Leading A Culture of Safety-A Blueprint For Success

Leading a Culture of Safety:
A Blueprint for Success

Contents
Letter from the Project Co-chairs i
Acknowledgments ii
The Culture of Safety Imperative iii
Introduction 1
Recommendations for Use of This Guide 4
A Culture of Safety: The Six Domains 5

Establish a Compelling Vision for Safety 6
Value Trust, Respect, and Inclusion 9
Select, Develop, and Engage Your Board 13
Prioritize Safety in Selection and Development of Leaders 17
Lead and Reward a Just Culture 21
Establish Organizational Behavior Expectations 25
Appendix: Key Terms Related to Patient Safety and a Culture of Safety 30

Bibliography 31
Self-Assessment Tool 33
Members and Staff 41
Leading a Culture of Safety:
A Blueprint for Success
American College of Healthcare Executives

The American College of Healthcare Executives is an international professional society of 40,000 healthcare executives
who lead hospitals, healthcare systems, and other healthcare organizations. Its mission is to advance its members
and healthcare management excellence. ACHE offers its prestigious FACHE® credential, signifying board certification
in healthcare management. Its established network of 78 chapters provides access to networking, education, and
career development at the local level. In addition, ACHE is known for its magazine, Healthcare Executive, and its career
development and public policy programs. Through such efforts, ACHE works toward its vision of being the preeminent
professional society for healthcare executives dedicated to improving health. The Foundation of the American College
of Healthcare Executives was established to further advance healthcare management excellence through education and
research. The Foundation of ACHE is known for its educational programs — including the annual Congress on Healthcare
Leadership, which draws more than 4,000 participants — and groundbreaking research. Its publishing division, Health
Administration Press, is one of the largest publishers of books and journals on health services management, including
textbooks for college and university courses.
For more information, visit www.ache.org.
The National Patient Safety Foundation’s Lucian Leape Institute

Established in 2007, the NPSF Lucian Leape Institute is charged with defining strategic paths and calls to
action for the field of patient safety, offering vision and context for the many efforts under way within
healthcare, and providing the leverage necessary for system-level change. Its members are national thought
leaders with a common interest in patient safety. Their expertise and influence are brought to bear as
the Institute calls for the innovation necessary to create significant, sustainable improvements in culture,
process, and outcomes that are critical to safer healthcare.
For more information, visit www.npsf.org/LLI.
The National Patient Safety Foundation at the Institute for Healthcare Improvement
The Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (NPSF) began working together
as one organization in May 2017. The newly formed entity is committed to using its combined knowledge and resources
to focus and energize the patient safety agenda in order to build systems of safety across the continuum of care. To learn
more about our trainings, resources, and practical applications, visit ihi.org/PatientSafety.
Leading a Culture of Safety: A Blueprint for Success
Letter from the Project Co-chairs

Dear Colleagues:
Healthcare is one of the most complex industries in our world. Amid all of the pressing priorities, we must
remember that the elimination of harm to our patients and workforce is our foremost moral and ethical
obligation. In our roles as healthcare leaders, we have numerous responsibilities for ensuring the quality of care
provided within our organizations, including patient and family experience, improving the health status of our
communities, and maintaining the financial sustainability of our organizations. However, one of the most critical
roles we must fulfill is ensuring the safety of patients who entrust their lives to our care, as well as ensuring the
safety of a workforce—both clinical and non-clinical—that entrusts their livelihoods to our organizations. It is the
ultimate duty of leaders to ensure the safety and prevention of unnecessary harm to these individuals and their
loved ones. Healthcare executives must address the need to create sustainable cultures of safety throughout a
healthcare system full of daunting challenges.
As our organizations aim to continually improve the reliability and safety of care, we can look to resources and
successful practices to assist us, our Boards, our executive colleagues, our healthcare professionals, and the
entirety of our workforce. The American College of Healthcare Executives (ACHE) and the National Patient
Safety Foundation’s Lucian Leape Institute (NPSF LLI) have partnered to collaborate with some of the most
progressive healthcare organizations and globally renowned experts in leadership, safety, and culture to develop
Leading a Culture of Safety: A Blueprint for Success. This document is an evidence-based, practical resource with
tools and proven strategies to assist you in creating a culture of safety—an essential foundation for achieving
zero harm. It is our hope that this guide will inspire and motivate, while providing approaches and tactics leaders
can implement in driving cultural change, with the goal of elevating healthcare into the realm of recognized
industries that have succeeded in reducing error and harm.
ACHE and NPSF LLI stand ready to assist you on this journey. We invite you to use this guide in both a strategic
and tactical manner to direct your efforts in creating and sustaining a culture of safety, and to evaluate your
success along your journey to zero harm.
Sincerely,
Gary S. Kaplan, MD, FACMPE Charles D. Stokes, RN, BSN, FACHE

Co-chair Co-chair
Letter from the Project Co-chairs i

Acknowledgments
The American College of Healthcare Executives and the NPSF Lucian Leape Institute gratefully acknowledge the
experts that contributed to this work along with Gary S. Kaplan, MD, FACMPE, and Charles D. Stokes, RN, BSN,
Culture of Safety Roundtable Participants

Gary Kaplan, MD, FACMPE* David Fox* Doug Salvador, MD, MPH*
Chairman and CEO President Vice President, Medical Affairs
Virginia Mason Health System Advocate Good Samaritan Hospital Baystate Medical Center
Project Co-Chair
Vicki Good, RN, MSN, CENP, CPPS Doron Schneider, MD
Charles Stokes, RN, BSN, FACHE* System Director for Quality and Safety Chief Safety and Quality Officer
Senior Vice President and Chief Operating CoxHealth Abington Jefferson Health
Officer
Memorial Hermann Health System Deborah Grubbe, PE, CEng Roger Seaver, FACHE
Project Co-Chair Senior Consultant President and CEO
DuPont Sustainable Solutions Henry Mayo Newhall Memorial Hospital
Jason Adelman, MD, MS Owner and President
Chief Patient Safety Officer, Lisa Shannon, MBA
Operations and Safety Solutions, LLC
Associate Chief Quality Officer Chief Operating Officer
New York-Presbyterian Hospital Helen Haskell, MA KentuckyOne Health
Columbia University Medical Center President
Jack Silversin, DMD, DrPH
Mothers Against Medical Error
Timothy Anderson, RN Founding Partner
Patient Safety Supervisor John Haupert, FACHE Amicus
Harry S. Truman Memorial Veterans’ President and CEO
Sara Singer, PhD, MBA
Hospital Grady Health System
Professor of Healthcare Management
Peter Angood, MD, FRCS(C), FACS, MCCM Mark Jarrett, MD, MBA, MS and Policy
President and CEO Senior Vice President, Clinical Excellence Harvard School of Public Health
American Association for Physician Chief Quality Officer
Maureen Swick, PhD, RN, MSN, NEA-BC
Leadership Northwell Health
CEO
Thomas Balcezak, MD, MPH, FACHE Cheryl Knapp, MBA, RN, CPPS, CPHQ American Organization of Nurse Executives
Chief Medical Officer, Senior Vice President Vice President, Chief Quality Officer Senior Vice President, Chief Nursing Officer
Yale New Haven Health System Bronson Healthcare American Hospital Association
Barbara Balik, RN, EdD Edward Lamb, FACHE Beth Daley Ullem, MBA
Cofounder President and CEO Patient Advocate and Governance Expert
Aefina Partners LLC Mount Carmel Health System
Kerry Watson
Principal Della Lin, MD President
Common Fire Healthcare Consulting Consultant Arnot Ogden Medical Center
Ruth Brinkley, FACHE Senior Fellow, Estes Park Institute Chief Operating Officer
President and CEO Physician Lead, Hawaii Safer Care Arnot Health
KentuckyOne Health John Lynch III, FACHE* Sam Watson, MSA, MT(ASCP), CPPS
Christine Candio, RN, FACHE President and CEO Executive Director
President and CEO Main Line Health Senior Vice President, Safety and Quality
St. Luke’s Hospital MHA Keystone Center
David Marx, JD, BS
Pamela Cipriano, PhD, RN, FAAN President and CEO Nicolas Wolter
President Outcome Engenuity Former CEO
American Nurses Association Billings Clinic
Michael Leonard, MD
Carolyn Corvi, MS Managing Partner Gary Yates, MD
Former Vice President and General Safe & Reliable Healthcare Partner, Strategic Consulting
Manager Press Ganey Associates, Inc.
Steve Muething, MD*
The Boeing Company Vice President, Safety Raul Zambrano, MS, MD, FAAFP, FACHE
Teresa Edwards, FACHE Cincinnati Children’s Hospital Chief Medical Officer
President Aurora Health Care’s Southeast Market
Sentara Leigh Hospital Jonathan Perlin, MD, PhD, MSHA,
MACP, FACMI
Derek Feeley* President, Clinical Services
President and CEO Chief Medical Officer
Institute for Healthcare Improvement Healthcare Corporation of America
*Participated in both Culture of Safety Roundtable meetings (May and December 2016)
Acknowledgments ii
The Culture of Safety Based on data from James and

