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Analysis

Patient Safety Efforts Need Engaged Leaders

By Tinker Ready  
   March 09, 2017

The Joint Commission warns that hospital leaders are not promoting changes needed to improve attitudes toward safety, and new research both confirms and challenges the validity of tools designed to measure patient safety culture.

Health system administrators concerned about patient safety can't personally control how expertly care is delivered. But researchers say that engagement from the C-suite is key to the promotion of patient safety culture needed to deliver high quality care.

Now, The Joint Commission (TJC) has issued a Sentinel Event Alert about leadership and safety culture.

Based on analysis of safety data collected by the accrediting organization, the document asserts that "leadership's failure to create an effective safety culture is a contributing factor to many types of adverse events, from wrong site surgery to delays in treatment."

The assessment comes with an 11-item list of safety culture "tenets" for health system leaders follow to promote a positive safety culture. It also comes as new data emerges both supporting and challenging the tools in use to measure safety culture.


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Rather than blame and punish those who make or are involved in errors, patient safety culture is moving toward "just culture," where, as described by TJC, "people are encouraged, even rewarded, for providing essential safety-related information."

With the exception of egregious behavior, the idea is to get people to identify and learn from mistakes, not to conceal them. (TJC notes, however, that "clear lines are drawn between human error and at risk or reckless behaviors.")

Stronger safety culture scores correlate with staff reporting events and near misses, according to a January study from the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine.

But there have been reports of "retaliation and intimidation targeting care team members who voice concern about safety and quality deficiencies," according to TJC. It cites instances of "overtly hostile actions, as well as subtle or passive-aggressive behaviors, such as failing to return phone calls or excluding individuals from team activities."

Leadership Involvement Imperative
Recommendations in TJC's "alert" call on leaders to "establish and continuously improve the five components of a safety culture… trust, accountability, identifying unsafe conditions, strengthening systems, and assessment."

The topic of leadership also came up in the National Patient Safety Foundation's status report marking 15 years since the publication of the seminal "To Err is Human" report on medical errors. Number one on that 2015 list of recommendations: "Ensure that leaders establish and sustain a safety culture."

Tinker Ready is a contributing writer at HealthLeaders Media.


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