Strategies to Create a Culture of Safety and Quality



Strategies to Create a Culture of Safety and Quality

Cheryl Miller

Ferris State University

Abstract

The following discussion outlines a proposed nursing administrative leadership plan to create and sustain a culture of safety and quality in the hospital setting. Research findings and knowledge gained through study of Advanced Roles in Professional Practice, Nursing Theory, Healthcare Delivery Systems, Nursing Research Design Methods and Analysis at Ferris State University support this proposed nursing leadership plan. Details include the importance of creating and sustaining a culture of safety at the organizational level, nursing administrative leadership recommendations, a targeted action plan, essential elements of a safety culture, two potential barriers of a safety culture, two proposed strategies to overcome these barriers, and an evaluation plan for continuous monitoring in order to sustain a cultural change. Concepts of a transformational nursing leadership approach and Lewin’s Change Management theory are utilized in the development of this plan. Administrative nursing leadership actions are supported by the guiding principles outlined by the American Nurses Association (ANA) (2009) in the Scope and Standards of Practice for Nursing Administration.

The Role of Nursing Leadership in Creating and Sustaining a Culture of Safety

Achieving quality care outcomes is of monumental importance toward the promotion of safe and effective health care delivery. The health care arena is deemed to be complex and diverse, requiring nursing leadership to not only understand current and future trends in health care but have an ability to respond with innovative thinking in order promote safe and effective patient care delivery. Health care reform, an increased need for management of chronic illnesses, and changes in regulatory standards and reimbursement practices are a few examples of contributing factors which complicate health care delivery practice. The current climate of health care delivery demands that nursing leadership be ready and able to face unending change in their practice environment, have an awareness of current issues and trends, and be knowledgeable of legal, ethical, and professional standards. The Joint Commission (TJC) (2010) affirms the importance of creating and sustaining a culture of safety and quality in health care organizations in order to promote organizational efficiency and improve patient care delivery. It is likely that safety and quality will remain a topic of concern for some time to come due to the very challenging nature of health care delivery. The purpose of the following discussion is to present a nursing administrative leadership plan to incorporate a culture of safety and quality in the acute care hospital setting.

Nursing Administrative Leadership Role

According to the ANA (2009), a nursing administrative leader’s primary responsibility is to advocate for nursing and promote systems of care that improve patient safety and quality care outcomes. As the health care environment continues to evolve, nursing administrative leadership must also change and adapt in order prepare and respond in an effective manner. It is important for nursing administrative leadership to be aware of the health care landscape, both externally and internally.

Staying informed of current health care trends at the national, state and local level helps nursing leadership remain abreast of changing medical care needs, changing reimbursement practices, changing regulatory standards, and developing issues. Kovner and Knickman (2008) find that the major concerns facing health care delivery are improving quality, improving access and coverage, keeping costs under control, encouraging healthy behavior, improving the public health care system, addressing social determinates of health, strengthening the health workforce, and encouraging realistic expectations. Nursing administrative leaders must takes these concerns into consideration while advocating for safe and efficient care practices and managing resource allocation (ANA, 2009). This discussion focuses on the concern of creating a culture of safety in the health care arena in order to promote quality patient care practices.

In order to promote quality care, a nursing administrative leader must seek to understand the practice environment in which they serve in order to gain knowledge regarding what is working well and what needs further improvement. This leadership action allows critical thinking and analysis so that effective decisions are targeted toward improving safety through the provision of quality patient care. According to the ANA (2009), the role of a nursing administrative leader is crucial toward developing and sustaining an organizational culture of safety. Nursing leaders shape the very environment in which health care delivery takes place (ANA, 2009). Their diligence to inspire excellent patient care practices and quality care outcomes is pivotal toward achieving patient care outcomes. Marshall (2011) notes that safety measures remain as a top priority for health care systems, despite past efforts to make improvements in quality and safety.

A second important health care concern, according to Havens, Vasey, Gittell, and Wei-ting (2010) is the need to communicate across diverse settings with multi-disciplinary health care teams in order to enhance safe and quality patient care delivery. The health care landscape often requires the need to coordinate care between a variety of settings and disciplines. As such, nursing administrative leadership must focus concerted efforts upon enhancing and improving communication between administrative leaders, physicians, advanced practice nurses, and other ancillary staff in order to enhance patient safety and quality care practices.

