a number of ways. High performance safety cultures hire people with positive attitudes about collaboration. A good example of hiring for attitude is the non-profit Mayo Clinic in Minnesota. There, people are selected for their ability to practise in the “Mayo Way”, where the needs of the patient come first.

Units in which caregivers have very positive, concordant perceptions of psychological safety, teamwork and leadership provide safer care environments for both caregivers and patients. It is important that the broader organisational themes around psychological safety, discussing errors and perceptions of teamwork are analysed. When significant numbers of caregivers are hesitant to speak up or fearful to disclose errors, these are key areas in which broad action needs to be taken.  

The adoption of consistent teamwork behaviours is a powerful mechanism to improve safety culture. Every unit in the care system should start the day or procedure with a briefing. Effective team leaders use people’s names and consistently invite other team members into the conversation, both to benefit from their expertise and to hear their concerns. Importantly, leaders should also ensure they are approachable and make it easier for others to speak up.

Two additional team behaviours are critical language and debriefing. In the absence of critical language, caregivers may not speak up or may engage in mitigated speech. This is dangerous - a busy clinician focused on a problem or procedure may miss this signal and errors could occur. Leaders effectively impact the use of critical language and psychological safety by being clear that everyone must speak up if they have a concern or are unclear as to the plan of care. Debriefing is the final teamwork behaviour that closes the loop and facilitates teamwork as well as learning.

Organisational fairness

We have all been trained in a culture that says skilled and capable practitioners do not make mistakes if they try hard and pay attention. This makes it personally threatening to talk about mistakes. Organisational fairness can only be successful when actively supported by leadership.

Human error is pervasive, even among skilled practitioners, and complex systems also generate errors. In order to learn and improve, caregivers need to know it is safe to talk about mistakes and near misses.

Discussing contributing factors and system thinking helps to identify opportunities and raises awareness among clinicians of system failures that need to be fixed.

Most adverse events stem from a combination of factors and often the shortcuts, or normalised deviance, are critical factors. Leaders must really understand how caregivers provide patient care to effectively manage it.

The learning system

Frontline caregivers routinely deal with defects and barriers to their ability to deliver optimal care, which leads to shortcuts and workarounds. The general inability to systemically identify these defects has two undesirable outcomes: it normalises shortcuts in safe procedures; and reinforces the perception that leaders are not really concerned about these problems.

Leaders can profoundly influence a culture of safety through their support of a learning system. This is a visible structure that captures the concerns and defects from frontline caregivers, thereby demonstrating that leaders are interested in their concerns, the information is acted upon and, once the issue is resolved, systematic feedback is provided to the people who gave the leaders the original information.

A learning system that captures information and tracks improvement builds trust in addition to the capacity to drive improvement.

Leadership plays a crucial role in creating and maintaining the learning system. By ensuring the system is visible and functional, leaders are sending an important cultural message - they are showing that the wisdom of frontline caregivers is valuable and must be acted on.

Leaders have a profound opportunity to enhance an organisation’s safety culture. Creating an environment of psychological safety enhances the ability of caregivers to voice concerns - an essential component of safe care. Reflecting the perceptions of caregivers at unit level by debriefing safety culture data identifies opportunities that are important and actionable.

Organisational fairness, or “just culture”, makes it safe for members of the care team to discuss errors and near misses so the organisation develops a strong learning culture. Effective leadership is a vital component in every aspect.

Dr Michael Leonard is co-chief medical officer at Pascal Metrics and adjunct professor of medicine at Duke University School of Medicine. Dr Allan Frankel is co-chief medical officer at Pascal Metrics and senior faculty at the Brigham and Women’s Hospital Patient Safety Center of Excellence in Boston and the Institute for Healthcare Improvement.

Find out more

This article is an extract from a a series of thought papers from patient safety experts, commissioned by the the Health Foundation. Other articles include Reinventing Healthcare Delivery, Proactive Approaches to Safety Management and The Role of the Patient in Clinical Safety.