Professional Documents
Culture Documents
Thought Paper - 230520 - 230235
Thought Paper - 230520 - 230235
Dr Michael Leonard
Dr Michael Leonard is Co-Chief
Medical Officer at Pascal Metrics,
which applies software-driven data
science to improving patient safety.
Dr Leonard has advised senior
clinical and executive leaders and
has led clinical intervention and
training in hospitals and healthcare
systems in North America, Europe,
and Asia. Most recently, he was
named Adjunct Professor of
Medicine at Duke University School
of Medicine. In addition to extensive
teaching and lecturing, Dr Leonard
has written widely on patient safety.
Dr Allan Frankel
Dr Allan Frankel, is Co-Chief Medical
Officer at Pascal Metrics.
Dr Frankel is senior faculty at the
Brigham and Women’s Hospital
Patient Safety Center of Excellence
in Boston and the Institute for
Healthcare Improvement. He
has advised clinical and hospital
leaders worldwide.
How can leaders influence a safety culture? Michael Leonard & Allan Frankel 3
Effective leaders must also address the Leaders contribute to psychological
behaviours that create unacceptable risk, safety and a collaborative care environment
such as disruptive or disrespectful in a number of important ways. High-
behaviour, and send a very clear message performance safety cultures hire individuals
that these behaviours will not be tolerated. with positive attitudes with regard to
The real test of leadership and collaboration, treating others with respect,
organisational culture comes when someone and working toward a common goal.
does act in this way. It is really not a While technical skill is necessary, healthcare
question of ‘if, but rather when’ this will is a profound social process for patients and
occur. Leaders need to know that their caregivers. Leaders need to continuously
response will be watched widely and closely, message the cultural values of the
and will send a very powerful message organisation. A good example of hiring for
within the organisation about its culture. attitude is the Mayo Clinic, where people
If leaders are consistent in holding people are selected and evaluated for their ability
accountable for unacceptable behaviours to practice in ‘the Mayo way, where the
that create risk, they will have laid the needs of the patient come first’.4 As Berry
foundation for a strong safety culture. and Seltman noted in their article about
the Mayo Clinic, one of the senior Mayo
Psychological safety physicians interviewed remarked, ‘I don’t
Creating psychological safety is a recall a speech or meeting I attended where
fundamental responsibility of leadership in the core values of the institution were
creating a safety culture. Psychological safety not mentioned.’5
is an environment where no one is hesitant to
voice a concern about a patient or anything Building a safety culture
that puts the organisation at risk.2 If you In addition to the importance of the
think of the people you are always manifestation of core organisational values
comfortable going to when you have a and behaviours, there is a fundamental need
question or problem, it is because it is to measure and understand safety culture at
psychologically safe to do so. Not only are a clinical unit level. The use of a validated
they going to help you, but you also know survey instrument, with a high response
that they will treat you with respect. The rate greater than 60% that reflects the
individuals you are hesitant to approach perceptions of individual caregivers at the
because it will be unpleasant or demeaning unit level, is important. Units where
personify a lack of psychological safety. caregivers have very positive, concordant
Unfortunately, there are numerous examples perceptions of psychological safety,
of serious, avoidable harm and death teamwork, and leadership, and feel
occurring in hospitals because a caregiver felt comfortable discussing errors, provide safer
intimidated to voice their concern because it care environments for both caregivers and
was psychologically unsafe to do so.3 patients.6,7 The concordance, or similarity,
How can leaders influence a safety culture? Michael Leonard & Allan Frankel 5
language refers to a phrase, that when heard, incompetent – and the absence of a simple
requires the team to stop and take one algorithm that makes it safe to discuss the
minute to reassess and ensure that they are events and learn from them reinforces a
going in the right direction. In the absence veritable wall of silence. Individuals need to
of critical language, caregivers may not be skilled, conscientious and play by the
speak up or engage in mitigated speech – rules. They should not behave maliciously,
the proverbial ‘hint and hope’. This is perform their duties when knowingly
dangerous, as a busy clinician focused on a impaired, engage in unsafe behaviour, or
problem or procedure may miss this signal, make mistakes that someone of similar skill
and errors could occur. A very nice critical and training would not make under similar
language term is ‘I just need a little clarity’. circumstances. If they can answer the above
This can be voiced in front of a patient or questions correctly, the problem is a
their family without causing undue alarm or system-derived error.
stress.11 Leaders effectively impact the use of Organisational fairness can only be
critical language and psychological safety by successful when actively supported by
being clear that everyone must speak up if leadership. Human error is pervasive, even
they have a concern or are unclear as to the among skilled practitioners, and complex
plan of care, and making it clear that they systems also generate errors. In order to
will always be treated with respect if they do. learn and improve, caregivers need to know
Debriefing is the final teamwork that it is safe to discuss mistakes and near
behaviour that closes the loop and facilitates misses. Leaders need to create the safe space
both teamwork and learning. Sustaining to have these conversations, model the right
these team behaviours depends on the ability behaviours, and act in response to these
to capture information from front-line events for organisational fairness to work.