Imperative the American Hospital Association,
an average, 100-bed hospital
committed errors in care that
Harm to Patients and the Workforce caused the death of 23 patients
in 2013. Such statistics indicate
In 1999, the Institute of Medicine (IOM) Committee on Quality of Health that each organization contributed
Care in America estimated that between 44,000 and 98,000 Americans die to the preventable death of almost
each year as a result of medical errors (IOM 1999). More recent estimates one patient every other week
place this number closer to 200,000 deaths per year (James 2013). Though
(AHA 2014, James 2013).
deaths due to medical error are notoriously difficult to measure, if this
number is accurate within 100,000 deaths, medical error kills four times
more Americans each year than motor vehicle accidents. It is important to
note that these statistics, while disconcerting on their own, do not account
for serious temporary or permanent physical and psychological harm caused
by medical error, and they do not include harm to the healthcare workforce. The Business Case
Regardless of the measurement or estimation used, the rate of error and for Safety
harm in healthcare is astounding, and sweeping, system-wide changes
are imperative.
While the business case for patient
safety continues to expand and to
Moreover, when patients experience harm, clinicians find themselves change with new regulatory and
negatively impacted as well. Being involved in an error that results in the reimbursement requirements,
harm or death of a patient is devastating for an individual who is committed the general consensus within the
to serving those who are sick. At its worst, this devastation can lead to healthcare research community is
self-harm, depression, isolation, and even suicide. The desolation that that organizational costs for error
often results from causing harm is compounded for clinicians who work in and harm are high and will likely
organizations without supportive systems. Based on the 2016 Agency for increase in the coming years. In
Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety addition to the increase in direct
Culture’s hospital comparative database, only 64% of staff respondents cost of care for the impacted
felt that reported mistakes led to positive changes in their organization. patient and family following an
Even fewer members of the workforce, only 45%, responded positively to error, organizations must also
questions related to their organization’s non-punitive response to error consider personnel costs, regulatory
(AHRQ 2016). costs, and resource costs including
investigation of errors, pursuit
Considering the impact described above, every healthcare executive of legal defense, and payment
should prioritize enhancing the safety of patients and the workforce. As an of settlements. Perhaps most
industry, healthcare has taken steps in improving quality and patient safety. important to consider are the
However, these small-scale, incremental improvements are not enough. Our potentially immense costs related
immediate work requires a focus on safety not just as a key improvement to repairing reputation after a
initiative but as a core value that is fully embedded throughout our catastrophic event has occurred and
organizations and our industry. been publically reported (Weeks
and Bagian 2003). When each of
In every healthcare organization, the ultimate responsibility for system- these costs is considered on top of
based errors and their resulting costs rests with the CEO and Board of the direct cost of patient care, the
Directors. CEOs and Boards will be held increasingly responsible for harm business case for improving safety
and death caused by error. In the long run, patient and workforce safety will becomes abundantly compelling.
not only be a moral imperative but will likely be critical to sustainability and
essential to delivering on value.
The Culture of Safety Imperative iii

A Case Study in Culture:

Mr. Jones is a previously healthy 55-year-old man, with ORGANIZATION B:
a recent history of shortness of breath that is related to
The inpatient team notifies the patient safety department
exercise. He has been referred by his primary care physician
about the missed test result, and a root cause analysis is
for a cardiology consultation, at which a stress test is
performed. Action steps include designing a new process
ordered. The results of the stress test indicate a positive
for communication of test results that includes an
finding for potential heart disease. These results are not
escalation policy when it is not immediately possible to
communicated back to his primary care provider, and
communicate critical test results to the ordering provider
although they are sent to the referring cardiologist, he is
and/or the patient.
away at a conference. Mr. Jones receives no communications
about the results of his test. One week later, Mr. Jones The primary care provider ensures that Mr. Jones begins
presents to the emergency department with chest pain taking the cardiac medication and also notifies the risk
and is diagnosed with an acute myocardial infarction. Upon management/patient safety department about the delay
further review of his medical records, the care team reviews in medication use. An additional root cause analysis
his past test results and learns about the positive stress test. is conducted, with a clear tracing of the breakdown
Mr. Jones requires placement of a stent to open his coronary during transition from hospital to rehabilitation and
artery, and requires rehabilitation prior to discharge to his rehabilitation to home, and how and why it may have
home due to reduced cardiac function. One week after occurred.
discharge from inpatient rehabilitation, Mr. Jones returns to
his primary care physician, who realizes that Mr. Jones is not The results of both RCAs, including strong action plans
taking one of the new cardiac medications that was ordered for improvement and metrics for sustainability, are
by his inpatient team. presented to the organization’s leadership team for
review and approval. The CEO presents the case and
action plan at the next quality and safety meeting.
A Tale of Two Organizations: Which is
more like yours? Mr. Jones’ care team informs him about these
breakdowns in communication, and how they may have
ORGANIZATION A: contributed to his myocardial infarction and could cause
future health issues. His care team extends an apology,
The inpatient team notifies the patient safety department as well as an offer for early resolution and compensation
about the missed test result, and a root cause analysis is that helps Mr. Jones pay for his medical bills, his time
performed to determine why Mr. Jones’ critical test result away from work, and the additional costs associated with
was not communicated to either him or his cardiologist. the need for his family to care for him.
Action steps from the root cause analysis focus on
re-educating the stress test department about the policy Six months later, an assigned member of the leadership
for communication of abnormal test results. team follows up with the frontline care team involved in
the event to evaluate and reassess the action plan and
The lessons from the root cause analysis are not shared review improvement metrics. These results are presented
beyond the safety team. The action plan is not presented to at the next Board meeting.
the leadership team or the Board for approval, and does not
include metrics for sustainability. The CEO and Board hear
about the event only as a statistic presented quickly at the
DEBRIEF
end of a quarterly Board meeting.
Many organizations report that their response to
Mr. Jones is not informed about either the missed stress test handling Mr. Jones’ situation is more similar to
result or the root cause analysis. Organization A than to Organization B. This example
is but one of many that illustrate why healthcare must
The primary care provider writes a new prescription for
create and improve systems that are committed to zero
the cardiac medication. Mr. Jones ultimately misses several
harm to patients and our workforce.
weeks of work.
The Culture of Safety Imperative iv

