Safer Culture Framework

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The Safer Culture Framework

Defining the conditions that create and sustain Safer Culture

Our goal in promoting a perinatal Safer Culture is preventing serious maternal events. To define the necessary components of an effective Safer Culture, we reviewed literature and examined frameworks from many industries where safety is a priority — aviation, aerospace, nuclear energy, and other high-reliability organizations. We sought to identify existing tools (measures, interventions and resources) that organizations can use to measure and improve Safer Culture.

The Functional Framework for Safer Culture details the foundational enabling factors that create the ideal conditions for an organization’s individual employees, groups, and leadership to adopt Safer Culture. The underlying assumptions, values, and norms of Safer Culture are manifested in employee behaviors, which in turn influence safety outcomes. Employees then learn from these safety outcomes to feed back into reinforcing the Safer Culture.

Functional Framework for Safer Culture

Factors and Behaviors that build a safer culture and drive positive health outcomes

Note: Figure adapted from Bisbey et al. (2019)

Enabling factors
The Safer Culture framework identifies seven enabling factors that form the foundation of Safer Culture. These seven enabling factors are grouped within three categories:

  • Organization (leadership commitment and policies/resources dedicated to safety)
  • Group (cohesion and psychological safety)
  • Individual (knowledge of safety, sense of control and commitment to safety)

Each enabling factor, or building blocks of Safer Culture, represents an essential component influencing the culture. Enabling factors set the context for the norms, values, and assumptions about safety that must take hold within the organization.

Evidence shows that a positive patient Safer Culture can only arise when each factor is present concurrently:

DEFINITIONS AND HEALTHCARE-RELEVANT EXAMPLES
FACTOR DEFINITION HEALTHCARE APPLICATION/TOOLS FOR TOOLKIT
ENABLING FACTORS factors that provide the necessary context for norms, values,
and assumptions around safety to develop
ORGANIZATION factors that impact all members within an organization or
department to a similar degree		 e.g., hospital, emergency department, cardiac unit, ICU
Leader commitment & prioritization of safety leadership is perceived to hold a priority of safety over all
other performance goals (e.g., profit, speed)		 Governing boards, executive leaders, and unit leaders all
verbalize and demonstrate a commitment to safety.Potential Tools:

  • Hospital Board Commitment (IHI Boards on Board)
  • Executive performance indicators linked to patient safety
  • Organizational structure for Quality & Safety (ACHE Leading a Culture of Safety: Blueprint for Safety)
  • Patient/family engagement indicators
Policies and resources for safety policies and resources provided by the organization concerning
safety (e.g., training resources, maintained equipment, safety policies and
protocols		 The organization has policies intended to support the delivery
of safe patient care such as policies about just culture, safety event
reporting, behavior expectations, and evidence-based safety practices.
Resources would include support for data analysts who can access data in the
EHR to monitor and improve safety, expertise in safety science, process
improvement, leadership development, etc.Potential Tools:

  • Checklist for policies:
    • to reduce risk
    • work hours, employee wellness
    • transparency, disclosure of events, reporting,
    • reward compliance
    • Access to data
  • Evaluation of policy development, dissemination, sustainability
GROUP factors that impact all individuals within a team or group to a
similar degree, and may differ across teams/ groups		 e.g., OR team , primary care team
Cohesion commitment to the group and its goals, as well as pride for the groups
values and perceived importance of being a member		 Each member of the group (OR team) commits and willingly
complies with patient safety initiatives such as doing the time out for
surgical checklist.Potential Tools:

  • Tools/practices to develop trust and commitment to goals
  • Evaluate relationships for:
    • Patient and Staff Perspectives
    • Learning Together
    • Peer to Peer Support initiatives
    • Commitment to group goals
Psychological
safety		 a collective perception that the group is safe for interpersonal
risk taking and can speak up without fear of embarrassment, punishment, or
ridicule		 Staff willingly report variances in care and participate in
multidisciplinary debriefings about safety events that occur on their unit.Potential Tools:

  • Measures of speaking up
  • Interventions to improve speaking up
INDIVIDUAL factors that may differ from person to person within the
organization		 e.g., fellows, residents, interns, staff, contractors, patients
and families
Safety knowledge
& skills		 the ability to recognize safety threats, understand their
origins and carry out procedures to address them effectively		 Clinicians, patients and families have the knowledge to report
safety threats and participate in quality initiatives to correct these
threats.Potential Tools:

  • Curricula on Patient Safety Science, QI principles
    • IHI Open School
    • CPPS
  • Assessment tools for employee safety knowledge and skill
    competence
Sense of control the belief that ones behavior has the potential to impact
important outcomes		 Clinicians, patients and families comply with completing surveys
assessing their attitudes about safety outcomes.Potential Tools:

  • Evaluate a sense of control and personal connections
    • Accountability
  • Interventions to improve sense of control
Individual commitment & prioritization of safety a positive attitude and motivation towards safe operations, and
a priority of safety over all other performance goals		 Clinicians participate in daily huddles about patient safety
issues and discuss patient safety on rounds.Potential Tools:

  • Tools to evaluate and interventions to address:
    • internal motivation to safety,
    • willingness to act as a role model for safety
    • individual values align with organizational values of safety

Enacting Behaviors
The Safer Culture created by an organization’s leaders, groups, and individuals determine the type of enacting behaviors the organization adopts to promote and ensure safe care. Enacting behaviors are the behavioral expressions of held assumptions, values, and norms about safety.

The four most common enacting behaviors for safety are:

  • Communication and information sharing
  • Incident reporting
  • Teamwork and collaboration
  • Fairly rewarding and punishing its members for safety outcomes
DEFINITIONS AND HEALTHCARE-RELEVANT EXAMPLES
FACTOR DEFINITION HEALTHCARE APPLICATION/TOOLS FOR TOOLKIT
ENACTING BEHAVIORS behavioral expressions of held assumptions, values, and norms
around safety		  
Communication & information exchange the exchange of information between individuals and/or teams,
and the extent to which messages are effectively sent and received		 Handoffs among clinicians regarding patient status, transitions
of care (inpatient to rehabilitation, intensive care to general ward,
inpatient to outpatient primary carePotential Tools:

  • Communication Training
  • Dashboards
Teamwork & collaboration observable behaviors groups enact in efforts to collaborate
towards task goals (e.g., monitoring, providing backup, goal-setting and
planning, coordinating)		 Operative room teams, ward teams, labor and delivery teams that
exhibit appropriate teamwork behaviorsPotential Tools:

  • TeamStepps
  • Simulation Training
Incident reporting engaging in reporting when an error or near-miss occurs that has
safety-related consequences		 Clinicians use the organization’s incident reporting system to
report patient safety eventsPotential Tools:

  • Usable, confidential reporting systems
  • Feedback of good catches and errors
Fair rewarding and punishing rewarding desired/effective behaviors and enforcing fair,
non-punitive consequences for errors. Should not be excessively punitive nor
lenient		 Clinicians who commit typical errors are not punished but
instead contribute to learning from the errors. Clinicians who intentionally
violate policies known to improve safety, or who exhibit other unprofessional
behavior are punished.Potential Tools:

  • Interventions for a Just Culture