Eight Steps to a Culture of Safety

Monday, October 6th, 2008
This post was written by Melanie Matthews

Leanne Huminski, chief nursing officer of McLeod Regional Medical Center, shares the eight steps to creating a culture of safety that reduced adverse medical events at McLeod by 90 percent and greatly simplified the medication reconciliation process.

1. Develop a Vision
This is our vision for medication safety: We are perfecting the medication delivery system to be safe for every patient, every time, while making it easy for the caregiver to do the right thing, and impossible to do the wrong thing. You do this by building reliability into your system. I was on the committee that helped to develop this vision statement. I initially had a problem with the word “perfecting,” because I thought “perfecting” was unrealistic and we should set a less lofty goal. However, our administrative leader suggested that this is a vision, and we have to look at where we would like to be when we’ve completed the process. So, “perfecting” stayed in the vision statement.

2. Realize It Can’t Happen Overnight
Words matter. For example, our medication committee at that time was called the Adverse Drug Event Committee. That has a very negative tone. We changed the name of our committee to the Medication Safety Committee, which has a more positive tone. We also began to use words such as “saves” instead of “errors” when a nurse avoided a mistake due to the bar-coded medication system. Positive words matter.

3. Involve Leaders in the Process
That means leaders attend meetings, provide necessary resources, and remove roadblocks that stand in the way of improving the system. It’s not effective to have leadership that mandates goals but never participates in the process. Leadership even participated in developing our vision statement.
Our group also studied together. When a group studies together they develop a common language and a common ground to develop processes and improvements.

4. Engage and Empower the Staff
\While leadership sets the tone, engaging the staff in the work is where you gain the biggest profit. We also worked to develop a “no blame” culture. However, the pendulum swung a little too far in the other direction. Therefore, we had to swing it back again and communicate that “no blame” does not mean “no responsibility.”

When you’re implementing a culture change, remember that there are a wide variety of people involved in the process, and they’re going to have many different attitudes toward change. For example, when we implemented the Computerized Position Order Entry (CPOE), the nurse saw herself as the gatekeeper. She got nervous when the orders went directly to the system rather than her having an opportunity to manage them. Therefore, we had to address that issue with our nurses. The unit secretaries were concerned that they’d lose their jobs. The physicians also had to be encouraged because they had to learn to trust that the system would work and send their orders to the right place without error. Remember that physicians have a key role. It’s important to keep the medical staff informed and get their input as you’re designing your system.

5. Develop a Sense of Urgency
We tell a story about medication reconciliation, where a patient went home on hypertensives. They then came back into the emergency room with very low blood pressure — they had fainted. The physicians made adjustments to the medications, and then the patient was discharged to resume home meds. Of course, the patient subsequently came back to the hospital. We use that story to engage and develop a sense of urgency with our staff.

6. Test New Ideas Before Full Rollout

Pilot or conduct small tests prior to rolling something out system-wide. This helps you to refine and eliminate the bugs. It’s also important to celebrate successes. Look back at how far you’ve come rather than focus on how far you still have to go. Have a little party or a dessert day to celebrate that you’ve been recognized as a safe hospital. We produced a movie, and all of the staff attended the movie, had popcorn and received a T-shirt to celebrate our recognition as a safe hospital.

7. Be Alert for Sabotage and Workarounds
Understand that there will be early adopters, late adopters, and people that don’t want to adopt at all. Watch out for people developing “workarounds” in your safety improvement system. Encourage all of the staff — be it at the bedside, peer-to-peer encouragement, the manager of the unit, vice-president, or the administrator walking around — to look for this.

8. Communicate the Change Vision
We start our day with safety rounds. The administrative team visits patients in different areas of the hospital. Throughout a two-week period, we visit all areas of the hospital. Encourage the staff. We talk to the patients, delivering newspapers and have conversations with them. Also, visit organizations outside of healthcare to see what they’re doing. For example, we took a trip to the Firestone plant, which received the governor’s quality award for safety. We went to see how they communicate safety, and we learned some lessons. For example, display your safety warnings at the point of use, rather than in a newsletter or some other communication. Steal shamelessly!

You cannot over-communicate. John Kotter says to communicate eight times in eight ways. We do that. We post the message, speak the message, publish the message and use a MAC memo, which is our bar-coded medication administration system. We developed a communication that each time we roll out something new, we publish a MAC memo and tape it to all of the computers so the staff gets the information. I also publish a nursing newsletter. Once you have communicated something, you must reinforce the message over and over again. The year after we offered “Medication 101,” we followed up with another educational offering called “Spring into Safety.” “Spring into Safety” emphasized things that we wanted to reinforce with the medication delivery system. This year we’ll add another medication safety component to our annual training.

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