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Embedding Safety Culture Training Into Quality Improvement Projects and Organizational Processes


This is the eighth 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 ninth tenet:  Embed safety culture team training into quality improvement projects and organizational processes to strengthen safety systems.

Coleen SmithBy Coleen Smith, MBS, RN,
Director of High Reliability Initiatives
Center for Transforming Healthcare

With everyone going 100 mph in their jobs anymore, team training can be one of the first things to slip off the priority list. 

Committing to embedding safety culture team training in your quality improvement projects can strengthen your safety systems, and it isn’t hard to accomplish once you get it on the calendar. 

This theory was tested by research teams at University of Nebraska Medical Center in 2012, and they found that hospitals with team training on patient safety culture had higher scores on the Agency for Healthcare Research and Quality’s (AHRQ) Hospital Survey on Patient Safety (HSOPS). The subsequent adoption of team behaviors led to better baseline performance on items reflecting the “essence” of safety culture, including:

  • leadership

  • situation monitoring

  • mutual support

  • communication 

Meaningful Training
As anyone who’s participated in unit “retreats” knows all too well, and as the University of Nebraska researchers found, the primary determinant of team performance is what an organization does after training to sustain behaviors.

That raises the issue of training session content.  TeamSTEPPS, developed by the Department of Defense in collaboration with AHRQ, is a teamwork system that is widely used among hospitals striving to improve safety culture. It is a training program that can improve communication and teamwork skills. TeamSTEPPS can:

  • help clarify team roles and responsibilities

  • provide tools that help resolve conflicts and improve information sharing

  • supply all of the training materials, free of charge, for organizations

Teaching Debriefing
One of the most essentials tools of TeamSTEPPS is also one of the easiest to implement. The “Briefs, Huddles and Debriefs” module allows teams to test conflict resolution. For the tools to work correctly, though, they really must be embedded in our daily routines. 

This exercise really comes into play after an incident, such as a fall. Training in an effective debrief can really help the team identify and address safety concerns with one another. It’s a skill that isn’t typically learned in college or new employee orientation. Teaching employees that it’s acceptable to make statements like “I’ve noticed we haven’t been great about putting the bed alarm on; I think that is an opportunity for us” can be empowering and help promote safe culture.

While it’s essential to practice difficult conversations, sometimes having a “template” can help get the ball rolling.

The “CUS” tool, part of TeamSTEPPS, gives individuals the language for communicating worries with a supervisor when it’s really necessary.

  • I am Concerned!

  • I am Uncomfortable!

  • This is a Safety issue! 

If safety’s being compromised, managers don’t care about semantics. What they do care about is mitigating a patient safety event, hopefully before it happens, and without alarming patients and families. Learning these simple statements can save time and sometimes every second counts. Since they are “I” statements, they don’t feel accusatory. This helps everyone focus on safety.  

Simulation & Communication
Hospitals and other health care settings with access to simulation labs have an advantage because they can practice real-world scenarios that may test safety culture. If your organization has the technology to allow role-playing during a simulated emergency or an agreement with colleges permitting use of their lab, this is an opportune environment to test not only expected procedures but also behaviors and communications styles.

Here too, the greatest aspect of simulation is the debrief. Emergencies bring out the default communication style in any individual, which may be too aggressive or hierarchical. The debrief is the time to tell a participant about their communication style and allow practice in improving it. Debriefing dialogue is a natural progression of training. This is a component of formal change management and part of the high reliability model. Dedicating time to this type of training speaks volumes about leadership’s commitment to patient safety.

One of the biggest challenges we have, in life as well as healthcare, is communication. Recognizing this as a gap area within safety culture and implementing some training and simulation exercises can help your organization to impact safety culture. Don’t get frustrated—it can take a while to change your culture. This is a great place to start!

Coleen Smith, MBA, RN, is director of high reliability initiatives for the Joint Commission Center for Transforming Healthcare. In this role, she is responsible for the development, coordination and implementation of activities supporting the adoption of high reliability practices in health care. Smith joined The Joint Commission in 2004 and the Center in 2011. Prior to her current role, she held the role of Project Lead and Robust Process Improvement Black Belt in the Center. Smith has also held positions in the areas of quality improvement, leadership and clinical pediatric specialty care at Rush University Medical Center in Chicago, Rady Children’s Hospital in San Diego and Lurie Children’s Hospital of Chicago.