There is a culture in every health care facility. Often this culture has more of an impact on patient safety than the process problems that exist. An example of how culture affects human actions is the speed people drive on the highway. Few people drive 65 mph even when this is the posted speed limit. Most drivers are traveling considerably faster. The Highway Patrol tries to enforce the speed limit, but with little impact. Why? The answer is simple. The driving public does not see any value in traveling at 65 mph. In order to reduce highway speeding, a culture change must take place among drivers. The same is true for health care professionals; they must value following safe patient care practices.

Changing the way people think about patient safety is not easy. Culture change is not a program. By definition, programs have beginnings and ends. They often are directed at manipulating people in some way to achieve an end result. They can even be punitive. Culture change is a process that, once embraced by the people, brings about lasting change. And that change is passed on to each new generation of physicians and employees. A five-step approach can be used to change the patient safety culture in a health care organization:

• Establish a vision of the desired safety culture and communicate it throughout the organization.
• Gather input to assess the culture's strengths and weaknesses.
• Develop a strategy to realize the desired changes and allocate budget resources, personnel, training, and time to the initiative.
• Implement the strategy and hold people accountable for meeting objectives.
• Conduct ongoing progress evaluations.

Physicians and staff must move from a level of involvement to one of empowerment. Instead of merely passing suggestions on to leaders for implementation, people must feel they can take action when presented with an unsafe situation. Trust is essential in using empowerment as a patient safety tool. This tool is for all levels of management, employees, and the medical staff. You cannot empower people unless you first trust them to do their job in a safe manner. Trust evolves in steps; it is not something that comes all at once. It is vitally important to understand that everyone has the same goal when it comes to patient safety.

Issues that have a large area of impact are referred to the group responsible for patient safety and jointly reviewed by management. The committee responsible for patient safety should operate its meetings on the principals of continuous quality improvement in which all present at the meeting have an equal voice. The physician that participates should have no more clout than the pharmacist. Anyone in the meeting should be able to raise issues of concern without fear of retribution.

Sponsor grassroots patient safety awareness campaigns. One might involve encouraging physicians and staff to report real or possible near-miss patient incidents. Another could be entitled, "What if"" and focus on discussions of hypothetical "close call" situations. Campaigns such as this can raise awareness of patient safety hazards at all levels. This in turn helps to reduce the likelihood of an adverse incident. In addition, physicians and staff will become more at ease in talking with one another about unsafe patient care situations.

Time is one of the most difficult challenges to face. The idea is to change the culture and not merely address the incidents or problems as they occur. Expecting people to change their attitudes and practices overnight is unrealistic. There has to be a commitment to support patient safety improvement long enough for the idea to impact the true culture. This usually takes from three to five years. An example of time being part of the commitment to patient safety is the issue of handwriting legibility. There may be many glitches along the way to legible patient records. Conflicts may cause tensions. But step-by-step caregivers will learn how to overcome the problem of illegible handwriting.

Every manager, physician and staff member is an equal partner in improving patient safety. There is no boss-subordinate relationship, no rank. Each person has unique skills to bring to the organization’s mutually shared goal of creating a safer patient care environment. The punitive aspects of mistakes must be de-emphasized and replaced by a positive, lessons-learned approach.

To Learn More: Patrice L. Spath is available for in-house presentations on this and other healthcare quality improvement topics. For further details, visit Brown-Spath & Associates on the web: http://www.brownspath.com or write to: Brown-Spath & Associates, PO Box 721, Forest Grove, OR 97116.

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