Introduction
Cultures of Safety
Dr. Lucian Leape, widely regarded as the father of the modern patient
Across the Continuum
safety movement, has repeatedly stated that “the single greatest
impediment to error prevention in the medical industry is that we punish Because error and harm happen
people for making mistakes.” By prioritizing, developing, and sustaining across the continuum, it is
an organizational culture focused on safety, we can drive the future of imperative that all improvement
healthcare to a place where patients and those who care for them are initiatives also encompass all care
free from harm. It is not only one of many priorities, but is the overriding settings. While some of the tactics
ethical imperative for all leaders. and recommendations throughout
this document will be more
AHRQ defines a culture of safety as one “in which healthcare professionals relevant in certain environments
are held accountable for unprofessional conduct, yet not punished for than others, the key principles
human mistakes; errors are identified and mitigated before harm occurs; developed throughout the six
and systems are in place to enable staff to learn from errors and near-
domains are applicable to all who
misses and prevent recurrence” (AHRQ PSNet Safety Culture 2014). The
oversee the delivery of care—not
leaders of organizations must set and, more importantly, demonstrate the
behaviors and expectations essential to a safe and transparent culture.
just hospital settings. This work is
intended to be adapted as needed
To help healthcare leaders achieve their mission of total system safety, to enhance applicability for all
ACHE and LLI have partnered to develop this guide, which is intended organizations. However, the key
to assist leaders in creating, shaping, and sustaining the type of culture concepts—building trust, respect,
needed to advance patient and workforce safety efforts. It is designed and enthusiasm for improvement
to inspire, motivate, and inform you as you lead your organization on its through behaviors and principles
journey to zero harm. that focus on ameliorating systems
issues while requiring fair and
The information in this guide comes from industry leaders and experts inclusive practices—are critical to
who have had success in transforming their organizations into system-wide safe care in all settings.
cultures of safety. It is designed for you and your team members to adapt
to your organization, wherever you may be on your journey.
Introduction 1
This resource is organized into six leadership domains that require CEO focus and dedication to develop and
sustain a culture of safety:
Establish a compelling vision for safety. An organization’s vision reflects priorities that, when
aligned with its mission, establish a strong foundation for the work of the organization. By
embedding a vision for total patient and workforce safety within the organization, healthcare
leaders demonstrate that safety is a core value.
Build trust, respect, and inclusion. Establishing trust, showing respect, and promoting
inclusion — and demonstrating these principles throughout the organization and with
patients and families — is essential to a leader’s ability to create and sustain a culture of safety.
In order to achieve zero harm, leaders must ensure that their actions are consistent at all
times and across all levels of the organization. Trust, respect, and inclusion are non-negotiable
standards that must encompass the Board room, the C-suite, clinical departments, and the
entire workforce.
Select, develop, and engage your Board. Governing Boards play a vital role in creating and
maintaining safety cultures. CEOs are responsible for ensuring the education of their Board
members on foundational safety science, including the importance of and processes for keeping
patients and the workforce safe. Boards must ensure that metrics that meaningfully assess
organizational safety and a culture of safety are in place and systematically reviewed, analyzed,
and the results acted upon.
Prioritize safety in the selection and development of leaders. It is the responsibility of the CEO,
in collaboration with the Board, to include accountability for safety as part of the leadership
development strategy for the organization. In addition, identifying physicians, nurses, and other
clinical leaders as safety champions is key to closing the gap between administrative and clinical
leadership development. Expectations for the design and delivery of relevant safety training for
all executive and clinical leaders must be set by the CEO and subsequently spread throughout the
organization.
Lead and reward a just culture. Leaders must possess a thorough understanding of the principles
and behaviors of a just culture, and be committed to teaching and modeling them. Human error
is and always will be a reality. In a just culture framework, the focus is on addressing systems
issues that contribute to errors and harm. While clinicians and the workforce are held accountable
for actively disregarding protocols and procedures, the reporting of errors, lapses, near-misses,
and adverse events is encouraged. The workforce is supported when systems break down and
errors occur. In a true just culture, all workforce members—both clinical and non-clinical—are
empowered and unafraid to voice concerns about threats to patient and workforce safety.
Establish organizational behavior expectations. Senior leaders are responsible for establishing
safety-mindfulness for all clinicians and the workforce and, perhaps even more importantly,
modeling these behaviors and actions. These behaviors include, but are not limited to,
transparency, effective teamwork, active communication, civility, and direct and timely
feedback. These cultural commitments must be universally understood and apply equally
to the entire workforce, regardless of rank, role, or department.
Introduction 2
The journey toward patient and workforce safety requires vigilance and the highest level of dedication. Safety
cannot be merely a strategic priority, but must be a core value that is woven into the fabric of our organizations.
A culture of safety demands the involvement and commitment of the full healthcare team, from patients to
clinicians to the rest of the workforce. However, an organization cannot be what its leader is not. It is both the
obligation and the privilege of every healthcare CEO to create and represent a compelling vision for a culture of
safety: a culture in which mistakes are acknowledged and lead to sustainable, positive change; respectful and
inclusive behaviors are instinctive and serve as the behavioral norms for the organization; and the physical and
psychological safety of patients and the workforce is both highly valued and ardently protected.
A Note about Disparities in Care

Across the United States, individuals experience great differences in life expectancy and other health outcomes
based on social determinants that may include ethnicity, religion, socioeconomic status, geographic location,
sexual orientation, and gender identity, among others. It is impossible to envision an organization driving toward
zero harm that is not also consciously focused on addressing these disparities.
Professor Margaret Whitehead, head of the World Health Organization (WHO) Collaborating Centre for Policy
Research on the Social Determinants of Health, defines equity in health this way: “Ideally everyone should have
a fair opportunity to attain their full health potential and, more pragmatically, no one should be disadvantaged
from achieving this potential, if it can be avoided” (Whitehead and Dahlgren 2006). The reality of healthcare
today is that quality and safety cannot be achieved without equity. Healthcare organizations have the power
to address disparities at the point of care and to make an impact on many of the determinants that create
these disparities (Institute for Healthcare Improvement 2016). Because equity in health is essential to quality
and safety, mitigation of health disparities must be prioritized across the six domains for developing a culture
of safety. Not only is creating health equity part of the safety imperative, but it requires many of the same
mechanisms recommended throughout this document.
A Note about Learning Systems