caregivers and take action as described in Discussing contributing factors and system
the section on ‘The learning system’, below. thinking helps to identify opportunities and
raises awareness among clinicians of system
Organisational fairness failures that need to be fixed. The ability to
or ‘Just Culture’? openly discuss errors and adverse events
In the aftermath of an adverse event or near internally is a necessity for open, honest
miss, caregivers need a simple set of rules, disclosure with patients and their families.
that allows for the determination between Most adverse events stem from a
unsafe individuals and skilled individuals combination of factors, and often the
set up to fail by an unsafe system. We have shortcuts, or normalised deviance, are
all been trained in a culture that says skilled, critical factors. Leaders must really
capable practitioners don’t make mistakes if understand how caregivers are providing
they try hard and pay attention. This makes patient care to effectively manage. For
it personally threatening to talk about example, a patient receiving emergency
mistakes – nobody wants to look stupid or care required antibiotics and pain
How can leaders influence a safety culture? Michael Leonard & Allan Frankel 7
The process board will have a maximum learning system. By ensuring that the
of 10 to 12 process or outcome measures learning system is visible and functional,
that are relevant to the delivery of care on leaders are sending an important cultural
that unit. The goal is to remind caregivers message – that the wisdom of front-line
every time they walk onto the unit about caregivers is valuable and needs to be
key aspects of care that are important and acted on. Also, by spending time on the
they need to pay attention to. On a medical clinical units with staff in front of the
ward, the measure – a single number learning boards, they validate and
reflecting what the current state is, next to reinforce the improvement work already
the stated goal – could refer to hand accomplished, and connect the attention
hygiene rate, falls with harm, rapid response and resources of leadership for problems
calls, percentage of patients at risk for beyond the scope of front-line caregivers
pressure ulcers who were turned every 60 to resolve by themselves.
minutes, and medications administered
within a given amount of time.
The annotated run charts reflecting the
story behind the work on process board lives
in the staff room, where the annotations, or
text, tell the story of what the staff talked
about, the tests of change performed and
how the process has improved over time.
This narrative is very important, as
improvement is a continual, iterative process.
Being able to see what the team has talked
about, what they have done, and how that
relates to positive improvement is an
important part of validating the work and
sustaining the effort.
The learning board can be divided into
the three boards: red for defects or
opportunities identified; yellow for problems
that are being addressed, with the individuals
responsible clearly identified; and green for
where the problem has been resolved.
A learning system that captures
information and tracks improvement
builds trust and the capacity to drive
improvement. Leadership plays a crucial
role in creating and maintaining the
How can leaders influence a safety culture? Michael Leonard & Allan Frankel 9
References
1 Classen DC, Resar R, Griffin F, Federico F, Frankel
T, Kimmel N, et al. ‘Global trigger tool’ shows that
adverse events in hospitals may be ten times greater
than previously measured. Health Aff (Millwood)
2011;30(4):581-9.
2 Edmondson AC. Managing the risk of learning:
psychological safety in work teams, 2002.
www.hbs.edu/research/facpubs/workingpapers/
papers2/0102/02-062.pdf (accessed 19 April 2012).
3 Bognár A, Barach P, Johnson JK, Duncan RC,
Birnbach D, Woods D, et al. Errors and the burden
of errors: attitudes, perceptions, and the culture
of safety in pediatric cardiac surgical teams.
Ann Thorac Surg 2008;85(4):1374-81.
4 Berry LL, Seltman KD. Management lessons from
the Mayo Clinic. New York: McGraw-Hill; 2008.
5 Berry LL, Seltman KD. Building a strong services
brand: lessons from Mayo Clinic. Bus Horiz
2007;50:199-209.
6 Hansen LO, Williams MV, Singer SJ. Perceptions
of hospital safety climate and incidence of
readmission. Health Serv Res 2011;46(2):596-616.
7 Hudson DW, Sexton BJ, Thomas EJ, Bernholtz
SM. A safety culture primer for the critical care
clinician: the role of culture in patient safety and
quality improvement. Contemp Crit Care 2009;
7:1-14.
8 Sexton JB, Paine LA, Manfuso J, Holzmueller CG,
Martinez EA, Moore D, et al. A check-up for safety
culture in ‘my patient care area’. Jt Comm J Qual
Patient Saf 2007;33(11):699-703.
9 Leonard MW, Frankel AS. Role of effective
teamwork and communication in delivering safe,
high quality care. Mt Sinai J Med 2011;78(6):820-6.
10 Lyndon A. Social and environmental conditions
creating fluctuating agency for safety in two urban
academic birth centers. J Obstet Gynecol Neonatal
Nurs 2008;37(1):13-23.
11 Leonard MW, Frankel A. The path to safe
and reliable healthcare. Patient Educ Couns.
2010;80(3):288-92.
12 Personal communication, Jim Conway.