1. Creating a Culture of Safety Sara J. Singer, Harvard University Anita L. Tucker, University of Pennsylvania Academy of Management—August 9, 2005

2. Research objective How do senior hospital leaders contribute to creating a strong culture of safety?

3. Motivation Creating a strong safety culture is a critical task of senior leaders in hazardous industries, such as healthcare (Roberts & Rousseau, 1989) Few hospital CEOs devote sufficient time or resources to patient safety (Leape & Berwick, 2005) Variation exists across hospitals in leadership’s awareness of safety risks and mistakes Senior leaders have a more optimistic view of safety culture than other personnel (Singer et al., 2003)

4. Methods Qualitative and quantitative methods at 8 hospitals 26 semi-structured interviews of 51 senior leaders and front line workers 7 site visits to observe leaders conducting an intervention to improve safety culture Survey items on safety leadership 7 items, alpha = 0.89

5. Safety leadership survey items Senior management provides a climate that promotes patient safety. Senior management has a clear picture of the risk associated with patient care. Patient safety decisions are made at the proper level by the most qualified people. Overall, the level of patient safety at this facility is improving. Senior management considers patient safety when program changes are discussed. Senior management has a good idea of the kinds of mistakes that actually occur in this facility. I am provided with adequate resources (personnel, budget, and equipment) to provide safe patient care.

6. Analysis of qualitative data Line-by-line review by 2 researchers Inductive coding, independently then jointly, negotiating differences and refining the coding scheme; guided by comparison with literature Use of software (Atlas TI) to record codes and facilitate analysis and reporting

7. Qualitative results: 6 dimensions Create a compelling safety vision Value and empower personnel Leader engagement in patient safety improvement efforts Lead by example Focus on system issues rather than on individual error Quest for improvement (even if already good)

8. Hospital ratings on 6 safety leadership dimensions Stronger leadership in hospitals 6 and 3 v. 7

9. Valuing and empowering front line staff Hospital 6 26 bed hospital in rural, mid-America “There was a lot of consensus building [about the new computer system]. A lot of evaluation. We have let management and staff chose the system. We have done a ton of training. Our own staff built the internal menus…” – Michelle Paulson, CEO Hospital 7 300+ bed hospital in urban Southwest “They [Senior managers] don't want to hear it, they don't want to know it, they don't care.” – Denise, RN Emergency Room Nurse

10. Engaging in the patient safety effort Hospital 3 5 hospital system in a midsize Midwestern city “Our CEO, he is constantly out and about, walking around, checking on things.” – Ed, Cath Lab Technician, Hosp 3 “I… worked on a board presentation [wrestling with] How do we present to board of directors this [analysis of an error] in a meaningful but actionable direction, such that the governing body understands?” Alan Eberhardt, Network CMO Hospital 7 “When people feel like they have one shot at [being heard by senior management], they want to…make sure they get their… issues raised. Because who knows if they ever get another chance.” – Viola Flynn, Outgoing QI Director

11. Improving systems rather than blaming individuals Hospital 6 “We treated that [mistake that caused no harm] as a sentinel event… When we did the root cause analysis, we realized that the process in the lab left a single tech, any tech, vulnerable … Initially the staff wanted to point to the tech…We had to back them up and actually protect the employee from that type of reaction.” —Michelle Paulson, CEO Hospital 7 “You quickly identify who you think caused the problem and you deal with them in a not-so educational way.” – Senior Mid-level Manager of Emergency Care

12. Survey results: Average % problematic response Hosp 6 and 3 have stronger safety leadership than hosp 7 Difference from hospital 7 significant at ** p<.01, * p<.05 Hsp63482517 LDRSHP items (7) 5.0**9.3**11.4**10.7**12.8 12.5**21.4 All safety climate items 12.0*15.9*16.218.517.016.516.621.9

13. Survey Results Large differences in views of senior leaders between Hospitals 6 and 7 10% v. 26% believed senior managers did not have a good idea of the mistakes that occur in their facility 4% v. 24% felt senior managers failed to provide a climate that promoted patient safety

14. Conclusions Quantitative results support our categorization of hospitals on the 6 dimensions Though many hospital leaders created a vision for safety, what distinguished strong leadership from weak was Extensive engagement of senior leaders Systems focus Valuing and empowering employees to act on behalf of patient safety Dissatisfaction with current safety performance