Yoder-Wise (2007) finds that having an organizational commitment to safety and quality requires one to utilize a systematic approach so that errors can be prevented before they happen. Ultimately success is dependent upon being able to identify organizational strengths and weaknesses so that a formalized action plan can be developed and adopted by health care leadership. Yoder-Wise (2007) outlines the following steps in the quality improvement process as: identifying patient needs, formation of a multi-disciplinary team to review these needs, collecting data related to providing these services, establishing measurable outcomes and indicators, implementing a plan to meet the desired outcomes, and evaluating the proposed plan. It is important to note that quality improvement initiatives require ongoing nursing leadership attention and evaluation (Yoder-Wise, 2007). These suggestions are, therefore, recommended.

Nursing Administrative Leadership Recommendations

In order to understand the current practice environment and organizational safety culture, nursing administrative leadership should collaborate with other key leadership professionals to develop and implement a cultural safety survey. This action is consistent with the Scope and Standards of Practice for Nursing Administration, Standard 1: Assessment, in which one collects data in a systematic and ongoing process to identify gaps in practice (ANA, 2009). The data obtained not only provides a snap shot view of the current cultural climate of the organization related to safety, but offers a working tool of information that can be used for future development of organizational goals and objectives. Knowledge of organizational gaps or trends can be shared with others to promote collaboration and targeted decision making. These nursing leadership actions are consistent with a transformational leadership approach as outlined by Marshall (2011) to first identify the need for change and create a focused plan or vision to guide that change.

Creating and communicating a vision for change is an important aspect of effective nursing administrative leadership. Kotter (2006) finds that sharing the vision with other stakeholders helps to gain nursing support and additional leadership influence. This is known as creating a sense of urgency (Kotter, 2006). Therefore, this is recommended. These nursing leadership actions are also consistent with a transformational leadership approach as described by Marshall (2011) in which organizational change is brought about by enrolling the help of other health care leadership. These nursing administrative leadership actions are consistent with the Scope and Standards of Practice for Nursing Administration, Standard 4: Planning, in which one develops an individualized plan with appropriate stakeholders according to identified, issues or trends (ANA, 2009).

Research by Porter-O’Grady (2011) finds that forming effective coalition teams can positively impact organizational policies, engage stakeholders, and develop working partnerships. As support is gained through this collaborative process, building a case for safety and quality initiatives gains positive momentum and creates organizational awareness. The end results help to promote necessary change toward a culture of safety by engaging health care staff.

According to Marshall (2011), it is important that the nursing administrative leadership vision be communicated throughout the organization from the top down using emotional intelligence and enthusiasm which is consistent with a transformational leadership approach. Speaking with positive energy and emotion helps to engage others build interest (Marshall, 2011). Utilizing a transformational leadership approach is recommended as an effective communication and collaboration tool toward building a culture of safety and quality at the organizational level. In addition, using emotional intelligence is critical to validate and promote acceptance of change (Marshall, 2011).

Lastly, it is recommended that Lewin’s Change Management Theory be applied. Weiner (2009) finds utilizing this change management theory in the complex field of health care helps nursing leadership evaluate organizational readiness for change by understanding what factors may impede or drive planned change processes. Nursing administrative leadership can use the discovery of information gained through these recommendations to build further success by eliminating any barriers and incorporating elements which help promote organizational acceptance and buy in. This gained knowledge serves to support the role of a nursing administrative leader by providing another working tool toward implementation of a culture of safety and quality. Understanding what drives organizational culture and nursing staff behavior related to safety and quality patient care delivery is essential.

Essential Elements of a Culture of Safety

Research findings by Sammer and James (2011) conclude that promoting a culture of safety in the health care environment is dependent upon the following 7 key elements: leadership, evidence-based practice, teamwork, communication, a just and fair work environment, a patient centered focus, and openness toward learning. This research knowledge provides a framework for nursing administrative practice that can be applied at the organizational level to ensure that these supporting factors are in place. For example, assessing the strengths or weaknesses of each of these key elements is consistent with the Scope and Standards of Practice for Nursing Administration (ANA, 2009) in which one synthesizes knowledge so that gaps and variances can be identified. The resultant variances will help create a future plan for improvement or change.

