Strategies for building and maintaining a safety culture

Organizational Readiness Level: Tactics

Examples of tactics that may be implemented to create change at much of these levels

Foundational

To engage your organization:

• Work with select individuals throughout the organization to develop understanding of key organizational interests and goals
• Work with leadership team to develop aspirational end state (e.g., zero harm) that will be incorporated into vision
• Communicate the definition and importance of a culture of safety
• Build awareness of current state through culture surveys, observations, and focus groups, and communicate this throughout the organization
• Include zero harm vision in all communications from leaders at all levels, and keep this communication simple, consistent, and repetitive
• Include equity of care as part of vision statement and communicate the definition and importance of health equity
• Conduct training and information sessions for all employees to build understanding and enthusiasm for the vision
• Spend time on all floors and units communicating the connection of culture of safety and vision to the work of the frontline

Sustaining

To engage your organization:

• Clearly articulate your vision to the workforce and the public
• Benchmark culture progress and best practices with other similar organizations (e.g., participate in collaboratives)
• Develop and implement a recognition program for leaders, clinicians, and the workforce based on growth and adherence to vision
• Establish organizational goals that address safety and disparities in care

To engage clinical leaders:

• Include physician, nursing and other clinical leaders in development of vision statement and strategic plan

To engage patients and families:

• Clearly communicate the vision statement and values to patients
• Incorporate patient and family stories, along with statistics, when discussing vision at the Board level
• Include patient feedback in the development of vision statement

---

Organizational Readiness Level: Tactics

Examples of tactics that may be implemented to create change at much of these levels

Foundational

To engage your organization:

• Commit to implementing and holding all leaders and the workforce accountable for processes and policies related to respect for people, just culture, and managing disruptive behavior.
• Encourage and promote open discussion of safety issues via leadership rounds and reporting systems, and ensure follow-up and feedback.
• Ensure that the workforce has dedicated time to devote to patient safety and safety culture work.
• Implement workforce safety programs to reduce physical and psychological harm to the workforce.
• Clearly define and encourage behaviors that show deference to expertise rather than hierarchy or title.

Sustaining

To engage your organization:

• Aim for total transparency, but explain situations in which the organization is unable to be completely transparent.
• Publicly share available information about events of harm, and plans for managing associated risks.
• Ensure follow-up and feedback on identified safety issues, and be transparent if an aissue cannot be resolved promptly.
• Create compacts for leaders that clearly define expected behaviors in trust and transparency as they relate to other leaders, peers, and subordinates.
• Build metrics for respect and trust (e.g. workforce psychological safety, error reporting) into the evaluation process for all leaders.

---

Organizational Readiness Level: Tactics

Examples of tactics that may be implemented to create change at much of these levels

Foundational

To engage your organization:

• Establish Board Quality and Safety Committee with oversight responsibility for culture change, safety, and performance improvement.
• Include an individual with safety and culture expertise on Board and appropriate committees, or ensure an advisor with these skills is available to the CEO and the Board.
• Begin each Board meeting with a slide detailing the number and names of patients and staff who experienced harm since last meeting, and include a story about at least one of these individuals.
• Regularly share and discuss a dashboard that includes patient and workforce safety and culture metrics.
• Utilize a Board self-assessment that includes inquiry on safety culture knowledge to determine educational opportunities.
• Identify a list of required Board competencies specific to leading culture improvement.
• Discuss whether Board reflects the community your organization serves and implement action plan to address any gaps.
• Invest in resources for Board education, including patient safety science and quality.
• Create a matrix of Board competency needs and seek candidates with these skills in mind.
• Regularly review accreditation survey results with the Board.
• Encourage ample clinical expertise, including physicians and nurses on the Board and/or on Board committees.
• Include a presentation on a current organizational safety culture issue by an expert in safety and quality at each Board meeting.
• Educate Board members on issues of disparities in care.