The IOM describes a learning healthcare system as one in which “science, informatics, incentives, and culture
are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the care
process, patients and families are active participants in all elements, and new knowledge captured as an integral
by-product of the care experience” (IOM 2013).
While this guide focuses on developing and sustaining a culture that drives patient and workforce safety
outcomes, a CEO’s accountability for developing and supporting a learning system is equally important.
Change implementation is a vast interdisciplinary undertaking that requires all aspects of a safety culture,
from safety science knowledge, to trust, respect, and visionary leadership (Friedman 2015). The design of
learning systems may vary—from high reliability to Six SigmaTM to the Toyota Production System and other
Lean methodologies—but the key characteristics are the same. Zero harm to patients and the workforce is
only possible with both a robust culture of safety and an embedded organizational learning system.
Introduction 3
Recommendations for
Use of This Guide
This guide was developed for CEOs and other executive leaders in order to provide a useful tool for assessing
and advancing an organization’s culture of safety. It can be used to help determine the current state of your
organization’s journey, inform dialogue with your Board and leadership team, and help you set priorities. The six
domains are intended to be discussed with your Board, your leadership team, your workforce, and your community.
These domains are interdependent, and each domain is an essential element that must be addressed along your
journey. This guide contains recommendations for developing and evaluating plans to flourish in each of the six
domains, and resources for helping you move forward and make measurable progress in your journey.
The high-level strategies and practical tactics in this guide are divided into two levels: foundational and sustaining.
The foundational level provides basic tactics and strategies essential for the implementation of each domain. The
sustaining level provides strategies for spreading and embedding a culture of safety throughout the organization.
However, it is important to note that the journey to zero harm is more complex than this simple two-level structure.
Each organization will be at a different place on the spectrum from developing the foundation of a culture of safety
to embedding and sustaining these principles. An organization may work on strategies and tactics across the two
levels, or may be at various levels of progress across each of the domains. In organizations that lack an empowering
vision statement or trust and respect among leadership, clinicians, and the workforce, it may be most effective to
begin improvement initiatives in these two domains. The keys to developing and sustaining a culture of safety are
honest and transparent evaluation of your organization’s current state, identification of gaps and goals, and an
action plan that engages all members of the Board, leadership team, and workforce.
Whether an organization is just beginning the journey to a culture of safety or is working to

sustain its safe culture, the following steps are recommended:
Ã 3 Share this document with your Board Chair and leadership team.
Ã

3 Complete the self-assessment with input from your Board, leadership team, clinicians and
the frontline workforce, and patient and family representatives, as appropriate.
Ã

3 Develop action plans based on an understanding of the current state of your organization.
Use assessment results to frame discussions with your leadership team and the Board that
focus on identifying ways to close gaps and aligning the direction of your organization with
key safety and culture initiatives.
Ã

3 Share the outcomes of the assessment, action plans, and progress with your senior leadership
team, the Board, your workforce, and your patients and families, as appropriate and helpful.
Ã
3 Ask for periodic feedback from your Board, your leadership team, and the workforce.
Ã
3 Refer to this guide as a resource for systematic check-ins and adjustments, as needed.
Recommendations for Use of This Guide 4

A Culture of Safety:
The Six Domains
Vision
Behavior Trust,
Expectations Respect, and
Inclusion
Zero Harm
to Patients,
Families, and the
Just Workforce Board
Culture Engagement
Leadership
Development
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An a A L L E A S I M P R ti o n
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terpretation • Change imp
A Culture of Safety: The Six Domains 5

Establish a Compelling Vision for Safety
GOAL: COMMIT TO DEVELOP, COMMUNICATE, AND EXECUTE ON AN ORGANIZATIONAL

VISION OF ZERO HARM TO PATIENTS, FAMILIES, AND THE WORKFORCE.
To engage and inspire all clinical and non-clinical healthcare professionals and the public, an organization’s vision
should reflect long-term, aspirational goals. This vision must be clearly aligned with the organization’s mission,
which establishes the foundation of what an organization does.
A compelling vision enhances performance, promotes change, motivates individuals, and provides context for
decision making (Lipman 1996). Clearly articulated, a strong vision addresses the why, the how, and the when
of the aspirational goal (Lipman 2003). Many CEOs of healthcare organizations strive to include safety among
their top strategic priorities, and this objective must be clearly reflected as a core value in the vision and mission
statements. The CEO is responsible for launching the critical first step of establishing safety as the most important
part of what everyone does, every day.
Foundational Sustaining
Strategies 3 CEO takes responsibility for educating 3 CEO and leadership team provide
himself/herself on how to develop consistent, personalized messaging
Overarching strategies vision and lead a culture of safety about the importance of safety and
for implementation at zero harm
the CEO level 3 CEO communicates and models a
shared vision of zero harm to 3 CEO relays importance and urgency
patients, families, the community, of safety vision to both internal and
and the workforce external audiences
3 CEO communicates genuine, clear 3 CEO practices transparency and
messages about vision, conveying shared accountability between
purpose of safety culture to Board and leadership team
everyone, in all settings, repeatedly regarding vision and relevant
and for the long term measurement and reporting
3 CEO communicates how vision is
critical to organizational success
3 CEO prioritizes measurement, gap
analysis, and improvement of culture
of safety as foundational for vision
3 CEO gains additional understanding
of safety by participating in full harm
investigation, including disclosure and
apology and root cause analysis

A compelling vision with patient and workforce safety as a core value is essential to achieving safe care. Zero harm
is the aspirational “North Star.” Healthcare CEOs demonstrate their belief that safety is a primary, non-negotiable
goal by working with their Board, clinical leadership, and workforce to develop such a vision, to embed it in their
organization, and to demonstrate their commitment and energize frontline workers through direct involvement in
safety activities (NPSF 2015).
The first step for a CEO in creating this vision is to understand, acknowledge, and communicate the current state
of their organization. A successful vision statement may be developed by top management and shared with the
organization, or created in partnership with the workforce. The key is that the vision statement must encompass
all organizational interests and engage the entire workforce. Visions that offer long-term perspective and include a
degree of difficulty or stretch are often the most powerful. Finally, a vision statement should be clear and concise,
allowing it to be easily remembered, repeated, and communicated (Kantabutra and Avery 2010).
Leaders must work with their teams, in direct partnership with physicians, nurses, and other clinical and non-clinical
leaders, to assess the internal and external landscape of their organization. They must consider safety metrics,
clinicians’ attitudes and perceptions, patient and family experiences, and current practices, as well as trends and
events that affect or might affect the healthcare industry. Landscape analysis is often accomplished through tactics
including focus groups, safety culture surveys, safety rounds, analysis of safety metrics and reporting, and other
diagnostic approaches. As one team of management researchers tell us, “The best way to lead people into the
future is to connect with them deeply in the present” (Kouzes and Posner 2009). Understanding and communicating
the current state enables leaders to connect and work with their teams and clinical experts to create a shared vision
that can inspire everyone within the organization and the community.
While it is important to get input and buy-in from all levels when developing a vision, CEOs must be the ones to
define and model the vision. Leaders at every level need to be visible in their commitment to patient and workforce
safety and vocal about supporting actions that align with the organizational vision.
A clear and aspirational vision inspires the workforce and the public. The CEO works with the Board, leadership
team, clinicians, and workforce to develop and embed this vision.
Conduct training to
build understanding and
Develop vision for safety enthusiasm for vision Benchmark progress
and zero harm among workforce with other organizations
Complete and review Clearly communicate

