Patient safety: what’s culture got to do with it?

THE increasing complexity of patient care has correspondingly increased our reliance on working together with other health care professionals. Being obliged to work as part of a group compels us to acknowledge and appreciate the dimension of organisational culture in the health care environment.

Culture exerts a powerful influence on individual and group behaviour. It brings together large numbers of people and gives them a sufficient similarity of approach, outlook and priorities to enable them to achieve collective responses. Attention to cultural reform is increasingly at the forefront of patient safety science.

Recent reports assessing the current status of patient safety (here, here, here and here) show that decades of regulatory and organisational support have failed to significantly improve outcomes; progress has been meagre at best with limited evidence of overall improvement. The seemingly intractable nature of patient harm and the sustained failure to reduce the incidence of health care-associated complications lead the reports to agree on an obvious need for radical, fundamental change in the approach to patient safety. Alongside calls for a cohesive systems approach to implementing patient safety initiatives is consistent recognition of the importance of patient safety culture.

Change management teaches us that successful reform needs attention to both technical (knowledge) and adaptive (sociocultural) aspects of change. The aphorism “culture eats strategy for breakfast” conveys the ineffectiveness and frustration of attempting to implement management directives without appreciating how organisations and people work. Improving patient safety performance is a difficult and complicated endeavour. Legitimate authority and contemporary knowledge must be combined with appreciation of local culture and willingness to collaborate and adapt as required.

Reality check for checklists describes the misrepresentation of the landmark program to reduce central line-associated bloodstream infections (CLABSI) in intensive care units (ICUs). The Keystone project was a complex cultural and organisational change effort, but success was misreported as being due to the introduction of a simple checklist. The checklists themselves were just one component of a more comprehensive program to change the culture of the ICUs.

When we begin to believe and act on the notion that safety is simple and inexpensive, that all it requires is a checklist, we abandon any serious attempt to achieve safer, higher quality care.

It is not the checklist itself, but the associated cultural and behavioural changes that affect the outcomes of care. Unfortunately, it is rarely acknowledged that health care’s understanding of culture is shallow and mistaken. References to culture often appear rhetorical, demonstrating no real appreciation of culture’s complexity and resistance to change.

What is organisational culture?

Organisational culture defies a neat definition and is best described by four characteristics:

• Shared – culture is not an individual phenomenon, nor is it simply the average of individual characteristics. It exists as shared behaviours, values, beliefs and assumptions that manifest as unwritten rules of behaviour (how we do things around here).
• Pervasive – culture permeates every level of a group, although it is not monolithic and can vary widely within an organisation. It manifests in collective behaviours, physical environments, group rituals, stories, and legends. Other aspects of culture are less overt, such as unspoken assumptions, mindsets, and motivations. Culture is a way of seeing and also not seeing and can lead to collective blind spots to important issues.
• Enduring – culture continuously evolves through shared experience and problem solving. Its endurance is partly explained by the attraction-selection-attrition model. People are drawn to organisations with characteristics similar to their own; organisations are more likely to select individuals who seem to “fit in”; and over time those who don’t fit in tend to leave. Culture becomes a self-reinforcing pattern that grows increasingly resistant to change and external influences. It can reduce organisational flexibility and adaptability – deeply held values and beliefs are slow to change.
• Implicit – the effect of culture is subliminal. People are instinctively hardwired to recognise and respond to it. Unconscious assumptions about behavioural norms are taken for granted. Culture acts as a kind of silent language, a shared understanding that facilitates cooperative action.

Strong culture reflects high levels of consensus around agreed core values. Cultural strength is also a function of the stability of a group and the length of time it has existed. Strength can be enhanced by belief in the rightness or moral superiority of an organisation’s purpose and values.

Patient safety culture can be thought of as organisational culture in which members recognise and attend to the priority of patient safety. Safety behaviour is characterised by planning, caution and preparedness. Safe work environments are predictable places where people are risk-conscious and think things through carefully.

How is culture measured?

Health care organisations can assess the status of their existing culture of patient safety and determine areas of priority to target for improvement. There are a range of surveys and measurement tools that can be used to systematically measure patient safety culture in various clinical settings.