It is important to note that organizational culture, according to Marshall (2011), is defined by values, assumptions, beliefs, patterns of behavior, and relationships that have been developed over a long period of time. As a result, nursing administrative leaders must be diligent and focused in their efforts to bring instill organizational change. Utilizing Lewin’s Change Management Theory (Weiner, 2009) to discover the barriers and drivers of organizational change will be of great assistance. By breaking down the identified barriers and promoting the drivers, organizational change is driven in the right direction. In addition, utilizing a transformational approach, as described by Marshall (2011), can break down common barriers to acceptance by creating trust, building relationships, and empowering others to take action.

Barriers toward a Culture of Safety

As a nursing administrator tasked with building and sustaining a culture of safety and quality, it is important to identify and understand potential barriers that stand in the way. Once that is complete, creation of an effective action plan to overcome these barriers is the next step toward achieving quality patient care outcomes and patient safety improvement. Barnsteiner (2011) identifies the following barriers which negatively impact patient safety: a complex and risk prone system, lack of a verbal, written or electronic communication system, tolerance of poor practice and lack of standardization, fear of punishment, lack of ownership and accountability, and lack of knowledge. For the purpose of this discussion, the following barriers: a lack of organizational ownership and accountability and a lack of knowledge related to factors which promote safety and quality in the health care setting will be considered.

As determined by Barnsteiner (2011), lack of accountability and personal ownership can directly impact safe and quality patient care delivery. As such, nursing administrative leadership must be accountable to Standard 7: Quality of Practice, as evidenced in the Scope and Standards of Practice for Nursing Administration (ANA, 2009). This practice guideline includes assessing and evaluating the practice environment and identifying potential opportunities for improvement (ANA, 2009). Establishing safety and quality as a top organizational priority within health care delivery helps to ensure cultural acceptance, accountability and staff ownership (Yoder-Wise, 2007). In addition, Barnsteiner (2011) finds that aligning safety goals with the organization’s strategic plan, fostering a learning environment, and increasing staff engagement through communication also promotes safety awareness and accountability. Therefore, these actions are recommended. Barnsteiner (2011) finds that promoting teamwork and collaboration between health care staff also promotes accountability toward safety. Therefore, a nursing administrative decision to develop a safety and quality steering committee to oversee and monitor key aspects of quality outcome measurements is recommended. In addition, utilizing a transformational leadership approach, as described by Marshall (2011), which fosters open communication in an enthusiastic and friendly manner should also be considered.

A second barrier, according to Barnsteiner (2011), is a lack of knowledge related to the health care practices which promote patient safety, also impacts nursing staff behaviors and individual nursing practice. Therefore, this is considered. Barnsteiner (2011) finds that educating staff regarding the benefits of safe work practices increases awareness and understanding which may drive day to day behavior in the health care setting. Nursing administrative leadership can assist in the promotion of continuing education in the health care setting by assuring that financial resources are in place to assist and support this goal. It is also important that nursing administrative leadership set an expectation for continuing education through role modeling, communication, and practice. The Institute of Medicine (IOM) (2010) recommends that nurses engage in life-long learning and that health care administrative leadership provide ample resources to support this endeavor. Other suggestions include providing ongoing competency evaluation to assess nursing performance and encouraging obtainment of advanced nursing degrees in order to assure that nursing is prepared to meet the ever-changing needs of health care delivery (IOM, 2010).

Strategies to Create a Culture of Safety

Nursing administrative strategies to create an organizational climate of safety must be aligned to the needs of the organization in order to be effective and promote quality patient care. The following chosen strategy assumes that the safety culture of the organization has not been clearly examined or defined. Therefore, the first and most important nursing administrative leadership decision is to implement an organizational safety survey in order to assess the organizational environment, increase staff awareness of this important topic, encourage collaborative discussion among health care professionals, and obtain information to establish future organizational goals. It is recommended that health care staff be engaged through ongoing communication in the hospital newsletter, as well as, communication from management.