regular culture of safety vision to patients and
surveys the public

Organizational Foundational Sustaining

Readiness Level
Tactics To engage your organization: To engage your organization:
Examples of tactics that 3 Work with select individuals 3 Clearly articulate your vision to the
may be implemented to throughout the organization to workforce and the public
create change at each of develop understanding of key 3 Benchmark culture progress and
these levels organizational interests and goals best practices with other similar
3 Work with leadership team to organizations (e.g., participate in
develop aspirational end state collaboratives)
(e.g., zero harm) that will be 3 Develop and implement a recognition
incorporated into vision program for leaders, clinicians, and
3 Communicate the definition and the workforce based on growth and
importance of a culture of safety adherence to vision
3 Build awareness of current state 3 Establish organizational goals that
through culture surveys, address safety and disparities in care
observations, and focus groups,
and communicate this throughout To engage clinical leaders:
the organization 3 Include physician, nursing and other
3 Include zero harm vision in all clinical leaders in development of
communications from leaders at vision statement and strategic plan
all levels, and keep this
communication simple, consistent, To engage patients and families:
and repetitive 3 Clearly communicate the vision
3 Include equity of care as part of statement and values to patients
vision statement and 3 Incorporate patient and family
communicate the definition and stories, along with statistics, when
importance of health equity discussing vision at the Board level
3 Conduct training and information 3 Include patient feedback in the
sessions for all employees to build development of vision statement
understanding and enthusiasm for
the vision
3 Spend time on all floors and units
communicating the connection of
culture of safety and vision to the
work of the frontline
YES / NO
Assessing Execution
Are the CEO and leadership team able to clearly communicate the vision
List of questions that to all parties, in both internal and external interactions?
should be asked to Can all members of the organization articulate the vision for safety and
further assess and how it relates to their individual work?
measure progress
Is a patient safety and quality dashboard (which includes safety culture
metrics) utilized and regularly reviewed in the context of organizational
vision?

Value Trust, Respect, and Inclusion
GOAL: ESTABLISH ORGANIZATIONAL BEHAVIORS THAT LEAD TO TRUST IN LEADERSHIP AND

RESPECT AND INCLUSION THROUGHOUT THE ORGANIZATION REGARDLESS OF RANK, ROLE,
OR DISCIPLINE.
Trust, respect for others, and inclusion are essential to creating environments that are both physically and
psychologically safe. Building trust involves managing conflict and making the environment safe for communicating
bad news. It also involves practicing honesty, inclusion, transparency, and respect with everyone. Each member
of the workforce must feel compelled and empowered to uphold mutual accountability and speak up for safety.
Healthcare leaders develop trust within their organizations by having authentic relationships and conversations. For
example, undertaking humble inquiry, asking questions to which you do not already know the answer, and building
relationships based on genuine curiosity and interest all help leaders find information that might otherwise elude
them (Schein 2013).
Strategies 3 CEO recognizes the critical importance 3 CEO establishes expectations and
of trust, respect, and inclusion in accountability for formal program
Overarching strategies shaping organizational culture focusing on trust, respect, and
for implementation at inclusion that includes patients and is
the CEO level 3 CEO creates expectation for trust,
respect, and inclusion, and models implemented across the organization
these through his or her interactions 3 CEO and organization have clear,
with every individual at every level of visible expectations of acceptable
the organization behavior and consequences for
3 CEO holds the leadership team behaviors that do not meet standards
accountable for modeling trust, of trust, respect, and/or inclusion
respect and inclusion 3 CEO establishes transparent practices
3 CEO directs policies that empower the with the Board, senior leadership,
workforce to first and foremost act workforce and community, as
within the guidelines of trust, respect, appropriate
and inclusion when making decisions 3 CEO takes ownership of partnering
3 CEO establishes the expectation that with similar organizations, through
learning from failures and improving Patent Safety Organizations (PSOs)
systems is a part of daily or other collaboratives, to share
organizational activity learning and best practices

The actions of leaders must be consistent over time and throughout the
organization. Behavioral standards and expectations should apply to
everyone, without exception. Respect for others—be they patients, family Cultural Diversity
members, peers, or subordinates—is essential for creating and sustaining and Respect in the
trust. Developing and holding all leaders and the workforce accountable
to codes of conduct or code of ethics can help to solidify the practices and
Workplace
behaviors that encourage trust and respect (Chassin and Loeb 2013).
It is imperative that CEOs
Beyond modeling behaviors of respect themselves, leaders may need to understand the cultural makeup
institute ongoing education for volunteers, students, clinicians, and the of both the community and the
workforce about appropriate behavior, and continue to actively encourage organization in which they serve.
changes designed to increase fairness, transparency, collaboration, Implementing and modeling
inclusion, and individual responsibility (Leape et al., 2012). behaviors that reflect a respectful
and inclusive environment is
In pursuing safety as a core value, trust, respect, and inclusion are essential to a culture of safety. This
fostered by CEOs who make and keep commitments to the workforce, should include placing a high value
who communicate when a problem cannot be fixed immediately, who on the positive impact of greater
consistently display a sense of fairness, and who engage in and encourage diversity and inclusion among
reciprocal, helping behavior throughout the organization.
leadership as well as the workforce.
It should also include efforts to
CEOs must also display their trust in others. Creating a strong team enables
evaluate and eliminate disparities
leaders to have confidence in delegating decisions and authority, though
trust does not mean believing nothing will ever go wrong. Leaders can in patient care. Unleashing the
expect to continually work on building, sustaining, or repairing trust. potential of workforce diversity
depends on the establishment of
inclusion, the building of trust and
respect, and training in skills and
behaviors that support an inclusive
and respectful organization. With
this approach, cultural diversity can
be an effective resource for creative
problem solving and organizational
learning, and can help to identify
and ameliorate disparities of care.
(EU-OSHA 2013)

Trust, respect, and inclusion are the foundation of a culture of safety. The CEO develops trust and respect with individuals
at all levels of the organization, and, with the Board, holds leaders, clinicians, and the workforce accountable for policies
and behaviors that reflect these values.
Provide education and Develop and share

training on respect, Encourage, recognize, patient and provider
diversity, and inclusion and reward reporting compacts
Implement workforce Implement Participate in full transparency

safety programs, communication with the public around harm
addressing both physical and resolution events and action plans for
and psychological safety programs improvement

Readiness Level
Examples of tactics that 3 Commit to implementing and 3 Aim for total transparency, but
may be implemented to holding all leaders and the work explain situations in which the
create change at each of force accountable for processes and organization is unable to be
these levels policies related to respect for completely transparent
people, just culture, and managing 3 Publicly share available information
disruptive behavior about events of harm, and plans
3 Encourage and promote open for managing associated risks
discussion of safety issues via 3 Ensure follow-up and feedback on
leadership rounds and reporting identified safety issues, and be
systems, and ensure follow-up transparent if an issue cannot be
and feedback resolved promptly
3 Ensure that the workforce has 3 Create compacts for leaders that
dedicated time to devote to patient clearly define expected behaviors
safety and safety culture work in trust and transparency as they
3 Implement workforce safety relate to other leaders, peers, and
programs to reduce physical and subordinates
psychological harm to the 3 Build metrics for respect and trust
workforce (e.g., workforce psychological
3 Clearly define and encourage safety, error reporting) into the
behaviors that show deference to evaluation process for all leaders
expertise rather than hierarchy
or title


