By Coleen Smith
Director, High Reliability Initiatives
Joint Commission Center for Transforming Healthcare
This is the fifth in a series of posts examining the 11 tenets of safety culture discussed in our Sentinel Event Alert and accompanying infographic: This post examines the fifth tenet: Recognize and praise care team members who report adverse events and close calls, identify unsafe conditions, or present good suggestions for safety improvement.
The “trust-report-and-improve” dynamic is a crucial aspect of establishing high reliability in health care. When team members report adverse events or share concerns or ideas about safety, it’s important for team leaders to recognize their contributions, use their information to make improvements, and communicate back to team members how safety was enhanced as a result.
Establishing a process for consistently recognizing individuals who identify safety improvement opportunities reinforces the importance of both identifying and responding to unsafe conditions. This recognition also creates a bond of trust with leadership and contributes to building a safety culture.
Personal Recognition Works Best
Expressing personal thanks for safety-related contributions within the unit or organization is so appreciated by team members. Many organizations offer small incentives for reporting safety issues such as:
- providing “good catch” awards in the shape of a baseball mitt for reporting close calls
- large trophies for the most improved adverse event reporting
- raffles for a close-by parking space among contributors of safety ideas
- recognizing individuals in newsletters and on bulletin boards
- paying for a unit pizza parties
- providing gift cards
In developing both recognition and a safety culture initiative, it is important to progress from simply reporting adverse events, to reporting close calls, and then to thinking more broadly about unsafe conditions or situations that could lead to adverse events or suboptimal outcomes. It’s a challenge to expand safety mindfulness from identifying mistakes that have or nearly happened to include what may happen.
What may happen because two patients on the floor have the same or similar names? What may happen because a particular piece of equipment is difficult to find or obtain? Situations that team members may currently view as daily annoyances may actually be unsafe conditions. After a potentially unsafe situation is found, it’s even better to devise a solution. For example, to prevent venous thromboembolism after surgery, a nursing unit decided to stock sequential compression devices on the unit, rather than in central storage, to reduce the time post-surgical patients waited for this intervention.
Hallmark of High Reliability
Getting team members to identify these kinds of situations is a definite evolution toward a safer culture. High-reliability health care is more than not harming patients; it’s making sure patients receive recommended care as soon as possible and without overuse. This highly reliable performance is particularly important for the diagnosis and treatment of sepsis, heart attack, stroke, and many other conditions. Proactive thinking leads to the best treatment and reduces the chances of errors.
As safety cultures within organizations become more adapt at anticipating and responding to potentially unsafe conditions, they move further away from the “sharp end of the stick” where adverse events occur. Reporting adverse events and close calls, and then further evolving toward identifying unsafe conditions and making safety suggestions is crucial work within a safety culture. Leaders must recognize and praise those contributing to this work; this creates the trust, report and improve dynamic that makes high-reliability health care possible.