There is growing evidence that the quality of care at the patient bedside is strongly influenced by the culture created in the hospital boardroom and cultivated throughout the organization. The Joint Commission called attention to the link between culture and safety in a Sentinel Alert[i] it issued this year. The Agency for Healthcare Research and Quality (AHRQ) previously presented evidence in a 2016 study[ii] that found correlation between the strength of a hospital’s safety culture and its patient safety improvement.

Many executives and practitioners that represent the full spectrum of care recognize the value of quality culture. The desire is there. For many organizations, the greater challenge is putting culture into practice. Some have succeeded by developing processes and supporting systems to encourage communication — especially about quality and safety problems.

“Absent a true culture of safety, improvements in these areas [patient safety] are difficult to sustain. Absent strong leadership, a culture of safety is difficult to develop and nurture,” Gary Kaplan, M.D., et al wrote in the July/August 2017 edition of Journal of Healthcare Management.[iii] The article introduces a report they wrote that was recently published by the American College of Healthcare Executives and the National Patient Safety Foundation, Leading a Culture of Safety: A Blueprint for Success.[iv] The report identifies six areas where leaders should focus to develop safety culture, includes examples of successful programs and references the bedside-boardroom link: “In every health care organization, the ultimate responsibility for system-based errors and their resulting costs rests with the CEO and Board of Directors. In the long run, patient and workforce safety will not only be a moral imperative but will likely be critical to sustainability and essential to delivering on value.”

Reporting to Improve, Not Blame

Safety culture and/or just culture need to be strongly supported and embodied at the top of the organization, but also need to be pervasive throughout it. One of the core principles to safety culture is to take a non-punitive approach to error reporting. Staff — clinical and others — should be encouraged to report errors and near misses so the organization will have data to inform and prioritize improvements to prevent future errors.

“Professionalism is a very important component of safety culture,” says Patricia Sullivan, Ph.D., chief quality officer at the University of Pennsylvania Health System (Penn Medicine). “People need to be comfortable about speaking up.”

Penn Health nurtures that comfort level and is trying to develop a generation of safety culture-conscious professionals by making a concerted effort to give residents and medical students training and encouragement to report events and near misses. The Philadelphia-based system is also expanding efforts to include patients in the safety feedback loop.

The Patient Experience Connection

“An increasing number of studies are showing that patient experience is linked to quality outcomes,” says Sullivan. “When patients have a better experience, they tend to be more engaged. That makes them more likely to be involved in joint decision-making, which in turn leads to better adherence to treatment plans and other follow-up instructions. Better adherence ultimately results in better outcomes.”

Sullivan gives an example of how focusing on patient experience has helped her system. The chief nursing officer in one of the Penn hospitals saw an opportunity to improve nurse communication based on patient-reported HCAHPS scores. The nursing executive conducted a series of patient focus groups and learned that patients wanted nurses to spend more time reviewing the plan of care with them and their families. That led the hospital to institute a new shift-change nurse rounding process. Now the outgoing nurse briefs the incoming nurse at the patient’s bedside, where the patient and any visitors can ask questions. “Nurse rounds are not cutting edge, but fully involving patients and families in the process is not as widespread. A consistent approach and attention to details have made an impact for us.”

Penn Medicine is very data driven, and data is used as a primary driver of process improvements. Its safety event reporting system is a valuable source. “Our system provides us with valuable information regarding where actual and potential safety issues exist, which is very important,” says Sullivan. These event reports include staff to staff reports of unprofessional behavior as well as system issues with clinical care. “If reporting systems are too time-consuming and difficult to use, it is hard to get people to communicate these issues on a regular basis. This is especially true for near misses, which people might skip if they think no one is going to take them seriously and/or act on them. Near misses are an extremely important source of information for it gives us the opportunity to improve our systems of care before actual harm occurs. More is definitely better when it comes to event reporting.”

Penn Health uses the RL6:Risk Incident Reporting & Management system from RL Solutions, which has earned the exclusive endorsement of the American Hospital Association (AHA). The AHA also recently appointed RL Solutions the AHA Champion Sponsor for Quality. This is a reflection of RL’s consistent alignment with the AHA’s mission, vision and major priorities, commitment to a long-term relationship with the AHA, collaboration with the AHA on many quality-focused initiatives, and creation of software solutions of demonstrated value to AHA members. RL Solutions is also the new sponsor of the AHA Quest for Quality Prize, which will next be awarded in 2018.

Reporting Raises Safety Improvement Effectiveness

Encouraging reporting not only reinforces safety culture, it raises the effectiveness of patient safety improvement efforts. Patient safety improved by an average of 5 percent at hospitals where the percentage of staff that reported an incident increased, compared to only 1 percent average improvement at hospitals that did not expand the amount of staff that reported incidents, according to analysis of 2016 and 2014 AHRQ Hospital Survey on Patient Safety Culture data.[v]

Ailish Wilkie, patient safety and risk management director for Atrius Health, echoes Sullivan in saying reporting needs to be easy to be effective. Staff at Atrius, an ambulatory care provider with 36 locations throughout eastern Massachusetts, can report safety events while updating the electronic health record (EHR) system by clicking a link that takes them to the safety event reporting system (Atrius also uses RL6:Risk). The convenience has contributed to an increase in reported events. Approximately a third of the events reported each month come in through the EHR link.

“Staff do not need to log out of the EHR to report a safety event, which saves busy clinical staff a considerable amount of time. In addition to time savings, another key benefit of reporting this way is that patient demographic information is pulled from the EHR, automatically populating the event report form, so it doesn’t have to be entered again.” Details like that have made reporting easier, which has given Atrius a lot more data to work with.

“We were capturing about 75 safety events per month before we began using reporting software; now we average about 1,200. That increase speaks volumes about how automation has helped drive our culture of safety,” says Wilkie. “Culture and a well-designed reporting system are both critical to achieving high rates of event reporting. In order to truly identify what is going on within your organization, all levels of staff need to be empowered to report safety events.


[i] Joint Commission Sentinel Event Alert “The essential role of leadership in developing a safety culture” Issue 57, March 1, 2017.

[ii] Agency for Healthcare Research and Quality “Hospital Survey on Patient Safety Culture: 2016 User Comparative Database Report” March 2016. AHRQ Publication No. 16-0021-EF.

[iii] Kaplan, Gary S. MD, FACMPE; Gandhi, Tejal K. MD, CPPS; Bowen, Deborah J. FACHE, CAE; Stokes, Charles D. FACHE “Partnering to Lead a Culture of Safety” Journal of Healthcare Management: July/August 2017 - Volume 62 - Issue 4 - p 234–237. doi: 10.1097/JHM-D-17-00084.

[iv] Kaplan, Gary S. MD, FACMPE; Gandhi, Tejal K. MD, CPPS; Bowen, Deborah J. FACHE, CAE; Stokes, Charles D. FACHE “Leading a Culture of Safety: A Blueprint for Success” Published by the American College of Healthcare Executives and the National Patient Safety Foundation Lucian Leape Institute, May 2017.

[v] Agency for Healthcare Research and Quality “Hospital Survey on Patient Safety Culture: 2016 User Comparative Database Report” March 2016. AHRQ Publication No. 16-0021-EF.