Among other responsibilities, patient safety organizations are charged with assisting providers to develop a culture of safety. This is no small task. Culture is a simple word that encompasses the huge range of what is shared by members of a group, including assumptions, values, beliefs, norms, symbols, language, customs, rituals, behaviors, etc. As organizational size and complexity increase so too does culture. Moreover, culture is multi-layered. The visible espoused values and rules (what we say) are less powerful than the deeper, less conscious basic assumptions, meanings and norms at influencing what we actually do, particularly in times of crisis.
While culture serves the basic human need for stability, it may be dysfunctional and filled with conflict and ambiguity. Culture is a product of the shared learning (cognitive, behavioral and emotional) of the organization and its component sub-groups. Among physicians and nurses in particular, culture is also influenced by professional norms that transcend organizational boundaries. For example, I’ve previously shared how the dysfunction QA model for clinical peer review has persisted based on its history.
Many hospitals have sought to assess their safety culture using the Hospital Survey on Patient Safety Culture developed by AHRQ or similar instruments. AHRQ has maintained a comparative database of voluntarily-reported survey results since 2006. The response has been excellent. Over 1,000 hospitals contributed data in each of the past two years. The results, however, are disturbing.
As the figure shows, the composite category Non-Punitive Response to Error has consistently run at a dismal 44% positive. The associated component survey items have the same flat-line trend. In other words, US hospitals have perfected a perfect system for casting blame. While individuals who commit reckless acts with disregard regard patient safety must be held accountable to prevent mimicry and recurrence, we know that blame is a toxic inhibitor of the shared learning required to advance safety and high reliability.
Marc T. Edwards, MD, MBA
President & CEO
QA to QI
An AHRQ Listed Patient Safety Organization