James Reason believes a safety culture is the product of several underlying, interdependent subcultures that build the foundation for a sustainable safety culture. The first building block to establish is a just culture in order to lay the groundwork for a reporting culture and an informed culture. The other two elements of a safety culture are a flexible culture and a learning culture.
A safe workplace is necessary, especially in the complex world of healthcare. How is it possible to empower people to openly report adverse outcomes and risky events while holding people accountable in a just manner? The challenge is to determine if the event or potential event results from poor system design, human error, or reckless behavior that intentionally puts lives or organizations at risk.
It is important to understand the three types of culture that can exist in an organization regarding reporting errors and near misses:
Historically, blame (and its sanctions) has become a way for managers and leaders to motivate people to comply with rules and regulations. However, swift blame can impede information flow and the ability to understand the cause of errors, often obscuring alternative solutions to organizational problems. Staff become aggrieved and disengaged, and this culture can generate counterproductive behavior that is contagious and toxic.
When leaders blame people for mistakes, this attitude can permeate the culture and lead to lower performance and increased employee turnover. Blaming makes it harder for workers to communicate with each other, trust each other, and work together. Organizations that are in the blame game create an unsafe space for members, thereby limiting creativity and reducing productivity and learning.
With the emphasis on safety in healthcare today, it is unfortunate that this culture continues to dominate the workplace and impede the advancement of a safety culture. People in a blaming workplace are not going to feel safe to speak up and report.
A just culture creates a psychological safety for clinicians and staff to freely discuss errors or potential safety hazards in an effort to improve systems and processes. According to Amy Edmundson, “… psychological safety is the belief that the environment is safe for interpersonal risk taking. People feel able to speak up when needed — with relevant ideas, questions, or concerns — without being shut down in a gratuitous way. Psychological safety is present when colleagues trust and respect each other and feel able, even obligated, to be candid.” (Edmondson, How fearless organizations succeed 2018)
In healthcare it is imperative to have psychological safety to encourage people to self-report errors and situations that might put the patient or organization at risk. Safety culture cannot be sustained without psychological safety and a just culture in which to review events. It is the responsibility of Executive and C-Suite leaders to both create this atmosphere and to model the behavior in everything they do. Building trusting relationships is at the heart of safety culture.
Authored by Cindy Ebner, MSN, RN, CPHRM, FASHRM
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