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. Case Study 1 The following case example illustrates selected human factors concepts that are depicted in the Swiss Cheese Model. The scenario also compares the different ways that human error would be perceived and managed in a culture of blame versus a culture of safety. Belinda has been working in an alcohol and drug abuse clinic since she received her master of social work degree four months ago. Belinda’s supervisor, Diane, has been out of state dealing with a family emergency for the past week, and Belinda is sharing coverage of Diane’s caseload with the clinic’s other social worker. It has been a week of back-to-back appointments that have included several crises. On Friday, Belinda’s last appointment is with Brad, the 12-year-old son of a prominent physician.
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. Brad’s mother called for an appointment for her son after finding marijuana in his room. She also told the intake worker that Brad had run away from home several times in the past year. During Belinda’s first session with Brad a week ago, she was frustrated and felt unable to conduct her assessment because Brad refused to make eye contact and provided monosyllabic answers to each of her questions. Brad’s mother is being treated for prescription drug addiction by the clinic’s psychiatrist, Dr. Bledsoe. The psychiatrist is supervising Belinda’s cases in Diane’s absence on an as-needed basis. Belinda, who admires Dr. Bledsoe and was excited about the opportunity to work with him, has been disappointed that Dr. Bledsoe has had no time to meet with her to discuss Brad’s case.
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