Sustaining

To engage your organization:

• Encourage the Board to link executive compensation to safety outcomes, while ensuring metrics chosen do not discourage safety efforts.
• Include Board members on guided leadership rounds.
• Align Board dashboards to show safety and quality metrics as segmented by categories related to disparities in care.
• Ask Board members to participate in events to show their support during Patient Safety Awareness Week and to be present at major quality, safety, and culture-related events.
• Bring frontline teams to Board meetings to share their success stories and receive recognition.
• Consider a rotating position on the Board or Quality and Safety Committee reserved for the frontline workforce.
• Request that Board members spend time on all floors and units communicating and supporting the safety agenda.
• Provide Board members with opportunities to learn from Boards and leaders of outside organizations and industries.
• Require Board approval on resolutions to all serious safety events.

To engage clinical leaders:

• Involve physicians, nurses, and other clinical leaders to present clinical and quality improvement efforts regularly to the Board.
• Bring clinical leaders dedicated to culture to Board meetings to share their experience and receive recognition.

To engage patients and families:

• Create positions for patient/family representations on your Board and on you quality/safety committee(s).
• Present patient stories at Board and appropriate committee meetings.
• Invite patients to attend Board meetings and personally share their stories and experiences (both positive and negative).

---

Organizational Readiness Level: Tactics

Examples of tactics that may be implemented to create change at much of these levels

Foundational

To engage your organization:

• Define and develop organizational leadership competencies in safety culture and safety behaviors and ensure that all current and future leaders and the frontline workforce receive education in selected competencies.
• Define cultural roles and expectations for all leaders within the organization, including clinical leaders.
• Create systems to support leaders in culture work at all levels of the organization through training, coaching, and mentoring.
• Consider safety expertise and credentialing along with leadership potential when considering emerging leaders.
• Discuss whether leadership team reflects the community the organization serves and develop plan to address any gaps.
• Create systems that ensure regular reporting on leadership development measures.
• Develop and employ a talent review process that is candid and transparent.
• Conduct gap analysis of CEO and leadership for knowledge. skills, and attitudes around patient safety and culture.
• Ensure all executives can clearly articulate how a culture of safety applies in their department, and that all leaders can do the same.
• Develop systems that encourage deference to expertise rather than hierarchy or title in issues of safety.

Sustaining

To engage your organization:

• Build an incentive program into leadership reviews that is focused on reporting performance on key culture of safety metrics.
• Provide continuing learning opportunities in safety and culture, with a focus on experiential learning.
• Tie measures and performance on safety and culture to leadership development priorities, talent management reviews, and succession planning.
• Provide opportunities and expectations for leaders to learn outside of the organization, both wiwth similar organizations and outside industries.
• Build a guiding coalition of champions, including clinicians and frontline workforce members, that provides candid and honest feedback to the CEO.
• Incorporate leadership development into organizational people strategy.
• Define talent as an organizational resource and allow for interdepartmental training and mobility.
• Ensure leaders are trained to teach and coach their employees.
• Recommend that each senior executive participate in communication and apology to patients and families who have experienced harm.

To engage clinical leaders:

• In leadership development programs, incorporate opportunities for clinical leader advancement.

To engage patients and families:

• Ensure leaders have competencies in how to partner effectively with patients at all levels of care.
• Include patient and family representatives in leadership recruitment and hiring process.

---

Organizational Readiness Level: Tactics

Examples of tactics that may be implemented to create change at much of these levels

Foundational

To engage your organization:

• Educate Board, leadership, and workforce about just culture through integrated training programs.
• Develop and implement a decision-making process and application of just culture that is bahavior-based, rather than harm-based.
• Ensure organization-wide leadership commitment to frameworks of just culture and accountability that are aligned across all departments.
• Create an interdisciplinary jut culture champion team to review organizational policies, provide training, and ensure policies are being followed at all levels.
• Identify metrics to track performance on just culture implementation.
• Align systems and sstandards for just culture across all organizational departments, including Human Resources.
• Ensure employees are well-trained in just culture algorithm and tools and utilize them in daily activities and decisions.
• Publicly reward positive examples of just culture.