Readiness Level
Tactics To engage your organization (cont): To engage clinical leaders:
Examples of tactics that 3 Recognize and reward reporting 3 Provide training for physicians,
may be implemented to with the goal of reducing and nurses, and other clinical leaders
create change at each of eventually eliminating anonymous around patient engagement and
these levels reporting communication
3 Provide education and training on 3 Provide cultural competency training
diversity and inclusion at every for all clinical leaders that is relevant
level of the organization to the patient populations they serve
3 Track employee engagement and
turnover as a metric to evaluate To engage patients and families:
trust, inclusion, and respect 3 Encourage and enable patients and
3 Include care disparity metrics on families to speak up if they notice
regularly reviewed patient safety a risk to safety
dashboards 3 Ensure that crisis plans address how
3 Translate tools and resources for to communicate with patients and
both patients and the workforce families in the event of an error,
into a variety of languages, keeping regardless of degree of harm
in mind cultural context and 3 Commit to shared decision making
linguistic idiosyncrasies and consider patient preferences in
3 Adopt communication and all treatment plans
resolution/reconciliation programs 3 Engage patients and families in
for patients and families after creating and disseminating patient
events of preventable harm compacts that include what patients
3 Establish patient and family advisory can expect from the organization,
councils their care providers, and the
workforce
YES / NO
Assessing Execution
Are all clinicians and workforce members provided with training in
List of questions that communicating with patients, including disclosure and apology?
should be asked to Are measures of respect included in all performance assessment tools?
further assess and
measure progress Is a formal program for respect and trust in place and evaluated
regularly?
Is there systematic training on diversity and inclusion for both the
clinical and non-clinical workforce?
Do the Board and leadership team regularly create and evaluate
improvement plans for addressing disparities in patient care?

Select, Develop, and Engage Your Board
GOAL: SELECT AND DEVELOP YOUR BOARD SO THAT IT HAS CLEAR COMPETENCIES, FOCUS,
AND ACCOUNTABILITY REGARDING SAFETY CULTURE.
Boards of healthcare organizations oversee the fiduciary performance, reputation, and key performance outcomes
of an organization, including those related to quality, safety, and culture. The accountability for safety is shared
between the CEO and the Board. The CEO is responsible for guaranteeing Board education on the importance
of safety, ensuring that the Board understands quality and safety metrics, and recommending the appropriate
representation of safety expertise on the Board, which could mean a safety expert from another field. In line with
the CEO’s responsibilities, the Board is responsible for making sure the correct oversight is in place, that quality and
safety data are systematically reviewed, and that safety receives appropriate attention as a standing agenda item at
all meetings. It is imperative that safety be a foundational factor in how healthcare Boards make decisions, so that
patient and workforce safety culture is a sustainable focus for the organization.
Strategies 3 CEO guarantees Board education on 3 CEO works with the Board to set
importance of safety, the meaning direction, goals, metrics, and systems
Overarching strategies of quality and safety metrics, and of mutual accountability for zero
for implementation at safety culture principles and behaviors harm to both patients and the
the CEO level workforce
3 CEO ensures Board membership
includes clinical, safety, and patient/ 3 CEO provides for the appropriate
family representation level of oversight of the credentialing
3 CEO provides adequate agenda time and re-credentialing process,
for review and discussion of safety including elements of quality and
culture metrics and issues safety
3 CEO sets up quality and safety 3 CEO works with the Board and/or
committee(s) with Board compensation committee to align
representation executive compensation with patient
and workforce safety and culture
3 CEO ensures each Board agenda metrics
includes time designated for
Chief Medical Officer or Chair of 3 CEO leverages patient stories and
Quality and Safety Committee presentations to educate the Board
to present safety and quality data 3 CEO provides opportunities for Board
3 CEO develops a robust Board-level member representation on
patient and workforce safety appropriate safety committees
dashboard that includes culture of
safety metrics

In recruiting new Board members, considerable thought should be given to the competencies, skills, experiences, and
diversity needed to create and sustain a culture of safety. These skills may include specific competencies related to leading
culture improvement efforts, as well as clinical and safety competencies. Ensuring that there is robust clinical expertise
in the Board room is critical to incorporating frontline perspective into all conversations and initiatives, and allows for
collaborative leadership in safety efforts throughout the organization (Goeshel et al. 2010). These decisions should also
include measures of diversity that ensure the board is representative of the community and workforce it serves. Finally,
leaders may encourage Boards or relevant committees to include a patient and family representative and safety experts
from relevant industries. These recommendations should be made at the appropriate level based on each unique
organization’s needs.
A well-rounded and diverse Board empowers and supports the work of the CEO in creating and sustaining a culture of
safety. The importance of Board education and training in safety science fundamentals, including just culture, human
factors, and systems engineering cannot be overemphasized (NPSF 2015). There is real power in support for the CEO
from the Board regarding issues of safety, allowing this focus to cascade to leadership and, ultimately, throughout all
levels of the organization.
Effective Patient and Family Representation on Boards and

Committees:
CEOs should consider the following characteristics of effective representation, while keeping in
mind the appropriate voice and level of representation of patient/family member(s) to meet the
needs of their organization and community:
Culture of the Board encourages total engagement and involvement of patient/family

member(s)
Patient/family member(s) are representative of the community the organization serves
Patient/family member(s) have representation on quality and safety committee(s) and

other committees, as appropriate
Patient/family representative is provided with ongoing learning opportunities in safety

science and safety culture

An engaged Board plays a key role in organizational culture and safety. The CEO encourages Board competencies
and commitment regarding safety, while providing a transparent line of sight between the Board and the rest of
the organization.
Include Board members
Include clinical and on rounds and in cross-
Invest in resources for safety expertise on all organizational and external
Board education Boards and committees learning opportunities
Board completes regular Include a patient/ Bring patients to the

self-assessments for family representative board to tell their
safety and culture on all Boards and stories
competencies committees

Readiness Level
Examples of tactics that 3 Establish Board Quality and Safety 3 Encourage the Board to link
may be implemented to Committee with oversight executive compensation to safety
create change at each of responsibility for culture change, outcomes, while ensuring metrics
these levels safety, and performance chosen do not discourage safety
improvement efforts
3 Include an individual with safety 3 Include Board members on guided
and culture expertise on Board and leadership rounds
appropriate committees, or ensure 3 Align Board dashboards to show
an advisor with these skills is safety and quality metrics as
available to the CEO and the Board segmented by categories related
3 Begin each Board meeting with a to disparities in care
slide detailing the number and 3 Ask Board members to participate
names of patients and staff who in events to show their support
experienced harm since last during Patient Safety Awareness
meeting, and include a story about Week and to be present at major
at least one of these individuals quality, safety, and culture-related
3 Regularly share and discuss a events
dashboard that includes patient 3 Bring frontline teams to Board
and workforce safety and culture meetings to share their success
metrics stories and receive recognition
3 Utilize a Board self-assessment 3 Consider a rotating position on
that includes inquiry on safety the Board or Quality and Safety
culture knowledge to determine Committee reserved for the
educational opportunities frontline workforce
3 Identify a list of required Board 3 Request that Board members
competencies specific to leading spend time on all floors and units
culture improvement communicating and supporting the
safety agenda


