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Using Unit-Level Safety Culture Survey Results to Make Quality Improvements


By Coleen Smith
Director, High Reliability Initiatives
Joint Commission Center for Transforming Healthcare

This is the seventh 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 seventh and eighth tenets: 7. Analyze safety culture survey results from across the organization to find opportunities for quality and safety improvement. 8. Use information from safety assessments and/or surveys to develop and implement unit- based quality and safety improvement initiatives designed to improve the culture of safety. 

With a previous blog post centered on tools hospitals can use to determine an organizational safety culture baseline, this post focuses on how to use the information gained from these survey tools to make improvements.

It’s important to make safety culture survey results relevant to individual units. Rather than only sharing hospital-level results, leaders who develop ways to share unit- or department-level results with area manager scan start conversations leading to unit buy-in and successful quality and safety improvement initiatives.

Presenting area leaders with the survey data provides them with an opportunity to spend time finding out why team members responded the way they did and for both leadership and unit members to fully understand how the data can lead to better quality and safety. The results of the survey may not be a surprise to unit leaders, but these results may not have routinely been shared with staff with an explanation on how to interpret the results. This can be accomplished by sitting down with unit members and having an open conversation led by an approachable individual that they trust.

‘Why did you say what you said?’
Edgar Schein, an organizational culture expert and former professor at the MIT Sloan School of Management, wrote a book titled “Humble Inquiry: The Gentle Art of Asking Instead of Telling.” Schein says that the mistake many organizations make is that they only ask people what they think and then tell them what they said. It’s important to take it a step further — ask them “why did you say what you said?”

For example, if units score low on a certain aspect of safety culture, try and understand why they scored low. The “why” will vary by unit, and it’s very important to understand the why before moving into an improvement initiative. In addition to comparing the latest data with previous results, look at factors such as unit response rate, the make up of respondents by job function, and whether or not there have been changes occurring within the unit, such as staff turnover, layoffs, or a change in unit leadership. And since many survey responses tend to be dominated by nurses — due to the sheer number of them — having discussions at the unit level about safety culture provides an opportunity to hear the viewpoints of other unit team members.

Unit discussions provide opportunity to reinforce the importance of reporting
These discussions also provide organizations with an opportunity to reinforce their commitment to just culture in regard to reporting of errors or unsafe conditions. Most hospitals still struggle to remove team members’ fear of disciplinary action or retribution — that something bad will happen after a report. Discussions about safety culture survey results give leadership an opportunity to thank unit members for their frank feedback and to express how valuable it is to the organization. 

In the 2016 User Comparative Database Report for the Hospital Survey on Patient Safety Culture the average percentage of respondents reporting events in the previous 12 months was 45 percent. 55 percent stated they had not reported any events and only 19 percent had reported more than two events. An average of 75 percent responded in the positive to the question “When a mistake is made that could harm the patient, but does not, how often is this reported?” This demonstrates the belief and perception that colleagues are reporting, but that most staff do not report. To create a true safety culture in the health care industry, leaders still need to work on establishing a just culture in which honest mistakes are seen as learning opportunities.

There are many opportunities for improvement – let your survey data help you set priorities and gain unit buy-in
There are many aspects of care that have great opportunity for improvement — handoffs, transitions of care, and teamwork across units, for example. There’s a perception among unit members that they are doing a great job within the units but not so great a job handing things off and having communication beyond their unit.

Safety culture surveys give organizations the information they need to develop unit-level action plans to help improve areas of opportunity. Not every unit will work on finding solutions to the same problem, but each unit should work on improving an aspect of safety culture they determine to be a high priority. 

Hospitals can then aggregate these individual unit efforts to demonstrate their organizational commitment to having a safe and just culture. Leaders can take the first step toward building this organizational-wide culture by examining unit-level data and having frank discussions with unit team members on how to make improvements. The data are a start — the discussion and buy-in from team members are the crucial next steps to improving quality and safety.