Sustaining

To engage your organization:

• Educate organization to be responsive to and transparent about actions related to professional discipline.
• Implement a peer support program.
• Hold workforce accountable for implementing just culture principles in daily practice and decision-making.
• Include actual and mock scenarios on meeting agendas that demonstrate application of just culture principles.
• Involve the media as a way to explain errors, decisions, and data to the public.
• Treat and respond to gaps in culture and expected safety behaviors as adverse events.
• Expect that leaders utilize just culture tools in all situations, even those not significant or punishable, to ingrain principles and use into organizational norms.

To engage clinical leaders:

• Include clinical leaders in the development of just culture policies.
• Provide training for physicians, nurses, and other clinical leaders in just culture to build understanding and enthusiasm.

To engage patients and families:

• Ensure that patients and family members who serve on Board and committees are educated on just culture principles.
• Include patients and families in mediation committees/tribunals to assist in resolving conflicts between departments.

---

Organizational Readiness Level: Tactics

Examples of tactics that may be implemented to create change at much of these levels

Foundational

To engage your organization:

• Complete culture of safety surveys every 12~18 months and review with Board, leadership team, and workforce; set targets for improvement and take deliberate action to achieve them.
• Stratify and track culture and safety metrics by sociodemographic variables taht are important to the organization's community and develop plans to address any gaps.
• Develop required processes for teamwork, communication, and handoffs among the workforce and with patients, using tools like SBAR, read back, 'stop the line', briefings, and de-briefings.
• Require, participate in, and give context for existing safety processes, including safety huddles and operational briefings, and use these opportunities as forums to build better teamwork and safety culture.
• Define organizational safety behavior expectations and respectful behaviors, as well as the organizational response to disrespectful behavior and conflict.
• Proactively promote and encourage teamwork by implementing a formal team training program.
• Break down hierarchical policies and systems for reporting, and encourage reporting without fear of punishment or retribution.
• Break down power gradients by communicating and rewarding a poliy that requires all staff to speak up for safety concerns.
• Develop and abide by leadership behaviors, including appreciative or humble inquiry.
• Celebrate and recognize individuals and teams who excel at key safety behaviors.
• Work with key stakeholders to clearly communicate and enforce the same behavioral standards for both employed and non-employed practitioners and staff.

Sustaining

To engage your organization:

• Require annual signatures on compacts for Board members, leaders, and the workforce that clearly define expected professional accountability behaviors.
• Educate and explain to your organization and the public what you will be transparent about, and what limits may exist on transparency.
• Design and implement a crisis communications policy and plan for both internal and external audiences.
• Align and integrate organizational safety and respectful behaviors with all departments across the organization.
• Provide feedback to employees when they report a safety issue, closing the loop and demonstrating how frontline callouts improve safety.
• Recognize and reward individuals and teams for demonstrating positive safety behaviors and reporting.
• Ensure the existence of measurement tools and/or report cards for individual performance.
• CEO requires and accepts notification of any serious safety events within 24 hours, without exception.
• SBAR for all serious safety events is shared with full administrative and clinical leadership teams and with the Board.
• Leadership distributes awards for teams and organizations based on culture of safetty metrics.

To engage clinical leaders:

• Recognize and reward physicians, nurses, and other clinical leaders who actively participate in teamwork and communication initiatives.
• Create (and require signatures on) physician and leadership compacts that clearly define behavioral expectations.
• Commit to and train the workforce on communication and resolution programs.

To engage patients and families:

• Include patients in the development of required processes for communication with patients, using tools like AskMe3 and shared decision making (SDM)
• Encourage and enable patients and families to report safety concerns, and follow up with families who have reported.
• Ensure that safety behavior expectations are centered around the patient, and involve patients in setting these expectations.
• Create, supply, and use understandable tools for patient involvement and shared decision making.
• Invite patients to utilize versions of communication and reporting tools (e.g. SBAR) and to participate in team processes.
• Have a designated team available to provide support to patients, families, and the workforce when an error has occurred.

---