Patient Safety Efforts Need Engaged Leaders

The Joint Commission warns that hospital leaders are not promoting changes needed to improve attitudes toward safety, and new research both confirms and challenges the validity of tools designed to measure patient safety culture.

Health system administrators concerned about patient safety can't personally control how expertly care is delivered. But researchers say that engagement from the C-suite is key to the promotion of patient safety culture needed to deliver high quality care.

Now, The Joint Commission (TJC) has issued a Sentinel Event Alert about leadership and safety culture.

Based on analysis of safety data collected by the accrediting organization, the document asserts that "leadership's failure to create an effective safety culture is a contributing factor to many types of adverse events, from wrong site surgery to delays in treatment."

The assessment comes with an 11-item list of safety culture "tenets" for health system leaders follow to promote a positive safety culture. It also comes as new data emerges both supporting and challenging the tools in use to measure safety culture.

IHI, NPSF to Merge, 'Re-energize' Patient Safety Agenda

Rather than blame and punish those who make or are involved in errors, patient safety culture is moving toward "just culture," where, as described by TJC, "people are encouraged, even rewarded, for providing essential safety-related information."

With the exception of egregious behavior, the idea is to get people to identify and learn from mistakes, not to conceal them. (TJC notes, however, that "clear lines are drawn between human error and at risk or reckless behaviors.")

Stronger safety culture scores correlate with staff reporting events and near misses, according to a January study from the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine.

But there have been reports of "retaliation and intimidation targeting care team members who voice concern about safety and quality deficiencies," according to TJC. It cites instances of "overtly hostile actions, as well as subtle or passive-aggressive behaviors, such as failing to return phone calls or excluding individuals from team activities."

Leadership Involvement Imperative
Recommendations in TJC's "alert" call on leaders to "establish and continuously improve the five components of a safety culture… trust, accountability, identifying unsafe conditions, strengthening systems, and assessment."

The topic of leadership also came up in the National Patient Safety Foundation's status report marking 15 years since the publication of the seminal "To Err is Human" report on medical errors. Number one on that 2015 list of recommendations: "Ensure that leaders establish and sustain a safety culture."

It makes sense that hospitals make sure everyone, from the CEO to the staff who handle waste disposal, be aware of and on board with efforts to protect patients from harm. Several tools enable hospitals and health system to gauge and monitor staff attitudes when it comes to safety.

Other Patient Safety Studies
Recent studies correlating patient safety culture measures with other quality metrics have had both positive and negative results.

One study, published in the BMJ Quality and Safety Journal, looked for a link between patient safety scores and two common hospitals acquired infections: central-line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). It didn't find one.

Jennifer Meddings, MD, is an assistant professor at of the University of Michigan Medical School and lead author of the study. Infection rates improved, she says, but safety scores didn't.

Meddings' findings suggest that the safety culture measure she used, the widely used Hospital Survey on Patient Safety Culture (HSOPS), may not be adequately measuring safety, since surveys like this one take up time that could otherwise be used for patient care, hospitals need to be sure they are valid, she says.

"If you can't correlate this survey with important clinical outcomes, perhaps you should be spending more time on discrete tasks at the bedside," Meddings says.

Jeff Brady, MD, is the director of Center for Quality Improvement and Patient Safety at the Agency for Health Quality Research (AHRQ). Academics and researchers working with his agency developed and vetted the HSOPS survey and are currently working on a revision, which will be tested at 40 hospitals starting next month.

Brady says the HSOPS is a well-vetted tool that has been key to improving safety. Each organization needs to understand its own unique culture, and the survey allows them to do that, he said.

"You figure out what areas you do well in, and you figure out areas where there might be opportunities for improvement and you take the next step by focusing on those areas," Brady said.

He notes that many of the "Tenets of Patients Safety Culture" in the Joint Commission Sentinel Every Alert are also in the HOSPS survey.

In his view, leadership's role is to attend to all of those necessary steps. "Know what your culture is and make sure it's optimalized for safety and quality."