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“Relationships Eat Culture for Breakfast” and Other Safety Leadership Lessons

Why It Matters

"I believe it’s those personal connections, the individual and team/group relationships, that ultimately support the shared belief system we call culture."

Jeff Salvon-Harman, MD, CPPS, CPE, IHI’s new Vice President of Safety, puts his own spin on management consultant Peter Drucker’s most famous quote when he says, “Culture may eat strategy for lunch, but relationships eat culture for breakfast.” In the following interview, Salvon-Harman describes the experiences that have shaped a career devoted to safety culture and human factors and what he learned as the leader of a system-wide patient safety initiative.

What kinds of career experiences led you to focus on patient safety?

My time in aviation medicine with the US Coast Guard was the most influential. Seeing the degree of reliability in not just the flying and maintaining of the aircraft, but the critical operational decision-making impressed me. Wondering if we could apply the same degree of rigor around consistency of process and high reliability moved me towards patient safety in my medical career.

In aviation medicine, I trained to be an aviation mishap investigator. [I learned] the root cause analysis (RCA) model applied by the military, which was driven by the Human Factors Analysis and Classification System (HFACS). I saw that most health care adverse event investigations didn't go into the same depth, so it became apparent that we could use this layered approach of core root cause analysis methods supported by HFACS to get much deeper learning and to understand the latent conditions and preconditions that ultimately result in adverse events.

What do you see as some of the keys to understanding human factors?

We see individuals in health care with the best of intentions trying to outperform insufficiently designed systems in pursuit of the organization’s mission. But this means they rely on innately fallible tools like memory and workarounds. With human factors, we acknowledge the individual influences and limits of human performance, while also directing our attention to higher level preconditions beyond the individual.

The structure reminds us to not just look at the event itself, but to look at supervisory and organizational influences. Whether it’s the culture, procurement processes, supervision, or policy, they all impact the system in which the individuals are operating. This is in addition to their immediate environment and working interactions. One area that human factors can expand in the future is social relationship dynamics among teams and co-workers. The [existing] model tends to be very focused on actions between individuals but not on one’s emotional state. Ultimately, we have to re-imagine systems of care built on human-centric design principles addressing human limits, social interactions, optimal work environments, fully aligned supervision, management and leadership, and enabling process guidance and policies.

How did you become engaged with IHI?

I attended an IHI patient-centered medical home workshop in about 2010 when I was stationed at the US Coast Guard mid-level command, and we were developing [what became known as] the Patient-Centered Wellness Home Model. Later, when I moved to Coast Guard headquarters, I completed the IHI Open School basic certificate. From there, I transitioned to the [former IHI Strategic Partner] Indian Health Service headquarters, where I led Improving Patient Care, a patient-centered medical home transformation program. In my most recent role, I began working closely with the IHI Leadership Alliance leadership team and the Alliance’s Workforce Safety and Well-Being Working Group. I was also selected to participate in the [2021-2022] IHI Fellowship. It has been a steady path [to deeper engagement with IHI] since that introduction over 10 years ago.

You led the Journey to Zero Preventable Harm initiative for the largest health care system in New Mexico. What were some of the leadership lessons that you learned from that effort?

  • Build relationships. Borrowing from the IHI Psychology of Change framework, developing one-on-one relationships and interconnecting them into aligned teams is critical to any improvement work. Identify those partners and strategic stakeholders who will help you understand where they’re currently at and what the barriers to change might be. This way you can present solutions to problems instead of problems for solving.
  • Use the right tools. A Framework for Safe, Reliable, and Effective Care was released in 2017 and had a profound impact on my practice. In fact, since that time, I have aligned all my patient safety strategic planning around that framework. I have identified key initiatives that align to the various components and then linked them with some of IHI’s other influential frameworks, like the Psychology of Change, to optimize the implementation process.
  • Create a strong operational plan. [Make sure] that folks understand what you’re going to ask them to do and the steps required to move in that direction. Present a cohesive and deliberate sequence of actions leading to complete implementation and address potential barriers to align and synchronize efforts while also illustrating the vision of “how good by when.”
  • Use small-scale tests. Build some of your implementation methodology around Plan-Do-Study-Act (PDSA) cycles beginning with standard frameworks. Support a degree of local customization to the framework to match the culture of the unit or the department. There are many subcultures within any organization, and [adoption is] driven by those relationships and individual personalities defining them.

The other lesson that crystallized in my mind is the importance of relationships within organizational culture. Peter Drucker said, “Culture eats strategy for breakfast.” I say, “Culture may eat strategy for lunch, but relationships eat culture for breakfast.” I believe it’s those personal connections, the individual and team/group relationships, that ultimately support the shared belief system we call culture. Successful strategies rely heavily on culture and relationships that foster a sense of belonging.

Editor’s note: This interview has been edited for length and clarity.

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RCA2: Improving Root Cause Analyses and Actions to Prevent Harm

Patient Safety Essentials Toolkit