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Joint Commission Encouraging a Tell-all Safety Culture

By Jennifer Larson, contributor

Are your colleagues and staff members willing to tell on each other, and themselves, in order to improve patient safety?

The Joint Commission certainly hopes so. Their latest sentinel event alert, released in December 2018, highlights the need for healthcare organizations to commit to developing a safety culture that promotes the reporting of “close calls” and situations that could lead to negative events.

Sentinel Event Alert #60: Developing a Reporting Culture: Learning from Close Calls and Hazardous Conditions includes guidance for healthcare organizations to aid in establishing “a psychologically safe environment that eliminates fear of negative consequences for reporting mistakes and actively encourages learning from ‘close calls’ in patient care.”

The Joint Commission recommends four steps that it calls the “4 Es of a Reporting Culture”:  

1. Establish trust.
2. Encourage reporting.
3. Eliminate fear of punishment.
4. Examine errors, close calls and hazardous conditions. 

“Creating a culture in which speaking up is encouraged is essential—and is supported by research,” wrote healthcare consultant Michael H. Ackerman, DNS, RN, in the winter 2018 issue of AACN Advanced Critical Care. “As providers of healthcare, we have an ethical and moral obligation to those we serve as well as to those with whom we serve to find our voice and ensure silence is a never event.”

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What happens after a close call?

Among other steps, the new sentinel alert calls for organizations to develop an incident reporting system that encourages reporting of close calls and hazardous conditions.

Unfortunately, too often, a minor incident or a near miss is treated as a failure.

“Individuals are blamed, rather than looking for systemic factors that may have contributed to an individual’s actions,” said Thomas Boyce, PhD, an applied psychologist with Center for Behavioral Safety in Menlo Park, California. “We tend to point fingers at people, not systems or processes.”

The Joint Commission acknowledges that a psychologically safe environment doesn’t exist in most healthcare settings at the present. The alert cites 2018 data from the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Surveys that showed 47 percent of survey respondents feel that unsafe events are held against them—that “the person is being written up, not the problem.”

As Christopher Lee, MPH, CPHQ, puts it, “People don’t report close calls for fear of negative results.”

“These may be formal, i.e. punishment by the employer or regulating bodies, or informal, i.e. being seen as incompetent by their peers,” said Lee, the clinical solutions marketing manager for Family Health Centers of San Diego.

The alert authors point out that leadership must take a central role in changing that kind of culture to one where “the need to report and do something about a safety issue outweighs the fear of being punished.”

Shared accountabilities

In some circumstances, consequences may be appropriate for certain incidents or negative events, and regulations may be helpful to some degree. But they cannot fix everything.

“They have their place,” said Boyce. “But when we look at the bigger picture, we realize that we may be misusing these things. There are other ways to improve situations in which we truly understand what led to the action. But we often don’t take the time to understand that.”

Systemic factors often play a role in causing close calls and mistakes. Organizations must dedicate time and resources toward uncovering and addressing those factors, rather than assuming that an individual person is solely responsible, Boyce noted.

The Joint Commission calls for organizations to “apply a standardized accountability process to assess the difference between system flaws, which are the causes of most errors and hazardous conditions, and at-risk or reckless behaviors” and suggests the use of just culture decision trees.

Shared accountability is very important in a reporting culture or culture of safety, noted Vicki Good, DNP, RN, past president of the American Association of Critical-Care Nurses (AACN) and a nationally recognized patient safety expert.

Individual practitioners, systems and leaders all have a stake and a responsibility. People have to experience and see for themselves that their organization is committed to that principle, which can take time. In many organizations today, practitioners are still fearful that the responsibility for a negative event could be placed entirely on the shoulders of the individual.

“The best way that we overcome it is building that trust,” Good said.

As the alert states, “All staff must see that those making human errors will be consoled, those responsible for at-risk behaviors will be coached, and those committing reckless acts will be disciplined fairly and equitably, no matter the outcomes of the reckless act. Senior leaders, unit leaders, physicians, nurse and all other staff must be held to the same standards.”

Additionally, Good pointed out that in order to shape an effective reporting culture, leadership must engage nurses in the discussions, since they spend the most time with patients and have a great deal to contribute. “The nurse needs to be involved in every single step,” she said.

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