Readiness Level
Tactics To engage your organization (cont): To engage your organization (cont):
Examples of tactics that 3 Discuss whether Board reflects the 3 Provide Board members with
may be implemented to community your organization serves opportunities to learn from Boards
create change at each of and implement action plan to and leaders of outside organizations
these levels address any gaps and industries
3 Invest in resources for Board 3 Require Board approval on resolutions
education, including patient safety to all serious safety events
science and quality
3 Create a matrix of Board competency To engage clinical leaders:
needs and seek candidates with 3 Involve physicians, nurses, and other
those skills in mind clinical leaders to present clinical and
3 Regularly review accreditation survey quality improvement efforts regularly
results with the Board to the Board
3 Encourage ample clinical expertise, 3 Bring clinical leaders dedicated to
including physicians and nurses on culture to Board meetings to share
the Board and/or on Board their experience and receive
committees recognition
3 Include a presentation on a current To engage patients and families:
organizational safety culture issue by 3 Create positions for patient/family
an expert in safety and quality at representatives on your Board and on
each Board meeting your quality/safety committee(s)
3 Educate Board members on issues of 3 Present patient stories at Board and
disparities in care appropriate committee meetings
3 Invite patients to attend Board
meetings and personally share their
stories and experiences (both positive
and negative)
YES / NO
Assessing Execution
Does the Board conduct regular self-assessments related to knowledge and
List of questions that understanding of culture of safety?
should be asked to Are programs in place to build competencies in culture improvement for
further assess and Board members?
measure progress
Is the amount of time spent on quality and safety during each Board meeting
tracked and at least comparable to time spent on finance and other items?
Do performance assessments for the CEO include the organization’s safety
activities and measures of culture?
Do patient safety and quality leaders participate in at least a portion of all
Board meetings?
Is a patient and/or workforce story presented at each Board meeting?

Prioritize Safety in Selection and

Development of Leaders
GOAL: EDUCATE AND DEVELOP LEADERS AT ALL LEVELS OF THE ORGANIZATION WHO
EMBODY ORGANIZATIONAL PRINCIPLES AND VALUES OF SAFETY CULTURE.
Healthcare CEOs, in collaboration with the Board, are responsible for establishing the direction and accountability for the
design and delivery of their organization-wide leadership development strategy. Within this strategy, it is imperative that
safety is part of the education for both current and emerging leaders. It is the responsibility of the CEO to establish the
priority for safety and culture in the development of leaders at all levels and in all departments across the organization.
Emphasis on safety education can also help close the gap between administrative and clinical leadership, providing all
leaders with the shared goal of driving toward a culture of safety for the betterment of the organization and the patients
they serve. Identifying and developing physician, nursing, and other clinical leaders as champions for safety is a key
responsibility of the CEO. Numerous studies indicate the positive impact clinical leaders can have on culture and safety,
particularly in an era when healthcare leaders are often in a position to make decisions that affect care at the frontlines.
Clinical leaders have extensive understanding of healthcare’s “core business” of patient care, and are therefore in a unique
position to connect administration with the clinical workforce, and to garner support for safety and culture initiatives. In
addition to safety education, CEOs can commit to developing effective physician, nursing, and other clinical leaders by
providing and encouraging training in non-clinical skills, including professionalism, emotional intelligence, team building
and communication, and basic business principles (Angood 2014).
Strategies 3 CEO sets expectations and 3 CEO serves as a mentor for other
accountability for the design and C-Suite executives
Overarching strategies delivery of the organization’s
for implementation at 3 CEO establishes expectation that
leadership development strategy quality and safety performance and
the CEO level
3 CEO ensures he/she and the competence are required elements
leadership team receive necessary for evaluating current and potential
safety education, and provides the leaders for promotion and succession
appropriate level of safety education planning
throughout the rest of the 3 CEO assigns accountability for
organization measurable outcomes of safety
3 CEO identifies physicians, nurses, education as part of leadership
and other clinical leaders as development strategy
champions for safety 3 CEO ensures patient and workforce
safety are key parts of the
organization’s reward and recognition
system
17
Prioritize Safety in Selection and Development of Leaders

The selection process for both current and emerging leaders should be predicated on their understanding of, dedication
to, and alignment with the organization’s vision for patient and workforce safety, communication skills, and modeling
of expected safety behaviors. Safety can be a topic for individual professional development as well as organization-wide
succession planning to ensure that the commitment to safety is sustainable throughout all levels and functional areas.
Many organizations already have a process in place for identifying individuals with high potential to succeed as leaders,
into which a safety and culture program can be integrated (Garman and Anderson 2014).
Finally, it is critically important to provide regular feedback to both current and developing leaders that is valuable to
them, whether that is a 360-degree review model or another structured review (Garman and Anderson 2014). Feedback
should clearly define, communicate, and embody required leadership competencies in safety culture, and safety
development plans should be reviewed at regularly scheduled check-ins. CEOs are responsible for not only setting this
direction, but also participating in these reviews from the perspective of gathering feedback about their own competence
in safety culture and behaviors, and sharing input for members of their leadership team.
A well-developed leadership team that is dedicated to a culture of safety provides a catalyst for the evolution of the
organization. The CEO, in collaboration with the Board, is responsible for establishing the direction and accountability
for the design and delivery of an organization-wide leadership development strategy.
Provide continuing
education opportunities Provide opportunities
Define organizational in safety science and for cross-departmental
leadership competencies culture training
Define processes for Develop systems for Provide opportunities

leadership development training, coaching, and for learning from
at all levels mentoring current and outside organizations
prospective leaders and industries
18


Readiness Level
Examples of tactics that 3 Define and develop organizational 3 Build an incentive program into
may be implemented to leadership competencies in safety leadership reviews that is focused
create change at each of culture and safety behaviors and on reporting performance on
these levels ensure that all current and future key culture of safety metrics
leaders and the frontline 3 Provide continuing learning
workforce receive education in opportunities in safety and
selected competencies culture, with a focus on
3 Define cultural roles and experiential learning
expectations for all leaders within 3 Tie measures and performance
the organization, including clinical on safety and culture to leadership
leaders development priorities, talent
3 Create systems to support leaders management reviews, and
in culture work at all levels of the succession planning
organization through training, 3 Provide opportunities and
coaching, and mentoring expectations for leaders to learn
3 Consider safety expertise and outside of the organization, both
credentialing along with leadership with similar organizations and
potential when considering outside industries
emerging leaders 3 Build a guiding coalition of
3 Discuss whether leadership team champions, including clinicians
reflects the community the and frontline workforce members,
organization serves and develop that provides candid and honest
plan to address any gaps feedback to the CEO
3 Create systems that ensure regular 3 Incorporate leadership
reporting on leadership development into organizational
development measures people strategy
3 Develop and employ a talent 3 Define talent as an organizational
review process that is candid resource and allow for
and transparent interdepartmental training
3 Conduct gap analysis of CEO and and mobility
leadership for knowledge, skills, 3 Ensure leaders are trained to
and attitudes around patient teach and coach their employees
safety and culture 3 Recommend that each senior
executive participate in
communication and apology to
patients and families who have
experienced harm
19


