Cultivate a Culture of Safety

Here’s how to make sure everyone buys into a collective mindset that keeps patients and staff free from harm.

There was a time, long, long ago, when ASC administrators felt like referees caught in the middle of a frustrating bout between productivity and safety. “When ASCs were first coming onto the scene, there was a productivity mindset,” says Spence Byrum, CEO and founder of HRS Consulting, a human performance improvement company based in Weston, Fla., that has contracted with more than 350 ASCs. “If you had somebody who was a big producer, no matter what they said or did, that trumped any safety issues because that person was so pivotal to the financial well-being of the ASC.”

A ticking bomb

Not anymore, says Mr. Byrum. The bout between efficiency and safety is over, and the decisive winner is … both. Time has ushered in the recognition that efficiency without safety is at best a masquerade, and at worst a ticking bomb.

Efficiency and safety can indeed seem like adversarial goals, says former ASC administrator Andy Poole, director of strategy and innovation for Plymouth Meeting, Pa.-based healthcare safety consultancy ECRI. “You have to move people through the system, and you don’t want anybody to slow the process down,” he says. “But ultimately, everybody has to feel comfortable speaking up and slowing things down if there’s a reason to do so.”

The stakes are simply too high to do otherwise.

“If you tolerate a rogue who does things on their own, you’re placing your entire enterprise at risk, and other people’s careers, too,” says Mr. Byrum. “Things like wrong-site surgeries and retained objects are ‘gifts’ that keep on giving. They can harm your license, harm your center, harm your reputation in the community and, most importantly, harm patients.”

What are the hallmarks of a true culture of safety? And how can you ensure that you’re never lulled into a false sense of security?

Walk the walk

“The biggest thing is visible and consistent leadership around safety,” says Mr. Poole. “Walk the walk and not just have it be, ‘Yes, everyone can speak up here. Now shut up and let’s get the case started.’”

True leadership, he says, requires a visible response. “When somebody speaks up and pulls the chain on the assembly line and grinds it to a halt, that’s a big deal,” he says. “But ultimately, you need to reward that person in a very public way by saying, ‘This is what we learned, this was a risk that was identified, and this person spoke up and did the brave thing.’”

Leaders should do this even if the concern turns out to have been unwarranted. Mr. Poole recalls an event from his days as an administrator. “A staff member perceived confusion during a time out when there actually wasn’t any,” he says. “Everybody was on the same page. Maybe that person was distracted, but she still called it out. And that should be OK, no problem. We regrouped, we made sure we were on the same page and we moved forward. But the interruption should still be supported.”

The alternative, says Mr. Byrum, is to sacrifice what could be an important safeguard down the road.

“If the response is, in effect, ‘Just sit there and be quiet,’ then that person’s going to feel disenfranchised, and you’ll lose a set of eyes and ears that could help with future safety interventions,” he says. “You have a chance to let that person know you value their opinion. If you show them you don’t, they’re just going to clam up and not say something later on.”

ASC leaders should regularly tell staff members it’s good to speak up when they have questions and concerns. But is that enough?

Not by a long shot, says Mr. Poole. “There can always be a disconnect between leaders and the people doing the work,” he says. “A leader may say, ‘Everybody’s able to speak up here,’ but then you talk to staff and they say, ‘Oh no they’re not. If I say something, I know that guy’s gonna yell at me.’”

Doing a survey, committing to providing full-disclosure feedback, and putting in action plans and follow-up surveys are important steps.
Andy Poole

In other words, simple but ultimately insincere encouragement may be rightly perceived as lip service. The best way to ensure people really feel that they and their opinions and observations matter is to train them that they indeed do matter.

“Include training on how to speak up,” says Mr. Byrum. “Because there’s a timing piece to it. There’s a way to focus on the ‘what’s right’ rather than the ‘who’s right.’”

Train and measure

“It’s hard to speak up,” Mr. Byrum acknowledges. “There’s still a hierarchy, and the people you might be addressing are the people who are bringing in the business.”

For the same reason you wouldn’t think of forgoing training on a new piece of equipment, don’t assume you can forgo the training needed to invest in a culture of safety. “It’s worth that little bit of extra time to make sure people are properly trained on that piece of equipment,” says Mr. Bynum. “It also makes sense to take the time to make sure people know when to speak up, how to speak up and what to say.”

Still, how do you know whether staff members feel comfortable speaking up? And how do you know whether you’re getting truly candid feedback?

Leaders can measure how well they’re doing and where they’re falling short in trying to build a culture of safety by, for example, using Agency for Healthcare Research and Quality (AHRQ) surveys on patient safety culture.

“It’s one of the biggest things you can do,” says Mr. Poole. “Doing a survey, committing to providing full-disclosure feedback, and putting in action plans and follow-up surveys are important steps. Find out whether you’re demonstrating the right behavior by having people invite open conversations around safety in a punitive-free fashion.”

Amber Hogan Mitchell, DrPH, MPH, president and executive director of the International Safety Center, recommends also scrutinizing internal reports. “Pay attention to your own surveillance data,” she says. “Not just an annual rate or ratio, but descriptions of how injuries and incidents occurred. Specific circumstances of incidents need to come from your own data, so that you can focus campaigns and initiatives.”

Always follow up when somebody takes the time to fill out an incident report. “People need to know it doesn’t just go into a file and sit there,” says Mr. Poole. “They need to know there’s action being taken, that there’s a feedback loop that’s closed. And you need to thank them for taking the time to do that, as opposed to reacting as if you’ve gotten another one of those damn sheets you’ve got to deal with.”

A tangible way to signal to your people that speaking up is welcomed is to implement a “good catch” program in which a person who brings forward a near-miss gets an award. Doing so can provide a great motivator.

“People say, ‘I want to be an award winner. I want to be recognized for being a safety advocate’,” says Mr. Poole.

Don’t overreach

Business is business, of course. You hate to turn potential customers away, but overreaching can raise serious safety issues.

“The pre-assessment of who you can take and not take in a surgical center is an important consideration,” says Mr. Byrum. “Sometimes there are just too many comorbidities to do something in an environment where there isn’t a significant backup available.”

Embrace true leadership

CULTURE WARS Spence Byrum, a human performance improvement expert who has worked with more than 350 ASCs, speaks to an engaged audience about what it takes to create a true culture of safety.

There’s no question that ASC leaders who want to adopt and fully embrace cultures of safety can face numerous obstacles along the way.

“If there’s a problem, it can be because leadership either hasn’t dealt with bad actors or because the leaders themselves are the bad actors,” says Mr. Poole. “And that makes it really challenging.”

“First and foremost, you must have a conversation with a problematic provider,” says Mr. Byrum. “And you have to be careful how you do that. Some people are more responsive to peers, some are more responsive to the administrator, and some might have to be dealt with at the board level.” The board level, says Mr. Poole, was where he staked out an absolutely critical emphasis on safety when he was an administrator.

“I led every board meeting with patient comments and usually with recognition of a staff member,” he recalls. “There should be an attitude that safety is important to us as an organization and that safety events are going to be the first thing we talk about — before we talk about financials.”

The only message that can permeate the entire organization is one that begins at the top and is continually reinforced, he adds.

“You’re not going to see the staff change the culture on their own,” says Mr. Poole. “There’s not going to be a groundswell underneath. It must be leadership-embraced change.” OSM