Start Small to Create a Safety Culture
By Jenny Slayton, Institute for Healthcare Improvement
We often hear about health care organizations that focus on creating a culture of safety. At Vanderbilt University Medical Center, it reminds us of how often in our journey we’ve paused and asked ourselves, “Will we ever get there?” The correct answer is that the job will never really be done because it’s an ongoing process. But we have a plan and we are on our way.
We started small. Just a few tests of change led us to establish a systemwide strategic plan for safety and quality. But it didn’t happen overnight.
Personnel in any size health care organization face massive amounts of work. This can paralyze us from trying anything new. We think we don’t have time, but just about everyone has time to start their pursuit of a safety culture.
How Vanderbilt Started Small
Start by doing something focused enough to represent a proof of concept. Run some PDSA cycles to fail fast and learn before presenting a plan to leadership. We chose something that allowed us to work out some of the kinks in our system.
We had been working on quality and safety initiatives for years, but our turning point occurred when we decided to improve our handwashing. “Choosing handwashing may seem trivial,” says Gerald Hickson, MD, Vanderbilt University Medical Center Senior Vice President for Quality, Safety and Risk Prevention. “But in years of working on this challenge, we still had difficulty performing this basic task in a highly reliable way.” Consequently, what sounded like a simple project became a stepping stone towards creating Vanderbilt’s organization-wide plan to address change.
At Vanderbilt, we didn’t ask, “Who in the world could be opposed to washing their hands?” Instead, we asked, “Are we willing to mutually support each other in our pursuit of high reliability?” This was important because the second approach is about values and our willingness to work together on our journey. It’s not about singling out individuals for blame.
In a safety culture, if one medical professional observes another who is not using the foam dispenser, they should avoid being judgmental. Instead, they should be willing to speak up about our collective commitment to our patients and each other. That is the type of culture we are pursuing.
4 Keys to Building a Safety Culture
At Vanderbilt, we’ve applied what we learned from our handwashing work to a range of other safety improvement opportunities. Says Hickson, “We first learned to wash our hands. We then decided that reliably implementing a certain practice bundle would reduce surgical site infections. Vanderbilt team members understood that [we were going to use] the same approach to roll out our new safety plan.” Here are some important lessons we’ve learned:
- Commit to safety — We must be dedicated to preventing injury to our patients and each other. “You ensure that each new quality and safety initiative is aligned with your strategic goals,” says Hickson.
- Demonstrate Respect — Modeling respect begins with senior leaders. You don’t have a culture of safety if people, especially leaders, don’t treat each other with respect and don’t respect safe medical practices like washing our hands, scrubbing the hub [to prevent central line infections], or using antibiotics thoughtfully. “Medical professionals have to trust that, if they speak up, what they say is going to be heard,” says Hickson.
- Focus on quality — At Vanderbilt, this means measuring ourselves against the best health care systems in the world. We wouldn’t be satisfied with being average.
- Focus on value — Remember that the goal should be to pursue high-quality outcomes from the patient and community perspectives. Our hand hygiene and surgical site infections prevention work, for example, have brought value to Vanderbilt, our patients, and our entire community.
At Vanderbilt, we have also tried to shift our culture from just thinking about rates and incidences to seeing our patients as individuals. “We harmed Sue. She was a 29-year-old mother of two.” Using our patients’ names puts our numbers into context and motivates us to design better systems to improve care. This approach reminds us why we got into health care in the first place.
Creating a safety culture also means promoting professional accountability while respecting fellow health care team members. For example, imagine someone who has repeatedly declined to follow the handwashing protocol. We sit down and have a conversation with them instead of pointing fingers. We acknowledge that team members work hard, and we all struggle from time to time. We work together to identify what’s gone well, sort out what the data tells us, and find best practices to move forward.
You also need to equip key team members to create a culture of safety and respect. For Vanderbilt, IHI’s Certified Professionals in Patient Safety (CPPS) credential has become instrumental to our organization’s mission. We have 26 individuals who are certified so far. Certification connects our team members to others outside Vanderbilt who regularly think about the pursuit of safety. Our team members also see certification as a professional development credential because they enter our leadership pipeline upon completion.
We can’t always predict the challenge of the day, but we can prepare team members with the right training and support them throughout our safety journey. You don’t go out one day and run a marathon. You start by running for 30 minutes, and then building strength and stamina from there. The journey can begin by doing just one new thing.
Jenny Slayton, RN, MSN, is Executive Director of Quality Improvement for Vanderbilt University Medical Center.
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