by Tina Hilmas, RN, BSN, Project Manager, Center for Patient Safety
Patient Safety Awareness Week is coming up March 12-18 and I’m always excited during this time of the year. You see, patient safety seems so simple yet is so complex and I could literally spend hours talking about it. But what I’d really like to do is intrigue you into becoming as excited about patient safety and patient safety culture as I am. The analogy that comes to mind for me is that of an onion. When you peel away the layers of an onion, you are left with the heart of the onion, or rather the core. The same is true with patient safety. As you begin to peel away the actions of an organization and look underneath at the rationales for those actions, you find the underlying beliefs of an organization, the foundation, the culture regarding Patient Safety and that is where a journey of patient safety must begin.
As a nurse, it seems like patient safety should be ingrained into our daily actions. After all, aren’t nurses supposed to promote, advocate for and protect the rights, health and safety of our patients? But can we honestly say that we have always, in every situation, put the safety of the patient first? How about that day where you were being called for one start of care after another? Or that day when you’d been on call, received multiple calls throughout the night, and began seeing patients the next day with little to no sleep? Were your first thoughts truly of patient safety or more on just how you could keep your head above water with all the visits you needed to complete? More importantly, does your organization have built in safety guards to help protect the safety of your patients? Does your organization promote a strong patient safety culture?
You see, patient safety is more than just the National Patient Safety Goals (NSPG) of the year. Patient safety is a combination of technical change and adaptive change and it never stops. It’s not something that is “achieved” rather it is an aspect of your organization’s culture and therefore ongoing. Culture, as it pertains to an organization, is defined as a way of thinking, behaving, or working. Safety culture can be defined as the following:
“The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management.” (Health and Safety Commission Advisory Committee on the Safety of Nuclear Installations, 1993; adapted by AHRQ)
So to break it up, the technical change aspect is focused on those NPSG’s – developing processes and policies for fall prevention, medication education and identification of the patient. The adaptive component of culture is the leadership component, the systems component and looking deeply at human factors engineering. Some nurses have called this the “touchy-feely” part of nursing because it deals not only with processes, but also the on-going evaluation of the organization’s behavior, from leadership all the way down to the home health aide, in regards to a specific item, the heart of the onion – patient safety culture.
So where do we begin this journey? Evaluate your organization’s culture, not just employee engagement, to actually look at how the employees within your organization feel about the organization’s commitment to safety. Look at your processes and what happens when a mistake is made. Is there an investigation or Root Cause Analysis of the event including not just the outcome of the mistake, but review of the system, including policies, and contributing factors? Is there a tendency to discipline or maybe terminate the employee responsible for the mistake with the reason being, if you eliminate the person responsible then the problem is solved? Do the employees in your organization feel comfortable admitting to near mistakes, mistakes that resulted in no harm, or pointing out unsafe conditions? If so, keep up the awesome job! If not, ask why? Is it because of the culture? Does everyone just keep their head down and try to sweep mistakes that didn’t result in harm under the rug? Surveys, such as the Survey on Patient Safety, can help leaders visualize where their organization is on the culture scale. It also allows for identifying a starting point for change.
When trying to change there are multiple frameworks that can be reviewed because change is hard and threatening. In organizations that have success in promoting a strong patient safety culture, there is one factor in common, it all starts with leadership. The leaders have to show that patient safety is a priority and part of the mission of their organization. The leaders should engage with their personnel on a daily basis and they should incorporate patient safety as part of their daily routine. Patient safety will only become a priority when it is incorporated and embedded into everyone’s daily routines.
But in focusing on patient safety, leaders shouldn’t lose sight of their most valuable asset – their employees. Employees need to feel supported and invested in by their leaders. This is where leaders and organizations should ensure they have a strong Employee Assistance Program, but maybe should also look into other supportive programs such as Second Victims. This program trains the staff on how to support a fellow employee who may have been involved in an adverse event. In home care and hospice, this is something that could help not just if an adverse event occurs, but also if a long-term patient expires. Even if it was expected in hospice and home care, relationships develop between the health care team and the patient; a Second Victims Program can help to provide the support needed to those involved in the care of a long-term patient who passes.
So hopefully, I’ve helped you to see why I’m so passionate about Patient Safety. It isn’t just the technical or the top layer of the onion, but the whole onion, the heart and core that I enjoy dealing with to make certain it is strong, healthy and sweet.
Don’t Miss HHQI’s Next Underserved Populations (UP) Network Webinar
Patient Safety: All in a Day’s Work! – Thursday, April 20, 2017, 2:00 p.m. ET
Ready to learn more about patient safety? Join Ms. Tina Hilmas, RN, BSN and the HHQI team for the next Underserved Populations (UP) Network webinar. During this webinar, you will learn how to begin preparing a Quality Assurance & Performance Improvement (QAPI) plan related to patient safety that will be required by all home health agencies. This will be a 2-hour interactive event that will include work on a QAPI plan. Register Here
About Our Guest Blogger – Tina Hilmas, RN, BSN
Ms. Hilmas has spent more than 20 years in the nursing profession both within hospital walls and outside in the home care arena. Her current work includes collaborating on quality improvement projects that include incorporating a strong patient safety culture. She also reviews patient safety events reported to the Center to analyze for trends and causal factors to assist organizations with changing their culture and improving patient safety.