When it comes to building a strong case and community for patient safety, we leave the advice to our experts.
Last month, a group of experts joined us in Community on RL HUB to share their advice about how to build community around patient safety. One of those experts was Edarhline Salas, Patient Safety Program Manager at Children's Hospital Los Angeles.
What policies are in place to ensure a strong community around patient safety at your organization?
Edahrline: Most of our clinical care policies have patient safety aspects and mention expectations about reporting. More specifically, we have embedded best practice bundles from our membership in the Children's Hospital for Solutions for Patient Safety within our respective policies. For instance, our skin care policies reflect our pressure injury bundle which are also reflected in our Cerner EMR. In terms of patient safety, we have an Event Reporting Policy that delineates expectations for reporting, along with another policy that outlines how we deal with events such as Serious Safety Events, Never Events and Sentinel Events.
How are you raising awareness about the use of RL/importance of reporting within your organization?
Edahrline: A few years ago, we came up with the mantra and tagline of "Patient Safety is Up to Me" for our organization-wide "Safe and Sound: Aim for Zero Harm" patient safety campaign as a message to ensure that staff feel connected to the work of patient safety, especially since patient safety can sometimes be abstract and often associated with specific things like medication errors or hand-washing.
Essentially, we wanted to say that at any given point, even while there are systems issues we can tackle and improve, an individual can indeed make a difference by speaking up or taking an active role in patient safety. One way to do this is by reporting events that would highlight our opportunities for change.
We tell staff that reporting events not only help us document what we did to address the issues identified, but they can help us track and trend data that could lead to actionable knowledge that would hopefully help us prevent events from recurring. To raise awareness and reinforce this message, we do the following (although this is not an exhaustive list):
- We establish expectations with our new employee/physician training and orientation, one-on-one and group onboarding, RL training for our management teams, and our patient safety training called "Safe and Sound: Aim for Zero Harm."
- We provide feedback by sharing success stories, data, and lessons learned in different venues, including our collaborative governance structure and medical staff committees.
- We recognize and reward reporting through awarding staff for catching near misses with the unit-based "Good Catch" Award and the organization wide "Great Catch Award"
- We actively work with leadership and staff during the event management process and reinforce the message of the importance of reporting.
- We participate in our annual house-wide Education Fair and host various fun activities throughout the month of March for patient safety awareness month to reinforce our message.
What is the importance of Just Culture with regards to patient safety?
Edahrline: Simply put, people need to feel safe to report events and unsafe conditions and patient safety requires an strong reporting culture.
This is in contrast to the historical approach to errors and professional conduct issues with what is considered the punitive approach. In this approach, if an error occurs, the employee involved is identified, held responsible, and punished for the outcome. As it were, the "bad apple" is detected, isolated, and potentially discarded without attention to what may have contributed to the spoilage in the first place.
This response is unfortunately short sighted in that it does not appreciate complexity and does not take into account that individual action is always performed in the context of systems and processes designed by teams and the organization as a whole. The result therefore is that understanding and learning are thwarted, actual root cause(s) are not identified, systems fail to improve, and the problem persists.
A side effect of such an approach is that fear becomes foundational and an open culture of reporting errors and opportunities suffers due to people's fear of retribution. In other words, psychological safety fails to be established and employee engagement and participation with performance improvement efforts are frustrated. As a further outcome, patient safety as a goal suffers since much of the work of becoming a high reliability organization requires that we have an acute sensitivity and awareness to occurrences and opportunities for change.
Just Culture, on the other hand, is about balanced and fair accountability. A Just Culture is one that functions fairly and does not blame an individual for systems failures. By the same token, it is also not a blame-free environment where anything goes and individuals are permitted to violate codes of conduct. Rather, clear values are present and individuals are expected to demonstrate competency and choose in a manner that supports standards of practice and behavior.