Patient Safety Executive Development Program
Safety Culture Assessment
Current state: Open and honest reporting is standard across the organization and includes defined feedback cycles. Both patients and the workforce are empowered to speak up about safety concerns. Robust communication and support programs are in place for patients, families, and the workforce.
Next steps: Review Foundational and Sustaining tactics: Publicly share information about harm events and plans to prevent recurrence; Enable and encourage patients and families to speak up for safety through available tools and education programs; Provide cultural competency training for leaders and workforce; Regularly evaluate metrics on disparities in patient care.
Current state: Organization’s Board and committees include safety experts, clinicians, and a patient and family representative. Patients are invited to meetings to present their experiences directly to the Board. Safety is a top priority and Board members understand how safety impacts the bottom line and feel empowered to ask questions.
Next steps: Review Foundational and Sustaining tactics: Link CEO compensation and bonuses to performance on safety and culture metrics; Provide opportunities for Board members to learn from other organizations and industries; Bring frontline teams to Board meetings to tell their stories and be recognized for exemplary performance.
Current state: Just culture algorithm is embedded in all reviews and decisions across all departments. The Board, leaders, and the workforce are held accountable for utilizing the just culture policy. Patients and the public are educated on just culture and transparency around events through their providers and use of the media.
Next Steps: Review Foundational and Sustaining tactics: Treat gaps in culture as adverse events requiring review with the just culture algorithm; Educate providers on transparent communication of errors; Work with the media to educate and inform the public about just culture and plans for improvement.
Current state: Formal respect and teamwork programs are in place across the organization, and all staff participate in regular trainings. The workforce reports errors and close calls anonymously and without fear of retribution. Leaders across the organization embody behaviors that focus on trust, respect, and inclusion in all interactions.
Next steps: Review Foundational and Sustaining tactics: Educate leaders and workforce on inclusion, diversity, and communication with both patients and co-workers; Develop and implement disclosure and apology program; Include metrics for trust, respect, and inclusion as part of annual review process for all leaders.
Current state: Organization has a quality and safety committee that reviews all serious harm events, but these are rarely presented to the full Board. Time spent on safety during Board meetings includes a story of harm told by the safety/quality manager, and some questions are asked about the event. Board meetings prioritize financial review over safety review.
Next steps: Review Foundational and Sustaining tactics: Consider including a patient/family representative on Board and all committees; Provide opportunities for all Board members to participate on guided leadership rounds; Share all serious safety events and action plans with the full Board.
Current state: Organization has a robust just culture policy that is well-communicated internally and utilized in processes and departments across the organization and/or system. All staff are trained on just culture principles and use of just culture algorithm.
Next steps: Review Foundational and Sustaining tactics: Work with the Board and organizational leaders to align just culture policies across all professions and departments; Develop and review metrics for just culture; Hold workforce accountable for the utilization of just culture algorithm.
Current state: CEO and organizational leaders understand the criticality of trust, inclusion, and respect, but may not model these values in all situations. The workforce fears punishment from reporting and disclosing errors to patients. Hierarchies based on rank and role exist throughout the organization.
Next steps: Begin with review of Foundational tactics: Develop organization-wide respect for people programs; Train all leaders, staff, and clinicians on respect program; Develop, implement, and train on anonymous reporting systems; Establish a patient and family advisory council.
Current state: Organization’s Board members have strong financial backgrounds, but lack quality and safety expertise. Safety metrics are presented briefly at each Board meeting, and few questions are asked. The majority of the meeting focuses on financial review.
Next steps: Begin with review of Foundational tactics: Provide educational opportunities in safety science and culture for all Board members; Include a safety expert on the Board; Develop a patient and workforce safety dashboard for regular review; Establish a quality and safety committee.
Current state: Organization may have a just culture policy, but it is not robust or embedded in decisions and processes across the organization. Patient safety and risk management professionals are systematically trained in just culture principles.
Next steps: Develop a robust just culture policy; Educate the Board, leadership team, and workforce on just culture principles and the daily use of the just culture algorithm; Ensure utilization of just culture principles in all event reviews.