The Australian Commission on Safety and Quality in Health Care has developed a toolkit (Measures of Patient Safety Culture 2021) that incorporates a modified version of the Hospital Survey on Patient Safety Culture Version 2 (HSOPS 2.0). The recommended survey tool was first developed by the US Agency for Healthcare Research and Quality (AHRQ) in 2004 and updated in 2019. Prior to release in Australia, the survey measurements were reviewed and assessed for appropriateness and pilot studies were performed in nine Australian hospitals.

HSOPS collects perspectives from all staff, clinical and non-clinical, to assess how the hospital works, what is going well, and what could be done better. The toolkit includes links to a range of AHRQ resources which can be utilised to target any identified weaknesses.

How is culture improved?

Culture continuously evolves through social learning and socialisation as groups solve problems together. Vogus, Sutcliffe and Weick developed the “enable, enact, elaborate” conceptual framework for understanding the process of safety culture improvement.

Leaders enable a safety culture by credibly and consistently communicating their expectations about safety and safe performance and they recognise and reward employees who act in accordance with these expectations. Leaders coherently reflect this commitment to safety by investing in policies, procedures, equipment and personnel to create a safety infrastructure. They collect and disseminate safety information within a robust safety management information system. They set the tone at the top and make it understood that everybody is responsible for safety. When leaders are credible and communicate and act consistently, individuals begin to develop consistent expectations about what is important and safe behavioural norms can emerge.

People across the organisation collectively enact – put into practice – the commitment to safety. Throughout the organisation, systems and processes that enable people to communicate about potential problems, errors and risks are in place. This means that people are willing and able to speak up about safety concerns, despite potential costs of doing so. In their day-to-day activities, people are encouraged to be mindful of problems and are preoccupied with risk, particularly when these activities are complex and non-routine. The organisation is collectively vigilant about safety.

The organisation and its units regularly and continuously elaborate its safety culture by reflecting on safety performance and attempting to learn from it. People reflect on causes of incidents, both large and small, in a number of ways, both formal and informal. Employees demonstrate the capability to learn in real time, reflecting on events as they unfold and quickly trying to derive lessons for the future. Moreover, leaders stress organisational learning, taking actions to improve its safety infrastructure based on notable incidents in its past and building into its operations opportunities for continuous improvements to its policies and procedures.

Conclusion

Decades of failure to significantly reduce the risk of patient harm forces us to confront the inadequacy of prevailing approaches to improving patient safety. There is a need to review our fundamental understanding of patient safety science, the systems approach to implementing patient safety initiatives, and the effect of culture.

The complex, dynamic, and uncertain nature of health care is intrinsically hazardous. A systematic approach to developing a safe environment needs to presume that errors and defects are abundant and ubiquitous, and that any of them could and would interact some day to produce a catastrophic event. Patient safety reform needs to focus on the resilience of the system to recover from an accident and prevent or ameliorate patient harm. Interventions should aim to make risks and consequences more apparent, actions more easily reversible, and enhance workers repertoires of effective responses.

The task of reforming health care is immense, and we should be wary of the temptation for “culture” to become yet another tick-box exercise. Rather than being presented as a problem to fix, culture needs to be appreciated for its influence on behaviour throughout an organisation and its impact on efforts to improve organisational processes. Building a patient safety culture is a collaborative process that needs clinicians to believe in the effectiveness of systems solutions over reliance on individual infallibility.

Health care workers are intrinsically motivated to care, and frontline experience of patient care provides a strong platform for identifying and addressing risk and participating in patient safety improvement.

We all revel in tales of heroic deeds performed by health care workers saving lives. But the idea that saving patient’s lives requires heroism is a harmful misconception. In the real world, true heroes are not just rescuing patients; they are voicing their concerns and taking proactive measures to reduce risk, before a patient is potentially put in harm’s way.

Dr James French is an anaesthetist and Clinical Lecturer at the Australian National University. He is studying the MAS in Patient Safety and Healthcare Quality at Johns Hopkins University.

Professor Kathleen Sutcliffe is a Bloomberg Distinguished Professor at Johns Hopkins University and holds joint appointments at the Carey Business School, the School of Medicine, the Bloomberg School of Public Health, and the Armstrong Institute for Patient Safety and Quality.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.