Creating a just culture to enhance patient safety
In light of widespread medical errors, communication of systemic problems by medical staff is key in discovering how to fix problems that put patients at risk.
There’s no doubt that medical errors are a major concern and factor impacting patient safety.
Medical errors are ranked as the eighth – and by some research organizations, as high as the third – leading cause of death in the United States. More people die from mistakes that occur in healthcare facilities than from breast cancer, motor vehicle accidents, or AIDS.
When a patient dies while receiving care, the cause is not just one thing, not the result of an action or inaction of one person, but a breakdown somewhere amid the whole jangle of pieces that ordinarily operate at peak excellence, administering care of incomprehensible complexity and effectiveness.
To prevent such tragedies, the medical establishment has sought to identify causes, seeking testimony, data and documentation that can piece together what happened and why. But when an event failure is evident, few of those who have knowledge of mistakes they or their colleagues have made come forward. The vast majority remain silent, even though their refusal to share all they know makes it more difficult to learn from whatever mistakes occurred.
The need for transparency
Why is it so difficult to obtain their cooperation? In a hospital survey on patient safety culture conducted by The Agency for Healthcare Research and Quality, hospital staffers were asked if they agreed with the following statements:
- • Mistakes they make are noted and retained in their personnel file (agreed to by 65 percent).
- • When an event is reported, the person is written up, but not the problem they reported (54 percent).
- • Staff do not feel free to question the decision or actions of those with more authority (53 percent).
- • Staff believes mistakes are held against them (50 percent).
- • Everyone works in crisis mode, trying to do too much too quickly (50 percent).
From findings such as these, it appears likely that the culture of the hospitals in which these caregivers serve is not conducive to candor.
Organizational culture
What is culture? What do we mean specifically when we refer to the culture of a hospital? And if there are elements of a hospital culture that are not conducive to obtaining the facts pertinent to a medical error, what can be done to change such a culture?
The culture of an organization embodies unspoken rules and assumptions governing the way its members work, interact with others or adapt to change (among much else). The cultures of most organizations are highly self-protective. When there is a problem, efforts to identify and fix it too often are overshadowed by an official organizational position of deflection and denial.
This posture, as practiced in medical organizations, has been candidly described by Dr. Timothy B. McDonald, chief patient safety and risk officer at RLDatix. While serving as legal counsel to a hospital where a patient died after a line on her chart was misread, the organization went into a classic defensive position.
“Forty-three depositions were taken. The doctors, nurses, students and residents went through hell, and we spent hundreds of thousands of dollars defending the indefensible. As a lawyer I saw that and thought it was crazy,” he recalls. “The other part is we didn't learn anything. How ironic is it that we knew our care was bad, but the message from our leadership, including legal, was we're still going to defend this. That sends such a hypocritical message to the medical staff.”
That culture, as McDonald and others realized, had to change.
A culture based on trust
The medical community has been working to protect patients more effectively by promoting a change in the culture of healthcare organizations, one based not on fear of disclosure but on trust, not on punishment, but on shared accountability in which all are treated fairly, that is, in a just manner. In a just culture, healthcare professionals feel safe if they report unintentional errors, because the highest priority of the organization is patient safety.
But the effort to create a just culture within any organization, particularly one in the medical community, has proven to be difficult. Writing in the Harvard Business Review, Jeffrey Brickman pointed out, “In healthcare, change is even harder than in most industries. Clinical and administrative staff are historically suspicious of senior administrators and resistant to strategic agendas. While a desperate need for change and organizational performance improvement may be obvious to the top team, staff can view that premise as fundamentally flawed. They’ve lived through tumultuous times before and the status quo has always returned.”
Efforts to build a just culture in healthcare organizations have been initiated and implemented for the past 20 years, but they have been overwhelmed by the pandemic. The shifting of priorities in response to critical needs engendered by COVID intensified the pressures and anxieties already endured by frontline caregivers, sapping their morale, inducing more burnout, creating greater risk of carelessness and more cases of medical errors.
The cultural virus threatening patient safety
According to a recent survey of 3,000 healthcare employees, 38 percent reported they are at the edge of burnout, and 39 percent are contemplating quitting their jobs.
The report also found that healthcare employees had lower scores than other industry employees, with only half convinced they are paid fairly for the work they do — the lowest score of any industry studied — and only 38 percent of healthcare employees feel their pay is clearly linked to their performance.
This situation has produced a vicious circle in which patients are in the center. When job satisfaction is low, it becomes much easier to fall victim to the virus of complacency. Rebecca Love, chief clinical officer at IntelyCare, has diagnosed the situation, noting that within hospital culture, “The rewards for risk taking are often immediate and positive (e.g., saved time), while the punishment (e.g., patient harm) is often delayed and remote. As a result, even the most educated and careful healthcare professional will learn to master dangerous shortcuts, particularly when faced with an unanticipated system problem (e.g., technology glitches, time urgency). Staff will drift from safe and controlled processes, as first learned, to unsafe and automatic processes. Over time, the risk associated with these processes fades and the entire culture becomes tolerant to these risks.”
Thus, patient safety is at risk from unconscious, habitually routinized medical practices, and in a culture that loses sight of its most sacred objective – the care of the sick – accidents will occur. Without the trust that is the foundation of a just culture, the reasons for medical errors are liable to remain unaddressed.
Without trust, it will remain difficult to obtain information about what went wrong. Without trust among hospital workers and their peers, the defense of the organization is liable to take precedence over the safety of the patients.
The foundation for a just culture
When staff believe their mistakes will be recorded in their personnel files, they are bound to believe that sooner or later their errors will be held against them. They will fear that any explanations they may have will not be accepted, that the organization punishes transparency, and that it has little interest in learning about and collaborating to fix system factors that may have played an even greater role in contributing to a patient’s harm.
By contrast, a just culture promotes candor and peer support after patient harm.
The challenge has been and continues to be how institutions can establish an atmosphere in which everyone prioritizes patient health over institutional protection.
To overcome this challenge, medical practices must be committed to a long-term, educational program that turns “just culture” from a catchphrase everyone uses into a personal and professional code that links directly to patient safety.
Justin Campbell is a vice president for Galen Healthcare Solutions.