Quality Update

Developing a Safety Culture with Front-line Staff

By Laura Lindberg, Kim Judd, R.N., and Jennifer Snyder

Patient safety efforts permeate every aspect of health care. Yet, medical errors and potentially unsafe practices continue to trouble administrators, managers and front-line caregivers on a daily basis. Determining where to focus improvement efforts can be a challenge, as well as how to fully engage employees and staff.

Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety and by confidence in the efficacy of preventive measures.

The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management.

Hospital administrators want to inspire staff and develop an internal culture that puts patient safety at the forefront. However, while safety may be the No. 1 priority in the mission statement, because of numerous budgetary pressures, it may not always be reflected that way in daily actions. Developing a culture that promotes patient safety requires all staff to regularly engage in practices that prevent harm.1

Front-line staff and patient safety

With mounting pressures, hospital administrators have become very reactionary, appearing to front-line staff to only focus on patient safety when something bad happens (see chart on, page 85). The efforts and planning that go on behind the scenes are not always communicated throughout the facility. A focus on patient safety cannot be limited to meetings of administrators or the patient safety committee. Engaging the front-line staff in daily efforts to improve patient safety is critical to success. If front-line caregivers are able to follow the process of problem identification, the formulation of solutions, the selection of an improvement plan, and finally, implementation, they will be more committed to the effort.

Front-line staff members are probably the most underutilized asset when developing a safe patient care area. With their hands and eyes directly engaged in patient care, well-trained safety-focused front-line staff can be a powerful defense against medical errors.

This front-line involvement can also help foster an organizationwide culture change that makes patient safety a recognized daily priority.

Developing the safety coach

Inspiring and developing a patient safety culture requires a focused and consistent effort. University Medical Center administrators knew that their safety culture needed additional focus and improvement. In 2007, the Lubbock, Texas-based organization conducted its first safety culture survey. Analysis of the survey data provided a complete view of the organization’s culture through the eyes of staff members and highlighted specific areas in need of the most attention. Developing a safety culture is a formidable challenge—without the data to guide the improvement, it is very easy to get lost.

UMC’s safety coach program was designed to promote open communication, teamwork and error-reporting. To engage front-line staff, managers asked them to apply for a safety coach position by filling out a form and submitting their most recent performance evaluation.

All units and departments throughout the hospital were encouraged to participate. A committee composed primarily of UMC administrators set up guidelines for representation—units that work from 8 a.m. to 5 p.m. would have one safety coach; units open 24 hours would have one for each shift. This structure provides equal representation across the hospital without creating a team that is too large and unwieldly.

Role of a safety coach

The role of the safety coach is twofold. First, they instruct colleagues on safety issues and take the lead in preventing errors. Their primary role is to resolve any immediate danger as soon as they spot a safety issue.

The second part of their role is to serve as the eyes of the administration. They take note of incidents and observations and discuss that information at the monthly meeting of safety coaches. The concerns are then shared with the appropriate leaders. In many cases, the process has led to effective patient safety projects.

The safety coaches often share their experiences in dealing with actual safety issues (without the use of names) as a training tool for the team. Most patient safety issues are a result of faulty or ineffective systems, not malice or negligence by an individual staff member. Therefore, safety coaches are trained to take a systems approach when examining medical errors. A good test for a systems error is to ask: “Is it reasonable to assume another person faced with the same set of circumstances would have experienced the same outcome?” In the majority of cases, the answer is yes, signaling that the system is unsafe. This no-blame culture is critical in order to correct larger safety concerns.

Safety Coach Program

UMC has corrected a number of processes thanks to the program, including:

An EMS driver reported a stretcher with wheels that did not lock. Administration replaced the stretcher.
Medication packaging was changed from blue-on-green to white-on-green because the previous label was difficult to read and could result in a medication error.
New isolation signs were created and posted to inform visitors and families of UMC’s processes.
Transfers within the hospital were eliminated during shift changes.

It was keenly observed that these small investments could have a significant impact on patient safety. Hospital administration therefore did not hesitate in approving the spending.

Future vision

As UMC continues to develop its culture to focus on patient safety, front-line staff will continue to be a valuable component. The goal is to involve the safety coaches in improvement project planning and implementation. Currently, most of the improvements are handled by the administration. To engage front-line staff in the long term, they will need to be offered new challenges and opportunities, along with the necessary training on project management and evaluation.

Safety coaches provide a daily connection between the front-line safety and the organization’s improvement efforts. They serve as a trusted and valuable resource for administrators and colleagues alike. The connection between a culture dedicated to safety and patient outcomes is evident. As more health care organizations measure their safety culture, their leaders will discover the gaps between their goals and the reality of front-line staff. Health care organizations will follow the lead of UMC and other similar organizations by engaging all team members in safety improvement efforts.—Laura Lindberg is a knowledge manager with Press Ganey Associates. She is responsible for researching and disseminating best practices in health care quality. Kim Judd, R.N., is senior vice president for patient care at University Medical Center, Lubbock, Texas. She develops the patient safety coaches program at the hospital, which is one portion of the overall patient safety program at UMC. Jennifer Snyder is manager of safety culture with Press Ganey Associates. She works with hospitals nationwide to improve the culture of safety within their organizations. Visit the AHA Quality Center at www.ahaqualitycenter.org to explore these and other topics.

Organising for Safety: Third Report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations) Study Group on Human Factors. Health and Safety Commission (of Great Britain). Sudbury, England: HSE Books, 1993.

This article 1st appeared in the September 2008 issue of HHN Magazine.

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