Pa Patient Saf Advis 2011 Sep;8(3):114-6.
Fostering Safety-Conscious Healthcare Providers: A Leadership Initiative
Behavioral Healthcare; Internal Medicine and Subspecialties; Nursing
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Author

Lea Anne Gardner, PhD, RN
Senior Patient Safety Analyst
Pennsylvania Patient Safety Authority

Introduction

Patient safety is a national priority1-3 and a fundamental part of healthcare4 that healthcare stakeholders address through a range of activities, including government legislation,5 accreditation programs,6 quality improvement initiatives,7 and research literature.8 Senior leadership is influenced by these activities while shaping and defining a healthcare facilities’ patient safety culture and work environment. Senior leadership is central to a patient safety culture that empowers healthcare workers to maximize their performance in the delivery of safe patient care.9,10 Yet patient safety is not solely the responsibility of senior leadership; it is the responsibility of the entire healthcare facility.

Organizational Empowerment

Patient care delivery is an accumulation of multiple individual decisions made by healthcare workers; one wrong decision can create a situation that leads to an adverse event. Although all healthcare workers set out to deliver safe patient care, the amount of control they have over their work plays a pivotal role in the outcome. The commitment of organizations to a patient safety culture empowers employees to make decisions that result in positive patient safety actions.11,12 Healthcare workers who can function autonomously yet interdependently within a team are more likely to make sound decisions about the patient care they deliver.

Employee empowerment is not a single activity or goal but an organizational attitude and strategy, created by leadership, that values each individual’s contribution to the organization.13,14 This organizational attitude enables teams and individuals within a team to think critically and act on their own initiative, for example, to question actions or situations that threaten the achievement of organizational outcomes, such as the delivery of safe patient care.13 An individual’s control over and responsibility for decision making is at the core of empowerment.13,14 It has been shown that employees who have more discretion over their work demonstrate improved feelings of confidence in their work, job satisfaction, commitment, and retention.9,11,13,14

Developing an atmosphere of employee empowerment depends on the leader’s ability to trust and support his or her employees’ expertise, skills, and judgment. The leader functions as a facilitator or coach and in this role establishes a model of team work, sets shared goals, and creates an environment that enables individuals within a team to make decisions so the team can arrive at a set of successful outcomes. Employee empowerment requires leaders to share their power and to acknowledge that employees help the organization to achieve its goals.13,15 This level of employee-leader interaction should to be introduced incrementally.

For the first six months of 2011, Pennsylvania healthcare facilities reported to the Pennsylvania Patient Safety Authority more than 8,000 near-miss events in which the actions of empowered healthcare workers prevented adverse patient events. Each reported event identifies healthcare workers whose attention to detail and ability to make decisions helped keep their patients safe. The following reported event exemplifies a patient safety action that prevented multiple patient adverse events:

A technologist discovered problem with calciums [calcium results] on evening shift following PM [preventive maintenance] on daylight shift, prompting her to rerun QC [quality check], which was out of range. Quality check following PM was acceptable. All patient specimens were sent to another lab for testing. The technologist alerted [the physician] that calcium results may be suspect. The technologist notified Urgicare [sic] that the original report was incorrect and relayed the correct results. The physician assured the technologist that no treatment was initiated based on incorrect results. The next morning, a review of results indicated that the reported glucose was also suspect and was corrected. The senior technologist notified staff of correct results for calcium and glucose.

Further details from the report indicate that the analyzer in question was not used for further testing until the next afternoon, after it was serviced. This technologist’s insight and actions prevented several patients from being treated incorrectly based on inaccurate lab test results. All healthcare workers have this potential to keep patients safe, but not all may feel empowered to question and investigate unusual work patterns or potentially dangerous patient care situations. How do individuals within a team setting achieve this level of commitment to patient safety? There are no clear-cut answers; however, there is growing consensus that a strong patient safety culture within an organization can lead to the empowerment of healthcare workers, improved patient safety climates, error reductions, and successful implementation of quality improvement initiatives.11,16-19

Empowerment Opportunities

Organizations with a positive safety culture and climate provide work environments that are fair and just, support collaboration across rank and discipline, and support life-long learning.11,17,20,21 An example of this model, “just culture,” is a structured process that uses a system approach to evaluate adverse and near-miss events. It advocates for the development of a fair and just environment where suspect actions and decisions regarding the delivery of safe patient care can be evaluated and lessons can be learned.20,22 Knowledge obtained from evaluations of these actions and decisions can inform and improve employee work processes, thereby improving the delivery of safe patient care.

