Why It Matters
Of the components that contribute to creating a lasting safety culture, trust, respect, and inclusion may be among the most difficult to sustain throughout an organization.
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Trust, Respect, and Inclusion: The Heart of Safety Culture

By Tejal Gandhi | Thursday, February 8, 2018

Trust Respect Inclusion_The Heart of Safety Culture

Those working in quality and safety have long recognized that an organization’s culture has profound influence on its ability to deliver safe, high-quality care. A recent IHI white paper emphasizes the fact that a safety culture and a learning system are required elements for ensuring safe and reliable health care consistently over time.

The truth is though, that work on culture never truly ends. The culture of an organization needs to be forged by strong leadership and nurtured through consistency of actions.

While we expect health care leaders to hold primary responsibility for the culture of their organizations, it is challenging for leaders to identify proven strategies and tactics to pursue. To that end, the IHI/NPSF Lucian Leape Institute and the American College of Healthcare Executives (ACHE) collaborated last year on a resource to help leaders develop — and sustain — a culture of safety in their organizations.

Creating a lasting safety culture requires continuous work in efforts such as engaging board members, developing leaders throughout the organization, ensuring a just culture, and building trust, respect, and inclusion. While each of these components is important and contributes to the others, trust, respect, and inclusion may be among the most difficult to sustain throughout an organization.

Researchers have noted the history of disrespectful behavior that was long tolerated in health care. In recent surveys of teaching hospitals, residents and fellows report too often witnessing or experiencing disruptive behavior or disrespect by senior physicians, nurses, or other staff.

It’s important to note that bad behavior is more than just unpleasant. A study that looked at reports of surgeons displaying disrespectful behavior found that those who had high numbers of reports correlated with a greater risk of complications for patients after surgery.

To turn the tide and create an environment marked by trust, leaders must consistently apply the same behavioral standards to everyone, regardless of position or rank. Respect is shown when concerns are acknowledged, considered, and, if possible, acted upon. Respect also means explaining when concerns will not be acted upon and why. Inclusive health care organizations recognize they are microcosms of the communities they serve, and listen to all stakeholders — be they clinicians, staff, or patients and families.

One way of demonstrating these values is by being transparent with clinicians and staff about safety and quality metrics, for example, by posting information about harm events and the actions being taken to prevent them. Another involves having formal programs in place to educate staff about behavior expectations and clear guidelines about how violations will be managed.

Building trust with patients and the public includes being open about quality and safety performance and formalizing programs for responding when something does go wrong.

In a solid culture of safety, these values are embraced not only by the CEO, but by leaders at every level within the organization, who must model them consistently.

Trust and Speaking Up

A core component of a culture of safety is that staff and patients feel comfortable speaking up about safety concerns. Feeling disrespected can shut down communication, leaving questions not asked and concerns not voiced. That applies to patients and family members as well as colleagues or students.

A recent study shows that interns and residents are less likely to speak up about disrespectful behavior than about more obvious safety risks, although unprofessional behavior was more commonly observed, leading one reviewer to note that the climate for speaking up may itself become a useful measure of an organization’s culture.

Speaking up is a byproduct of a safety culture. In a continuous loop, those who speak up bring problems to the fore, when problems get addressed and solutions communicated, it demonstrates respect and encourages others to also voice concerns. Similarly, each of the components of a safety culture can help bolster the others.

How does your organization measure up when it comes to trust, respect, and inclusion?

Tejal Gandhi, MD, MPH, CPPS, is IHI's Chief Clinical & Safety Officer.

The importance of speaking up and the work needed to create a culture of safety are subjects that IHI intends to highlight during Patient Safety Awareness Week, March 11-17. Led for 15 years by the National Patient Safety Foundation, this is the first such event since IHI and NPSF merged into one organization.

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