continued by people. This can be a problem within groups. Organizational culture is no different from our larger human and societal culture (Oster & Braaten, 2021). Oster and Braaten (2021) point out that researchers who study organizational culture use several defining characteristics to help identify the elusive nature of organizational culture. ● It does really exist. ● It is characterized by ambiguity. ● It can be malleable and specific. ● It is the result of group interactions and is thus a social construction. ● It exists in healthcare. Furthermore, there are drivers and factors that ultimately create or contribute to the creation of a specific organizational Culture of Safety and High Reliability Organizations The concept of a safety culture originated outside of healthcare and emerged from studies of high-risk industries such as nuclear power, aerospace, and aviation. Researchers identified a culture of safety embedded within what they called a high reliability organization (HRO), which is best described as a complex organization that engages in high-risk activities but experiences few catastrophes (Oster & Braaten, 2021). Despite its hazardous environment, an HRO operates for long periods of time without catastrophe because of its “error-tolerant” culture, which means that it recognizes the futility of eliminating human error and designs work processes in which errors can occur without leading to disaster. Below are some of the characteristics of HROs as they might relate to behavioral healthcare. HROs create a culture of safety by first acknowledging the risky nature of their activities and then operate to effectively manage risky situations through organizational control and the ongoing calculation of probabilities of error. Clearly, this approach is typified by facing risks, understanding them, and trying to anticipate their probable occurrence. Moreover, the HRO will seek to identify weaknesses within their system and create management and process steps to mitigate these risks. A culture of safety encourages—and actively fosters within an HRO—collaboration across ranks, disciplines, specialties, and departments to solve safety problems. The HRO focus is on teamwork to proactively identify latent (hidden) vulnerabilities (Oster & Braaten, 2021). A culture of safety is committed to learning. In a culture of safety, adverse events and near misses (close calls) are viewed as opportunities to improve the system. For this type of learning to occur, the organization must develop an atmosphere of trust that encourages workers to report adverse events and near misses. In this transparent, supportive reporting culture, workers are confident that they can report problems without being punished. When something bad happens, the focus is on what happened rather than who did it. Oster and Braaten (2021) define HRO principles as follows. ● Sensitivity to operations: Systems and processes that affect client care are constantly assessed to prevent risks. ● Reluctance to simplify: Simplistic explanations of failure (e.g., unqualified staff, inadequate training, communication failure) are avoided, and underlying factors that place clients at risk are explored. ● Preoccupation with failure: Near misses are viewed as “symptoms,” that is, evidence that an area or work process needs to be improved to reduce potential harm to clients. ● Deference to expertise: Leaders and supervisors listen and respond to the insights of frontline staff who understand how processes work and know the risks to clients. ● Resilience: Leaders and staff in high reliability organizations are trained and prepared to respond when system failures occur.
culture. One of these factors is identified as an artifact, namely processes and structures that have survived and existed within the organization for a considerable amount of time. These artifacts can be the direct result of espoused positions or goals of the organization that have also had a considerable life span, adopted and repeated by successive groups of leadership, providers, and frontline staff. Additionally, much of organizational culture can often be further linked to conscious and unconscious assumptions held within the organization by current staff or previous staff. Certainly, organizational culture is palpable, sometimes powerful, but this milieu of historical and assumptive factors can make it more difficult to objectify, study, and change (Oster & Braaten, 2021). Self-Assessment Question 1 At a monthly patient safety meeting, a frontline nursing manger suggests reducing steps used to dispense medication in an acute behavioral unit. From an HRO perspective, how should other staff present at this meeting respond to this recommendation? a. Go along with the recommendation because frontline staff are complaining about burnout b. Object to this simplification of medication distribution because it may increase patient risk c. Conduct a postdischarge survey of patients, seeking their input on this issue d. Take a vote of meeting members to see what the majority want Unfortunately, the predominant organization culture of blame still burdens most healthcare and behavioral health settings. This attitude delimits the growth of a safety culture because it encourages professionals to hide their mistakes for fear of being punished. A just culture of safety balances its blame-free environment with zero tolerance for blameworthy behaviors (such as impairment, felony, malfeasance, reckless behavior, and failure to learn over time), which are addressed with administrative processes that are timely and fair. This balance is known as a just culture (Seshia et al., 2018). Veazie and colleagues (2019) researched the potential application of HRO principles within the Department of Veterans Affairs for their National Center for Patient Safety. The authors published their findings from 20 HRO studies covering the period from 2010 through 2019. Upon deeper study of this research, the authors identified several HRO principles and concepts that can successfully lead healthcare organizations from concept to implementation. These strategies are: ● Develop leadership. Seek commitment from board members, senior leaders, and lead providers to adopt the goal of zero harm. ● Identify and build a new culture of safety. Foster trust, responsibility, and ongoing communication about unsafe patient processes and procedures, within a concerted effort to always evaluate cultural change. ● Improve data systems to monitor progress, measure improvements, and share data results widely within the organization. ● Commit to ongoing training and educational efforts within the organization to actively support these new organizational initiatives. ● Implement critical improvement interventions without needless delay and safeguard their adoption.
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