Creating a just culture that empowers employees is a process as individualized as leadership management styles and is influenced by organizational culture, complexity of work tasks, and level of trust between leaders and employees.11,13 For example, some leaders may feel comfortable allowing employees to make autonomous decisions in just a few situations, while other leaders may identify a broader set of situations in which employees can make autonomous decisions when performing their jobs.

Following are activities that senior leadership can engage in with employees to foster and build a patient safety culture of empowerment:

  • Support employees by providing positive feedback, especially in situations that are questionable, such as when employees question or override authority.13,14,23,24
  • Devote time to listening to employees and seeking their input on and solutions to identified problems.14,24
  • When talking with or listening to employees, give them full attention, and attend to body language.24
  • Provide clear expectations to employees; express trust in their ability to make the right decisions.13,14
  • Follow through on promises.
  • On a case-by-case basis, question or change rules that have been shown to be flawed.
  • When possible, allow employees to choose their own path and structure their work, so they can achieve good results while getting the job done.14
  • Adapt work conditions as demands change; use an incremental process.12-14
  • Vary levels of empowerment based on job responsibilities and tasks.13,14
  • Celebrate near misses internally with an employee recognition program.13,14
  • Consider moving to a just culture.12
  • Invest in teaching and development of employees to foster their expertise.12-14
  • Facilitate periodic sharing of information and knowledge about the organization that helps employees understand and contribute to the organization’s goals and performance.13,24,25
  • Explicitly tell staff to speak up if concerned.

Conclusion

Employee empowerment is an ongoing process that can improve the delivery of safe patient care. The challenge for leaders in creating an atmosphere of empowerment is to change their approach for relating to their employees. This article provides a list of suggested activities that can move an organization toward empowering its employees, which will improve employee engagement in delivering safer patient care.

