Catch trophy. The program recognizes those who speak up and fosters a culture of transparency and safety.
Speaking up for safety requires more than reporting actual or potential errors. It also involves clinicians stopping a care process whenever a member of the care team has a safety concern. This may be uncomfortable for clinicians who have historically viewed health care as hierarchical. As a result, nurse leaders must clearly communicate that everyone has the authority to stop for a safety concern at any time. Nurses are expected to voice their concern and “stop the line” if they sense or discover a safety issue. The acronym CUS may be used. The letters represent “I am Concerned;” “I am Uncomfortable;” and “This is a Safety Issue.” Consider this powerful and effective way of speaking up: “I am concerned with Mr. Lopez's sudden hemiparesis and am concerned with your choice of not implementing the stroke protocol. I believe this is a safety issue.”
Managing Behavioral Choices
The just culture model requires leadership competencies to manage behavioral choices. The Just Culture recognizes that many errors result from interactions between humans and the systems in which they work. Nurses and other clinicians should not be held accountable for system failings over which they have no control. Discipline should be tied to the behavior of individuals and the riskiness of their behavior, not only to the actual outcome of their actions (Marx, 2001). Nurse leaders must appropriately hold individuals accountable for their behaviors and investigate the behaviors that led to the error.
Building and reinforcing accountability is part of managing behavioral choices. Nurse leaders must set clear behavioral expectations, educate staff, and build staff skills. Everyone within the organization must be educated on these expectations. Nurse leaders must recognize that three types of accountability exist: vertical, horizontal, and intrinsic accountability.
Vertical and Horizontal Accountability
Vertical accountability occurs when humans perform in a certain way because someone, like a manager, is watching. Horizontal accountability occurs when humans perform in a certain way because of peers, teamwork, or the desire to function as effectively as others.
Intrinsic Accountability
Intrinsic accountability exists within the individual. Nurse leaders need to expect accountability and enhance the intrinsic motivation of the nurse to meet performance expectations. In addition, nurses need to hold their peers accountable for safety. While each type of accountability is important, the ultimate goal is for staff to practice in a safe manner even when nobody's watching.
A Performance Management Decision Guide is available to guide management decisions when human error occurs (Reason, 1997). The first step is a deliberate act test. If the individual acted with malicious intent, disciplinary action and a report to a professional group, regulatory body, and/or law enforcement is warranted. If there is confirmed ill health and the individual was unaware, a leave of absence and physician referral is appropriate. If substance abuse is suspected, testing, disciplinary action, and treatment are warranted. If the individual chose to take an unacceptable risk based on policies, procedures, and protocols commonly used within the organization, disciplinary action may be warranted. However, if the individual adhered to generally accepted performance expectations and simply made an unintended error, the individual needs to be consoled and coached. In every case, leadership is also responsible for correcting safety problems that contributed to the error.
The just culture model acknowledges that humans make mistakes. As a result, no system can be designed to produce perfect results. However, health care systems can be designed to decrease risk. Consistent with creating a Just Culture and demonstrating sensitivity toward operations, nurse leaders must identify and correct system problems.
Daily Safety Huddle
Many system problems can be discovered at a daily safety huddle, a short meeting at the beginning of the day that includes senior and operational leaders. This meeting allows the organization to address safety issues for patients or staff quickly and efficiently. Operational leaders review actual or potential safety issues from the past 24 hours and anticipate issues that may occur over the next 24 hours. They identify how the safety issues may impact other departments. They discuss any barriers to safe care, such as inadequate staffing, supplies, medications, or technology. They describe any high‐risk or non‐routine situations, such as a planned surgery for an incarcerated individual. Appropriate experts are mobilized and empowered to solve the problem. For example, leaders from several clinical areas may report a needle stick injury to a nurse. Without a daily safety huddle, leaders may not be aware of this increase until monthly or quarterly data are tabulated. Because of the safety huddle, however, the information may be used to quickly launch a system‐wide task force to determine the causes of the injuries and develop strategies to decrease the needle stick injuries.
Frequent and regular leader rounding in clinical practice areas allows nurse leaders to see the conditions under which care is delivered and to talk with staff about safety concerns for themselves and their patients. Nurse leaders can also provide feedback and reinforcement to staff. Both positive and constructive feedback is needed to decrease human errors, and the majority should be positive. Immediate and specific feedback helps to reinforce positive behaviors. Thanking nurses for practicing safely helps to reinforce safe behaviors. If nurse leaders observe unsafe behaviors, they should immediately correct the behavior and offer a practice tip to extinguish the unsafe behavior. For example, a nurse leader may see a nurse enter a room and provide care without sanitizing her hands. The nurse leader should correct the nurse, tie hand hygiene to the core value of safety, and ask the nurse to commit to performing hand hygiene and helping others to do the same in the future.
Assessing Organizational Culture
Nurse leaders must also assess the organizational culture to determine the shared values and beliefs of individuals in a group or organization. This chapter will consider culture as it relates to safety and high reliability.
Culture is sometimes described as the way people act when no one is looking. For example, consider Beth, a patient care technician caring for a patient in isolation. Beth entered the patient's room without wearing appropriate personal protective equipment. By deviating from policy, she put herself, her family, her patients, other staff, and everyone she encountered at risk for infection. When asked about her behavior, Beth stated that she knew the patient was in isolation and that she should put on a gown and gloves. She further explained that she did not think anyone was watching. This illustrates an employee who has not yet internalized a culture of safety.
On the other hand, consider Bill, a housekeeper who informed his supervisor that he found a sharp metal edge on a door handle on the Adolescent Behavioral Health Unit. Bill and his supervisor were concerned that someone could get hurt and alerted the unit manager. The manager asked Joe from facilities to fix the handle as quickly as possible. Joe noticed that two screws were missing from the metal plate. The manager of the unit was notified, and staff members searched the unit including each patient's room. The missing screws were eventually located in a patient's tooth brush holder. Because Bill and Joe paid attention to detail and spoke up, the patient was kept safe from harming himself. This scenario exemplifies employees who are living a culture of safety.
Many organizations use a culture of safety survey tool to capture the perspectives of health care providers. Two commonly used tools are the Survey on Patient Safety Culture (AHRQ, 2017) and the Safety Attitudes Questionnaire (Sexton et al., 2006). Organizations may also choose to assess their stage of organizational maturity toward becoming an HRO using a model proposed by Chassin and Loeb (2013).
The AHRQ sponsored the development of separate patient safety culture surveys for hospitals, nursing homes, medical offices, community pharmacies, and ambulatory surgery centers. Each survey measures multiple dimensions of safety culture. For example, the hospital survey measures teamwork within units; supervisor/manager