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Update on Safety Culture

Allan Frankel, MD, and Michael Leonard, MD | August 22, 2013 
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Safe and reliable care requires a culture of safety: a collaborative environment in which skilled clinicians treat each other with respect, leaders drive effective teamwork and promote psychological safety, teams learn from errors and near misses, caregivers are aware of the inherent limitations of human performance in complex systems (stress recognition), and there is a visible process of learning and driving improvement through debriefings.(1)

Collecting safety culture data for the past 10 years has taught us that culture is uniquely local—determined at the unit level—and that the range of perceptions is wide. A medical floor may have excellent scores and be co-located with a medical ambulatory clinic with abysmal results. Measuring safety culture well, with high response rates (more than 60% of caregivers), at the unit level provides valuable insights as to what it really feels like to be a secretary, technician, nurse, physician, or other caregiver in this unit where culture lives. The power of these insights is that they are personal ("here's what you said"), they can often be quite disparate ("the doctors think it's fine, and no one else does"), and we can link the data to specific actions and insights.

Recent evidence shows that roughly one in three hospitalized patients experiences an adverse event, and in 6% of cases the adverse event is severe enough to prolong the patient's hospitalization and send him or her home with a permanent or temporary disability.(2) Technology alone cannot fix the harm in health care. A sociotechnical approach is needed that focuses on skilled clinicians working collaboratively in an increasingly complex technical environment, as discussed in recent Institute of Medicine reports.(3,4) This is where culture is critically important. Think of safety culture as the social glue that holds the care process together.

The evidence on safety culture and clinical metrics is growing and indicates that perceptions about teamwork, safety, and leadership correlate with the quality and safety of care. For example, the Veterans Health Administration system's teamwork training program decreased surgical mortality by 18%, improved safety culture scores, resulted in better operational and clinical process metrics, and significantly reduced harm.(5) In Michigan, bariatric surgical outcomes were better in operating rooms whose nurses rated their safety as being "excellent."(6) Hansen and colleagues showed correlations between improved safety climate measures and lower readmission rates for coronary artery disease and congestive heart failure.(7)

A particularly interesting example of the influence of culture comes from the Rhode Island intensive care unit (ICU) collaborative that worked on the prevention of central line infections and ventilator-associated pneumonia over several years. In year 5 of the collaborative, they gave ICUs the opportunity to reflect on their survey results, looking at their strengths and weaknesses and evaluating differences in perspective by discipline. The units then identified simple areas of opportunity and committing to action. The units that did so showed significant improvements in safety culture and decreased infection rates.(8) We have unpublished data from large integrated health care systems that are compelling. In one system, never events occurred once every 38 months when more than 60% of surgical suite personnel perceived safety as good or excellent, versus once every 12 months in surgical areas with scores below 60%. The lesson: high reliability and great culture don't eliminate the risk of events, but improving culture can decrease their occurrence dramatically.

Working to improve safety culture is most effectively done within a framework that incorporates leadership, safety culture, effective teamwork, reliable processes of care, systematic learning, and measurable improvement. Such a framework supports ongoing intentional work rather than isolated projects. There are specific areas of safety culture that provide valuable leverage points.

Perceptions of senior and clinical unit leadership are a valuable reflection of trust and frontline caregivers' confidence that their concerns will be heard and acted upon. High performing organizations do this well and consistently. Building clinical leadership is a broad need in health care, as these skills have not been traditionally taught. Effective leaders drive high levels of collaboration among team members and ceaselessly promote psychological safety—an environment where everyone will raise their hand and voice a concern about a patient. Psychological safety has a huge impact on how teams perform and the care experience.(9) The ability to learn from errors is essential. Without a clear model of accountability—one that effectively balances the need for individual professionalism with not holding individuals responsible for system failures beyond their control—learning does not occur and the same failures are repeated, hurting both patients and clinicians.(10)

Effective teamwork is a necessity for safe care. Using briefings, debriefings, and other teamwork tools helps structure communication and increase predictability. Consistent use of these tools is a great way to embed the desired behaviors and improve safety culture.(11) Gaps in stress recognition—the impact of fatigue, stress, and high workload on human performance—are effectively addressed by educating clinicians about how teamwork can effectively counteract these stressors.(12,13)

The last area of focus is building the capacity for improvement at a unit level. Every day, clinicians deal with obstacles and defects that are frustrating and get in the way of delivering optimal care. Having a clear, reliable process to identify defects and show that someone owns the problem and is fixing it can rapidly build trust and drive unit-level improvement. All the above components have been integrated into the TEM (Team-based Engagement Model) that we developed with the Mayo Clinic and are being embedded across that organization.

Clinical units with high levels of safety culture deliver better care because they are able to do the basics every time, like turning patients every 60 minutes to avoid pressure ulcers, using a central line checklist, or washing their hands frequently. They also create a culture of accountability through clear agreement as to the behaviors and cultural norms that create value for patients and caregivers. Focusing on a few specific insights of safety culture at the clinical unit level is a valuable endeavor and is a necessary component for the reliable delivery of safe patient care.

Allan Frankel, MDCo-Chief Medical Officer, Pascal Metrics Inc.Patient Safety Faculty, Institute for Healthcare Improvement

Michael Leonard, MDCo-Chief Medical Officer, Pascal Metrics Inc.Adjunct Professor, Duke University



1. Leonard M, Frankel A, Federico F, Frush K, Haraden C, eds. The Essential Guide for Patient Safety Officers, 2nd edition. Oakbrook Terrace, IL: Joint Commission Resources, Institute for Healthcare Improvement; 2013. ISBN: 9781599407036.

2. Classen DC, Resar R, Griffin F, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30:581-589. [go to PubMed]

3. Committee on Patient Safety and Health Information Technology, Board on Health Care Services, Institute of Medicine. Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC: National Academies Press; 2011. ISBN: 9780309221122. [Available at]

4. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Institute of Medicine. September 6, 2012. [Available at]

5. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304:1693-1700. [go to PubMed]

6. Birkmeyer NJ, Finks JF, Greenberg CK, et al. Safety culture and complications after bariatric surgery. Ann Surg. 2013;257:260-265. [go to PubMed]

7. Hansen LO, Williams MV, Singer SJ. Perceptions of hospital safety climate and incidence of readmission. Health Serv Res 2011;46:596-616. [go to PubMed]

8. Vigorito MC, McNicoll L, Adams L, Sexton B. Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans. Jt Comm J Qual Patient Saf. 2011;37:509-514. [go to PubMed]

9. Edmondson AC. Managing the risk of learning: psychological safety in work teams. In: West MA, Tjosvold D, Smith KG, eds. International Handbook of Organizational Teamwork and Cooperative Working. England, UK: John Wiley & Sons Ltd; 2003:255-276. ISBN: 9780471485391. [Available at]

10. Leonard M, Frankel A. How Can Leaders Influence a Safety Culture? The Health Foundation; May 2012. [Available at]

11. Edmondson AC. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Francisco, CA: Jossey-Bass; 2012. ISBN: 9780787970932.

12. Salvendy G, ed. Handbook of Human Factors and Ergonomics, 4th Edition. England, UK; John Wiley and Sons Ltd: 2012. ISBN: 9780470528389.

13. Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature. 1997;388:235. [go to PubMed]

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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