According Porter-O’Grady (2011), 2 such surveys: the Hospital Survey of Patient Safety Culture (HOSPC) from the AHRQ and the Safety Attitudes Questionnaire (SAQ) from the University of Texas are accessible to health care leadership and could be distributed to health care staff. Therefore, this will be considered. The safety and quality results can then be compiled and compared with other similar health care organizations in order to track outcomes and share solutions (Porter-O’Grady, 2011). Doing so, validates the given results, and allows nursing administrative leadership to gain outside feedback and collective ideas for the development of future organizational safety goals. Hinchliffe (2009) finds that key indicators of safety in the health care arena include the following topics: fall assessment, food and nutrition, pressure area care, pain management, patient observations, infection prevention and control or medication administration. Therefore, these topics will be considered for analysis. The value of using safety and quality performance data is that this information is easily presented for evaluation and scrutiny. This nursing administrative leadership strategy is consistent with Standard 7: Quality of Practice as outlined in the Scope and Standards of Practice for Nursing Administration (ANA, 2009) in which one evaluates the practice environment and drives quality improvement initiatives focused on patient safety and quality. This nursing administrative strategy also allows one to analyze safety and quality outcomes from a systems perspective which is consistent with a transformational leadership approach (Marshall, 2011).

A second nursing administrative strategy to create an organizational culture of safety is to foster teamwork and relationship building through the formation of a multi-disciplinary team of health care professionals dedicated to quality and safety goals. One such example is a quality and safety steering committee. This group of individuals would bear the responsibility of reviewing and improving patient care processes by keeping a critical eye on established safety criteria and organizational goals via benchmarking data. The team should consist of administrative board members, administrative leadership, physicians, nursing managers, utilization management staff, social work, staff development and other frontline staff who participate in patient care delivery (Marshall, 2011). One advantage of having a multi-disciplinary team is that that each person brings their unique viewpoint to the table in regards to performance improvement needs. The value of forming collaborative partnerships according to Marshall (2011) is empowerment of all members. Hinchliffe (2009) finds that common health care performance metrics include the following: an evidence base, a list of patients, staff and organizational benefits, a range of criteria for measurement, and visual products for individual and corporate reporting. Therefore, these strategies are recommended. These proposed strategies and leadership actions are consistent with a transformational leadership approach as teamwork and collaboration are key features (Marshall, 2011). This leadership strategies are consistent with Standard 11: Collaboration and Standard 15: Leadership as outlined in the Scope and Standards of Practice for Nursing Administration (ANA, 2009) in which one partners with others to enhance patient care and safety through the development of multi-disciplinary committees.

Evaluating the Outcome and Results

Nursing administrative leadership bears the professional responsibility to conduct systematic and ongoing evaluation of these proposed strategies targeted toward creating and sustaining a culture of safety and quality in the health care environment. This is evidenced in the Scope and Standards of Practice for Nursing Administration (ANA, 2009) as outlined in Standard 6: Evaluation. In addition, these practice guidelines recommend that results be shared with all stakeholders in accordance with state and federal regulations (ANA, 2009). Therefore, this is recommended. According to Yoder-Wise (2007) evaluation of quality improvement and safety initiatives are ongoing, just as the patient care work flow is ongoing. Benchmarking is a suitable means to evaluate safety and quality outcomes as the results can shared between like health care facilities and used to promote learning (Yoder-Wise, 2007). As a result of these findings, it is recommended that benchmarking data be presented on an ongoing basis to the organization through the safety and quality steering committee in order to remain appraised of safety and quality outcomes. This action allows nursing administrative leaders to be on constant vigil and ready to respond through policy development, education, communication, and promotion of teamwork in order to support and sustain a culture of safety in the organization.

Summary

In conclusion, creating and sustaining an organizational culture of safety and quality is a crucial responsibility for nursing administrative leadership. The ability to promote safe and effective health care delivery while managing costs, balancing resources, and meeting the ever-changing medical care needs is difficult to say the least. Success is partly dependent on knowing the internal and external forces which drive the health care machine. In addition, critical knowledge of current and future trends in health care, current research and practice literature, the current practice environment, nursing administrative practice guidelines, change theory principles, transformational leadership skills, and potential barriers toward a safety culture drive nursing leadership decisions and strategies. There is no single solution toward promoting and sustaining a culture of safety. Multiple strategies must be employed as the health care arena is a complex working environment with many moving parts which are in a constant state of change. The solutions, therefore, must flex and change as well.

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