How can leaders enhance safety culture? The importance of leadership for patient safety in corporate culture

This is article seven in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

My patient died today. A cat that was loved by its family. A mother, a father and a little girl who looked up at me with tears spilling from her eyes. They had trusted me to help. Instead, I had to tell them their cat died, during the procedure that was supposed to make her better. We all cried in the consult room, when I broke the news.  All of us stunned and devastated, in overwhelming measures.   

I didn’t know where to turn for help. I was embarrassed, afraid to talk to anyone about it for fear of what they might think of me. Surely I could have, should have avoided this – if only I knew better. But I didn’t really know, and I didn’t know how to do it better next time. My colleagues were equally unprepared to talk about it. There were whispers and sideways glances. 

Eventually, the awkwardness subsided as people forgot and time marched on. But time doesn’t always heal all wounds, sometimes a scar remains. However, time does give you experience, which prepares you for when you are faced with similar situations again. Like running my finger along a scar, I often think about that cat and her family. They are the reason why I do what I do today. Because I don’t want other people to have the same experience I did, to feel like they have nowhere to turn for help, to get answers to the question that we all inevitably ask ourselves, ‘how could I have done better?’

Over the years that followed, I struggled to do my best to learn from these events, never quite feeling comfortable that I was asking the right questions or seeing the whole picture. I had never experienced a setting where people openly talked about their mistakes and at that point, had never heard of the terms, significant event audit or contributory factors. However, as can happen with things viewed in hindsight, the more I lived with the questions, the answers began to unfold. Some incredibly supportive and kind mentors demonstrated, through their wisdom and experience, that patient safety and quality improvement methods provided the direction that I was looking for. 

Now, as Director of Quality Improvement (QI) for a large practice group, it is my mission to provide practice teams with structure and guidance to help improve the quality of care that they provide and learn from those events where a patient was harmed, or nearly harmed, due to veterinary care, in a way that people feel supported rather than shamed.

Leaders have an opportunity to enhance a safety culture

A ‘safety culture’ relates to the extent to which organisations prioritise and support improvements in patient safety. 

The level of importance to which building a safety culture is placed in an organisation will influence the impact of any quality improvement measures. 

Patient safety is not just the responsibility of front-line teams.  Senior leaders within an organisation also have an opportunity to play an important role and their engagement will positively influence patient safety¹.

First steps to creating positive change

1. Discuss quality and safety during management meetings. Data from human healthcare demonstrates that high-performing hospitals—defined as those ranking highly on objective measures of quality and safety—tended to have leaders who were more skilled in quality and safety issues and who devoted more time to discussion of quality and safety during board meetings. Align quality and safety goals with the organisational strategy.
2. Use data to enhance care. Set specific quality goals and use data points that demonstrate improvement to measure progress. This may include participation in vetAudit initiatives, which provide audit and benchmarking tools.
3. Engage directly with front-line teams. Front-line teams and senior leaders may have different perceptions of both the goals and results of QI efforts, and the lack of a shared commitment and understanding by leadership and staff may hinder the effectiveness of QI initiatives. Actively involve front-line teams in the planning and design of change, as they know the work best. This will help to overcome negative reactions due to the challenges created by change².
4. Build and sustain trust.  Build psychological safety within teams by encouraging feedback and collaboration. Levels of trust will improve naturally and help the organisation work toward its strategic goals. Establishing open communication is an important element of a  ‘Just Culture’: making it safe for members of the practice team to discuss errors and near misses so that the organisation can learn and iteratively improve³.
5. Promote teamwork. When people feel supported by a strong team, they are more comfortable talking about mistakes and identifying improvement goals.  A strong team supports each other when things don’t go to plan and equally celebrate together when things go well. This contributes to the establishment of a learning culture.
6. Celebrate success. Celebrating success whenever quality goals are achieved, is an important step to spreading the cultural ethos  Learning how a goal is reached is equally important as reaching the goal itself. Sharing stories may help others to adopt similar solutions.

Remember what it is to be human

Creating a safety culture in an organisation requires a delicate combination of setting out a collective vision and sensitivity to the views of others. Transforming this into action will take time, especially in large organisations where there are many people who have ‘skin in the game’. Don’t be discouraged if you feel like it is taking a long time, culture change can flourish with sustained commitment, including stakeholders at all levels, and by making an effort to understand what motivates people⁴. 

Most importantly we must always remember what it is to be human. To know what it is like to fail, pick ourselves up and try again.  Our capacity to walk in someone else’s shoes is key to understanding and supporting people in improvement goals.  To paraphrase Ghandi, ‘Be the change you hope to see in your organisation’.

Discussion point

What steps can you take to support a safety culture in your organisation?

Checklist: what can you do next to create a practice dedicated towards improvement?

• Watch the webinar, ‘The power of a growth mindset: Why certain habits of mind matter in clinical improvement’, by Bill Lucas, Director of the Centre for Real-World Learning & Professor of Learning at the University of Winchester.
• Listen to Shobhan Thakore’s podcast on Getting your team on board to deliver quality improvement.
• Visit RCVS Knowledge’s Quality Improvement hub to start taking advantage of our free templates, courses and resources (over 20 hours of free CPD).
• Take a strategic approach to supporting QI in your area of work
• Read the BVA Policy Position on Good Veterinary Workplaces
• Check out the other resources at www.civilitysaveslives.org
• Passionate about QI? Why not submit an application to win an RCVS Knowledge Champion Award.

References

¹Leadership role in improving patient safety [Agency for Healthcare Research and Quality. Patient Safety Network] [online] Available from: https://psnet.ahrq.gov/primer/leadership-role-improving-safety  [Accessed 29 March 2021]

²Transformational leadership and evidence-based management (2004). In: Page, A. (ed) Keeping patients safe: Transforming the work environment of nurses. Washington (DC): National Academies Press. Available from: https://www.ncbi.nlm.nih.gov/books/NBK216194/  [Accessed 29 March 2021]

³How can leaders create a culture of safety?  [The Health Foundation] [online] Available from: https://www.health.org.uk/newsletter-feature/how-can-leaders-create-a-culture-of-safety  [Accessed 29 March 2021] 

⁴Lyons, R. (2017) Three reasons why culture efforts fail [Forbes] [online] Available from: https://www.forbes.com/sites/richlyons/2017/09/27/three-reasons-why-culture-efforts-fail/  [accessed 29 March 2021]

About the author

Angela Rayner BVM&S PgDipPSHCF MRCVS

Angela is Quality Improvement Advisor for RCVS Knowledge, Director of Quality Improvement for CVS, and is an RCVS Knowledge Champion for her role in improving CVS’ systems for controlled drugs auditing.

In 2018, Angela began an MSc in Patient Safety and Clinical Human Factors at the University of Edinburgh. The programme supports healthcare professionals in using evidence-based tools and techniques to improve the reliability and safety of healthcare systems.

It includes how good teamwork influences patient outcomes, key concepts around learning from adverse events and teaching safety, understanding the speciality of clinical human factors, as well as the concept of implementing, observing and measuring change, monitoring for safety, and it focusses on quality improvement research and methodologies.