Culture of Safety

Support Materials

Slide Presentation

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References

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  1. Organisational Safety Culture; Why Bother? Richard Morris [PDF]
  2. Institute of Medicine. to Err is Human. Washington, D.C.: National Academy Press, 2000.
  3. Schein, E.H. (1992). Organizational Culture and Leadership (2nd ed.). San Francisco: Jossey-Bass.pp.12
  4. IEE Health and safety briefing 07: safety culture

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Facilitator's Guide and Outline

A full outline of the key messages for this module, including links to slides, references, and facilitation tips.

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Video

First, Do No Harm

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Facilitation Tips

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  1. Administrators may require a deeper understanding of the concepts of culture and how it applies to patient safety

    • Use of case examples and taking the Conway tool [PDF] may be useful in identifying what leaders know about culture in their organizations
    • Review of malpractice claims data and executive summaries may pinpoint problem areas to use as examples
    • Use of business-oriented references may be useful here

  2. Clinicians and other hands-on staff may gain most from imbedding into existing learning opportunities lessons in how to assess, enhance, or sustain a safety culture in their own setting. Some suggestions for this include:

    1. Use established learning venues to teach culture: e.g.,
      • M and M’s
      • Grand Rounds
      • Quality improvement meetings
      • Teaching rounds
      • Staff meetings
      • Resident teaching sessions
      • Interdepartmental meetings
    2. Select 2 – 3 specific learning points to use as focus for each session
    3. Choose a specific topic that has been identified by the target audience for improvement
    4. Present a case that embodies both the improvement topic and the cultural points you wish to make. Questions to group might include:
      • How do we usually deal with this?
      • Do we have policies, procedures, guidelines that address this situation?
      • If so, do we generally follow them? Why or why not?
      • Has a situation like this occurred before?
      • If yes, why hasn’t it been addressed?
      • Have previous improvement methods failed?
      • What needs to change to fix this?
      • What is the value in fixing it?
      • Do we believe we can fix it?
      • How do we feel about collaborating with others to address this problem?

  3. To determine current state of institution’s culture of safety, you can conduct a “before” survey using one of these tools.

    If your group is willing, propose a follow-up survey (using the same tool) a month or two after the initial program.

  4. Institutional culture is “the water in which we swim.” It is difficult to penetrate this medium and to make it change—even for improvement. To demonstrate how one institution changed a piece of its culture for the improvement of patient safety:

    • Present case M7-2
    • Discuss how each clinician in each department defined their professional roles (ordering physicians, radiology, IS, others)
    • Identify role of technology in the communication gap
    • Discuss what factors had sustained this system to continue as long as it did (professional cultural assumptions, silos that promoted misunderstandings, professional language, IS translations, culture that promoted work rounds)
    • What changes are needed? How can the departments change the culture?

  5. To demonstrate what a culture of safety is using the Medication case

    • Present case
    • Discuss how this would be handled in your organization
    • Ask a nurse to look at the system and create a fix in that department?
    • What cultural issues does this present?
    • What would be needed to create a cultural change?
    • Determine next steps and assign responsibility

  6. Charting a path to a safe organization: a five-year plan [PDF]

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Exercise

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