Notes

  1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system [online]. [cited 2011 May 31]. Available from Internet: http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx.
  2. National Priorities Partnership. Aligning our efforts to transform America’s healthcare: national priorities and goals [online]. 2008 Nov [cited 2011 Jul 5]. Available from Internet: http://www.nationalprioritiespartnership.org/AboutNPP.aspx.
  3. Department of Health and Human Services. Report to Congress: national strategy for quality improvement in health care [online]. 2011 Mar [cited 2011 Jul 5]. Available from Internet: http://www.healthcare.gov/center/reports/quality03212011a.html.
  4. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century [online]. [cited 2011 Jul 1]. Available from Internet: http://www.nap.edu/openbook.php?record_id=10027&page=R1.
  5. Pennsylvania Patient Safety Authority. Patient Safety Authority: a successful beginning—a plan to achieve [online]. 2007 May [cited 2011 May 19]. Available from Internet: http://patientsafetyauthority.org/PatientSafetyAuthority/Documents/strategic_plan_brochure_copy_5-04-07_(web)_(2).pdf.
  6. Joint Commission. Sentinel event alert, issue 43: leadership committed to safety [online]. 2009 Aug 27 [cited 2011
    May 19]. Available from Internet: http://www.jointcommission.org/sentinel_event_alert_issue_43_leadership_committed_to_safety.
  7. U.S. Department of Health and Human Services. Understanding the affordable care act [online]. [cited 2011 May 19]. Available from Internet: http://www.healthcare.gov/law/introduction/index.html.  
  8. U.S. Department of Health and Human Services. Partnership for patients: better care, lower cost [online]. 2011 Apr 12 [cited 2011 May 19]. Available from Internet: http://www.healthcare.gov/center/programs/partnership/index.html.
  9. Westrum R. A typology of organisational cultures. Qual Saf Health Care 2004 Dec;13(Suppl 2):ii22-ii7.
  10. Ginsburg LR, Chuang YT, Berta WB, et al. The relationship between organizational leadership for safety and learning from patient safety events. Health Serv Res 2010 Jun;45(3):607-32.
  11. Armellino D, Quinn Griffin MT, Fitzpatrick JJ. Structural empowerment and patient safety culture among registered nurses working in adult critical care units. J Nurs Manag 2010 Oct;18(7):796-803.
  12. McCarthy D, Blumenthal D. Stories from the sharp end: case studies in improvement. Milbank Q 2006;81(1):165-200.
  13. Ford RC, Fottler MD. Empowerment: a matter of degree. Acad Manag Exec 1995;9(3):21-9.
  14. Conger JA, Kanungo RN. The empowerment process: integrating theory and practice. Acad Manag Rev 1988;13(3):
    471-82.
  15. Block P. Empowered employees. Train Devel J 1987 Apr:34-9.
  16. Speroff T, Nwosu S, Greevy R, et al. Organisational culture: variation across hospitals and connection to patient safety climate. Qual Saf Health Care 2010 Dec;19(6):592-6.
  17. Squires M, Tourangeau A, Spence Laschinger HK, et al. The link between leadership and safety outcomes in hospitals. J Nurs Manag 2010 Nov;18(8):914-25.
  18. Singer SJ, Falwell A, Gaba DM, et al. Identifying organizational cultures that promote patient safety. Health Care Manag Rev 2009 Oct-Dec;34(4):300-11.
  19. Huang DT, Clermont G, Kong L, et al. Intensive care unit safety culture and outcomes: a US multicenter study. Int J Qual Health Care 2010 Jun;22(3):151-61.
  20. The Just Culture Community [website]. [cited 2011 Jun 22]. Available from Internet: http://www.justculture.org/about/default.aspx.  
  21. Ramanujam R, Keyser DJ, Sirio CA. Making a case for organizational change in patient safety initiatives. In: Henriksen K, Battles JB, Marks ES, et al. Advances in patient safety: from research to implementation [online]. 2005 Feb [cited 2011 June 22]. Rockville (MD): Agency for Healthcare Research and Quality. Available from Internet: www.ahrq.gov/downloads/pub/advances/vol2/Ramanujam.pdf.
  22. New focus on averting errors: hospital culture [online]. Wall Street Journal 2010 Mar 16 [cited 2011 Jul 1]. Available fro Internet: http://online.wsj.com/article/
    SB10001424052748704588404575123500096433436.html?mod=WSJ_hpp_MIDDLENexttoWhatsNewsSecond#articleTabs%3Darticle
    .
  23. Finley DS. Supporting those who support us. Healthc Exec Jan-Feb 2010;25(1):52-4.
  24. Zimmerman R, Ip I, Daniels C, et al. An evaluation of patient safety leadership walkarounds. Healthc Q 2008;11:16-20.
  25. Feitelberg SP. Patient safety executive walkarounds. Perm J 2006 Summer; 10(2):29-36.

Celebrate Patient Safety Attainment

The Pennsylvania Patient Safety Authority periodically highlights reports of healthcare workers who take exceptional action to avoid patient safety adverse events. There are many lessons to be learned from the everyday successes of healthcare workers who do the right thing at the right time.

In this issue of the Pennsylvania Patient Safety Advisory, a lab technician’s astute observation and investigative skills, triggered by suspect lab data, identified the root cause of a potential series of incorrect clinical decisions and actions. This one person prevented multiple patients from inadvertently receiving an incorrect treatment.

The Authority would like to hear from Pennsylvania facilities in which someone’s actions resulted in the avoidance of a patient safety adverse event. There are several ways to notify the Authority, including through regular reporting in the Authority’s Pennsylvania Patient Safety Reporting System, by notifying the facility patient safety officer, or by contacting a regional Authority patient safety liaison.

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