By Kelly Teal
The quest to make a hospital an infection-free environment seems never-ending. That’s especially the case as new antibiotic-resistant bugs crop up and as staph and sepsis continue to risk patient lives. The responsibility for addressing these problems does not rest solely on infection preventionists, of course, but there are measures these healthcare professionals can and should implement to better ensure a highly functioning safety of culture. Indeed, in early March, the Joint Commission released a new Sentinel Event Alert to these very points, laying out 11 tenets for establishing and improving a safety of culture:
1. Transparent, non-punitive approaches to reporting and learning from adverse events, close calls and unsafe conditions.
2. Clear, risk-based processes for recognizing and separating human error and error arising from poorly designed systems.
3. Adoption of appropriate behaviors and championing efforts to eradicate intimidating behaviors.
4. Establishment, enforcement and communication of all policies that support safety culture and the reporting of adverse events, close calls and unsafe conditions.
5. Recognition of care team members who report adverse events, close calls and unsafe conditions or who have suggestions for safety improvements.
6. Establishment of an organizational baseline measure on safety culture performance.
7. Assessment of safety culture survey results from across the organization to find opportunities for improvement.
8. Development and implementation of unit-based quality and safety improvement initiatives in response to information gained from safety assessments and/or surveys.
9. Implementation of safety culture team training into quality improvement projects.
10. Proactive assessment of system (such as medication management and electronic health records) strengths and vulnerabilities, and prioritizing them for enhancement or improvement.
11. Organizational reassessment of safety culture every 18 to 24 months to review progress and sustain improvement.
Much of this insight codifies what infection preventionists seek to do every day and experts agree, cementing institution-wide success begins at the top. “The leader sets the tone,” says Lori Paine, director of patient safety for the Johns Hopkins Hospital and Armstrong Institute for Patient Safety and Quality.
Ana Pujols McKee, MD, executive vice president and chief medical officer for the Joint Commission, said much the same in a March 1 press release announcing the Sentinel News Alert. “[Success] begins with leadership; their behaviors and actions set the bar,” Pujols McKee says. “Establishing and improving safety culture is just as critical as the time and resources devoted to revenue and financial stability, system integration and productivity – because a lack of safety culture can have serious consequences for patients, staff and other stakeholders.”
Infection preventionists can help hospital executives and other leaders spread this message in a couple of ways. Above all, threading some common culture among the disparate hospital units – the operating room, the emergency room, and so on – is key, or change will not happen. “It’s not really an organizational culture, it’s a set of local cultures,” says Paine. “Leaders recognize that and know they have to have some common organizational threads but appreciate the variability.”
Also, leaders must buy in to the importance of measuring the hospital’s culture of safety. Otherwise, again, change will stop as soon as it starts. “I tell my leaders there’s no purpose in measuring the safety culture if we have no intention of using the data,” Paine says. “Leaders have to be committed to developing that culture but also working on fixing it where it might be broken.”
Once leadership has agreed to promote a highly functioning culture of safety and supports its enforcement, infection preventionists have more work to do. The first order of business will be to put a stop to, or prevent altogether, double standards that let “untouchables” do what others cannot. “It’s perceived that certain people can get away with behaving in certain ways that not everybody can,” Paine says. In such an environment, a physician could forgo washing her hands, for instance, while a nurse could not do the same. “A tolerance of disruptive behavior is an example of one way to erode a culture of safety,” Paine said. Making sure everyone adheres to the same rules is imperative.
But punishing people for reporting wayward behavior also hurts safety, Paine adds. Well-known physician and patient safety advocate Lucian Leape of the Harvard School of Public Health has spoken to this issue, stating, “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.” Rather than putting staff in a bad position for speaking up, infection preventionists must advocate for a fair culture, Paine says. “Encourage people to report when they make errors and near misses, and seek to learn from things when they go wrong.”
In fact, infection preventionists are uniquely positioned to do this, Paine said, because they can “step back and look at the big picture. They don’t have to get caught up in the emotions of it, where the clinical staff for the patient might be defensive or worried they’re going to get blamed.” In this vein, infection preventionists can look out not only for patients but for staff, “to make sure they have the tools they need.”
Still, the closer an infection preventionist gets to identifying the cause of a safety error, the chances of experiencing resistance from staff will grow. Some may fear they will be reported or that the procedures they employ will morph beyond their current comfort zones. Paine says the chance of running into this type of pushback increases in environments that lack transparency and openness with consumers. This is where the infection preventionist will benefit from having established strong ties with the doctors, nurses, technicians, food servers and other staff within the hospital. That way, the infection preventionist can approach a problem as a champion for everyone, asking how to help reduce infection rates, rather than putting people on the defensive. “It often boils down to relationships and trust,” Paine says.
Once that obstacle is surmounted, an infection preventionist then can turn to using data to avoid another occurrence. But owning the information without having control of the practices that need to change can be tough, Paine says. Practitioners and staff who do not collect or oversee the data may think they are off the hook for its implications or turn combative when an infection preventionist pursues new practices. Make room for small tests that prove the change worthwhile and provide evidence to address concerns, Paine says. “This all helps build trust and creates some shared ownership of the problem.”
And, she adds, infection preventionists with strong people skills seem best positioned to do this. “I think really, really skilled infection preventionists are able to convene people around the fact that they have a common problem, and how are we going to work together to make sure patients get the care they need, without pointing fingers?” Paine said.
She noted that several interpersonal capabilities help achieve this goal, including:
- How one chooses to act as a change agent;
- Seeking to understand before being understood; and
- Gathering information from diverse sources.
“While an infection preventionist may not always view themselves as part of a very specific team of people caring for patients, they’re an integral part of the team,” Paine says.
On the whole, changing hospital safety culture can take a year or more given human nature and employee turnover. “In general, we say 12 to 18 months,” Paine says. The Sentinel News Alert then gauges the timeline for reassessment at 18 to 24 months. Indeed, around the 12 to 18-month mark Paine mentioned, infection preventionists and their colleagues can think about maintaining that highly functioning culture of safety. This effort requires a different approach from implementation. “It’s not just summiting the mountain and you’re done,” Paine says. “You’ve got to nurture it and reinforce it and respond when stressors are introduced. Maintenance is something that managers and the team need to constantly be vigilant about.”
To do that, continue to talk with staff on a regular basis to gauge whether anything is going awry. “It’s hard to do,” Paine says. “The work of daily life changes so frequently. Maintaining a culture of safety requires vigilance and flexibility and a certain resilience of the unit.” It’s similar to getting vaccinated and therefore having immunity from a disease, Paine said. “With a higher safety culture, staff are more resilient to certain stressors,” Paine said. “But with a lower safety culture, any new stress that comes in, the unit may have a harder time getting over it.”
Finally, resist the urge think of a highly functioning culture of safety in pure dollar terms. The efforts to achieve this optimum level may not actually save a hospital money, Paine said. Instead, focus on the culture of safety itself. Any financial benefits that flow as a result are exactly that – benefits. “One problem we have in health care is we wait too long to find out if something is a problem,” Paine says. “If we had lenses that allowed us to pick up on those hazards earlier, we would save time in training, education, processes and devices that are faulty to begin with. …The ROI for safety, it’s hard to prove.” However, one can presume a highly functioning culture of safety pays for itself in infections avoided and lives saved. And isn’t that the whole goal? “None of us entered this profession intending to harm someone,” Paine says.
Kelly Teal is a freelance writer.