Top 10 Signs of Safety Culture and Virtue (10 mins)

Have you ever questioned the credibility of your safety culture survey? So many safety culture assessments describe vague things to avoid, but how can you tell if you have it? This season, we're sharing the Top 10 Signs that your healthcare organization has a solid safety culture.

Key Points:

-What is "good" healthcare?

-Virtue and ethics in safety culture

-Introducing the Top 10 Signs

References:

Norwood, Arlisha (2017). "Dorothea Dix." National Women's History Museum. Accessed October 2, 2024 from https://www.womenshistory.org/education-resources/biographies/dorothea-dix.

Transcript

Over the past few weeks, I have wrestled with the idea of safety culture. Safety culture is itself a symptom of something that is difficult to pin down: virtue. The further I dug into safety culture in terms of virtue, the more questions arose. How can we tell if our organization has a culture of safety? How can we know that we are doing morally good work that will stand the test of time? And if virtue is missing, what should we do about it besides grieve and quit? 

To answer these questions, I went back to consider Plato and Aristotle, the Bible, along with more recent authorities like James Reason, Deming, or Weick and Sutcliffe to really consider what is “good” healthcare. What does a virtuous organization with a robust safety culture look like and how can we tell if we’ve got it? After all, philosophers spent centuries discussing how an individual could constrain their selfish instincts so that society could obtain Virtue with a capital “V.” But none of us have centuries to sort these things out. Our patients need care today. How can we easily identify if our organization is on the right track when it comes to safety culture, even if we don’t have the free time to sit and ponder the big questions of Aristotle?

One of my assumptions is that culture in patient safety involves defining what is good for patients and constraining our systems and behaviors to meet that standard. The Hippocratic Oath with the vow to do no harm was borne out of this thinking, and the Golden Rule to treat others as we would want to be treated has guided healthcare professionals for millennia. Today, character traits like telling the truth, respecting others, protecting the vulnerable, and restraining blind violence are familiar examples of virtue that are spoken about readily in healthcare. But surely there are signs that our healthcare organizations are practicing what they preach and promoting safety culture, and I wanted to pin it down in specific terms. 

To create an effective environment for patient safety, everyone on the team must believe that doing wrong is abnormal and un-virtuous. For example, without virtue, healthcare providers would not wash their hands because hand washing is an inconvenience, and leaders are rarely watching. With virtue, diligent personnel will report a near miss (even though no harm was done) simply because they love truth, and they want to save lives and treat people well. Even though the investigation of an incident may be mandatory, the reporting is often voluntary, and a rich array of qualitative data is brought forth from an engaged member of a virtuous healthcare culture. I think that is why so many books, articles, and consultants in patient safety emphasize the need for a culture of safety, but we must be specific about what is safe and what is dangerous to invoke that kind of culture. What exactly are we asking for? I would never tell my kids to “be good” without first teaching them and making my expectations clear about how I measure good behavior. Without it, all other efforts begin to drift like a ship without a compass and the potential for harm increases with each misguided intervention.

So here is my definition: Virtue in healthcare is to value human life, and patient safety is the practical application of that virtue. All the noble efforts and personal sacrifices of healthcare professionals across the world come down to this truth because no one would do it unless human beings were valuable, and lives were worth saving. Likewise, the ultimate failure that we work to avoid is an unexpected death. Why? Because human life is valuable.

In bedside practice, there were always these critical decision moments where I could either act, sound the alarm, probably irritate some people in the process, but in the end, know that I did the right thing. Or, I could play nice with my colleagues, not be a troublemaker, and offer false reassurance to the patient. My faith is what drove my decisions. So, what is the interplay between personal virtue and safety culture? Is it possible to shore up ethics in healthcare and prevent the degradation of what must be one of the most virtuous industries to keep it functioning correctly?

One of my favorite examples of virtuous culture comes from healthcare professionals who served both sides during times of war. For example, Dorothea Dix, a nurse during the Civil War, is famous for advocating for improved care of the mentally ill. She toured facilities and visited political leaders to report on patient conditions and advocate for asylums. According to the National Women’s History Museum, her work in healthcare reform and improvement of care for the mentally ill “culminated in the restructuring of many hospitals both in the United States and abroad.”[1] But she was also known for treating both Union and Confederate soldiers during the war. Her great accomplishments in mental health and her determination in political advocacy was paired with a high ethical standard that valued human life.

Dorothea Dix faced a lot of barriers to improving care for patients, but she displayed resilience and grit as she advocated for their benefit because they could not advocate for themselves. She believed they were valuable. This is the type of behavior displayed in a culture of virtue where a vulnerable patient is treated as a person with intrinsic value. I love stories of healthcare heroes who practiced patient safety in the real world. Dix treating both sides in a war is a fairly easy virtuous action to identify.

But what if I want to identify whether my organization has virtue? If there is no war or disaster to test how virtuous we are, how could a patient safety professional measure virtuous culture? In the most practical of terms, I’ve created a list of the Top Ten Signs that an organization’s safety culture is healthy. My assessment is unconventional, but it is intensely practical. It’s not something that you will see on any other safety survey in the industry, and it assesses our care of each other as much as our care of patients. Further, you may find that it applies to other industries and organizations as a simple test for an ethical safety culture. I will also discuss some of our tendencies toward a toxic work environment with a few tips on how to avoid such unfortunate outcomes.

Some of my listeners are going to be struck by the lack of some of these elements in their workplace, perhaps convicted that there is a façade of safety in the organization paired with a very real threat that it could crumble under just a bit of stress. That can be discouraging, but I want to encourage you to not give up – change is possible, and it’s closer than you think. Others are going to be surprised and encouraged by the presence of a truly noble culture that they had not fully realized or appreciated before. If that’s you, then remember to point it out and applaud your colleagues for their compassion, virtue, and a positive safety culture. As we look through each of the ten items that are signs of virtue, the assessment item will be defined in practical terms with an explanation of why it matters and tips on what to do when it’s missing.

What are these traits? The top ten list that I will be digging into over the next few weeks includes these behaviors:

1.        Non-mandatory reporting of errors occurs.

2.        End of life care is dignified and meaningful.

3.        Families are celebrated.

4.        Security is robust to protect the lives of both staff and patients.

5.        The environment is clean.

6.        Team members willingly cover each other’s lunch breaks.

7.        Employees donate to staff who are sick, injured, or affected by a disaster.

8.        Retirement is celebrated without disdain.

9.        Managers help during busy times.

10.  Experience is respected and mentorship is coveted.

I hope that you wonder at some of these items, because I’m looking forward to unlocking some of the more mysterious inclusions and explaining why they are central to safety culture – even if they are often overlooked.

[1] Norwood, Arlisha (2017). "Dorothea Dix." National Women's History Museum. Accessed October 2, 2024 from https://www.womenshistory.org/education-resources/biographies/dorothea-dix.