Readiness Level
Tactics To engage your organization (cont): To engage clinical leadership:
Examples of tactics that 3 Ensure all executives can clearly 3 In leadership development
may be implemented to articulate how a culture of safety programs, incorporate opportunities
create change at each of applies in their department, and for clinical leader advancement
these levels that all leaders can do the same
3 Develop systems that encourage To engage patients and families:
deference to expertise rather 3 Ensure leaders have competencies
than hierarchy or title in issues in how to partner effectively with
of safety patients at all levels of care
3 Include patient and family
representatives in leadership
recruitment and hiring process
YES / NO
Assessing Execution
Do all leaders receive training in patient safety science and safety culture?
List of questions that Is at least one member of the executive leadership team a
should be asked to Certified Professional in Patient Safety or a safety expert?
further assess and
measure progress Are leadership development plans reviewed annually? Do they include
measures of key safety culture competencies?
Do leadership development programs include cultivation of a robust skill set
in communication, engagement, listening, performance improvement, and
emotional intelligence, as well as business acumen?
20
Lead and Reward a Just Culture
GOAL: BUILD A CULTURE IN WHICH ALL LEADERS AND THE WORKFORCE UNDERSTAND
BASIC PRINCIPLES OF PATIENT SAFETY SCIENCE, AND RECOGNIZE ONE SET OF DEFINED AND
ENFORCED BEHAVIORAL STANDARDS FOR ALL INDIVIDUALS IN THE ORGANIZATION.
Healthcare organizations that are successful in improving safety and eliminating harm have leaders who understand
and commit to the principles of just culture. A just culture “focuses on identifying and addressing systems issues that
lead individuals to engage in unsafe behaviors, while maintaining individual accountability by establishing zero tolerance
for reckless behavior. Just organizations focus on identifying and correcting system imperfections, and pinpoint these
defects as the most common cause of adverse events. Just culture distinguishes between human error (e.g., slips), at-risk
behavior (e.g., taking shortcuts), and reckless behavior (e.g., ignoring required safety steps), in contrast to an overarching
‘no-blame’ approach” (PSNet Safety Primer 2016).
Strategies 3 CEO encourages commitment to 3 CEO employs just culture principles
just culture framework as an throughout organization and
Overarching strategies essential business philosophy communicates that rules apply to all,
for implementation at regardless of rank, role and discipline
the CEO level 3 CEO communicates and models
the use of just culture principles in 3 CEO sets expectations for
all decisions and actions as part of accountability for anyone interacting
daily responsibilities and interactions, with the healthcare organization to
including root cause analysis commit to utilizing just culture
3 CEO educates Board and leadership principles in every day practice
team on principles of just culture and decisions
and role models these principles 3 CEO ensures just culture principles
are implemented in all interactions
A just culture is not a blame-free environment; clinicians and the workforce are still held accountable for following
protocols and procedures. The vast majority of errors are not a result of individual failures, but are the result of systems
that are inherently flawed and create environments of risk. A just culture acknowledges that punishing people for
mistakes discourages reporting, fails to correct problems in the system, and sets up the likelihood of recurrence. Just
culture also emphasizes the importance of the affected workforce after events occur, and focuses on support and
peer-to-peer counseling for affected clinicians and the workforce.
When clearly defined, articulated, and implemented by leadership, a just culture approach encourages the reporting of
errors, lapses, near-misses, and adverse events. It is through reporting and event analysis that the organization learns
what went wrong, or could have gone wrong, and how to prevent it from happening again.

The hard work of establishing a just culture, however, goes well beyond agreeing to the concept itself. It involves
incorporation of expertise in human factors engineering and systems design, full support and resources from the CEO
and all leadership, and full engagement of departments such as Human Resources and Organizational Development.
It also requires robust reporting systems with mechanisms in place to provide timely feedback to the workforce about
not only what went wrong, but why it went wrong. This feedback also includes strong action plans to prevent future
occurrence. Developing a just culture policy is just the first step, and organization-wide, systemic implementation is key.
While training of leaders and the patient safety workforce on just culture is vital, everyone at all levels of the organization
must consistently integrate just culture principles as an organizational norm. The CEO’s role in ensuring that just culture
principles are understood and implemented across the organization is fundamental to success. If one individual within
the organization is punished for a system flaw, just culture efforts can be severely undermined. Leaders must be
transparent with the Board, physicians, the workforce, and the public about the organization’s approach, so that when
something does go wrong, the response is expected, practiced, and applied uniformly throughout the organization.
Just Culture Principles

Human behaviors within a just culture can be described as follows:
HUMAN ERROR = An inadvertent slip or lapse. Human error is expected, so systems should be
designed to help people do the right thing and avoid doing the wrong thing.
Response: Support the person who made the error. Investigate how the system can be altered
to prevent the error from happening again.
AT-RISK BEHAVIOR = Consciously choosing an action without realizing the level of risk of an
unintended outcome.
Response: Counsel the person as to why the behavior is risky; investigate the reasons they
chose this behavior, and enact system improvements if necessary.
RECKLESS BEHAVIOR (NEGLIGENCE) = Choosing an action with knowledge and conscious

disregard of the risk of harm.
Response: Disciplinary action.
(PSNet Safety Primer 2016)

A just culture that focuses on identification and resolution of systems issues supports clinicians and the workforce
when these systems break down. CEOs ensure that the principles of a just culture are implemented organization-wide
and that they inform every action and decision.
Develop just culture

policy and align Utilize just culture
across systems and principles in all event Treat gaps in culture
departments reviews and decisions as adverse events
Educate Board, Develop metrics for Involve the media

leadership, and just culture and hold to explain errors,
workforce workforce accountable data, and decisions
to the public

Readiness Level
Examples of tactics that 3 Educate Board, leadership, and 3 Educate organization to be responsive
may be implemented to workforce about just culture to and transparent about actions
create change at each of through integrated training related to professional discipline
these levels programs 3 Implement a peer support program
3 Develop and implement a 3 Hold workforce accountable for
decision-making process and implementing just culture principles
application of just culture that in daily practice and decision-making
is behavior-based, rather than 3 Include actual and mock scenarios
harm-based on meeting agendas that
3 Ensure organization-wide demonstrate application of just
leadership commitment to culture principles
frameworks of just culture and 3 Involve the media as a way to
accountability that are aligned explain errors, decisions, and
across all departments data to the public
3 Create an interdisciplinary just 3 Treat and respond to gaps in
culture champion team to review culture and expected safety
organizational policies, provide behaviors as adverse events
training, and ensure policies are
being followed at all levels 3 Expect that leaders utilize just
culture tools in all situations, even
3 Identify metrics to track those not significant or punishable,
performance on just culture to ingrain principles and use into
implementation organizational norms


Readiness Level
Tactics To engage your organization (cont): To engage clinical leadership:
Examples of tactics that 3 Align systems and standards for just 3 Include clinical leaders in the
may be implemented to culture across all organizational development of just culture policies
create change at each of departments, including Human 3 Provide training for physicians,
these levels Resources nurses, and other clinical leaders in
3 Ensure employees are well-trained just culture to build understanding
in just culture algorithm and tools and enthusiasm
and utilize them in daily activities
and decisions To engage patients and families:
3 Publicly reward positive examples 3 Ensure that patients and family
of just culture members who serve on Board and
committees are educated on just
culture principles
3 Include patients and families in
mediation committees/tribunals
to assist in resolving conflicts
between departments
YES / NO
Assessing Execution
Do Board, leadership, and workforce development programs include
List of questions that training on just culture?
should be asked to Is there one set of defined behavioral standards for all individuals within
further assess and the organization, including leadership, physicians, and the workforce?
measure progress
Is compliance with the established just culture framework part of regularly
reviewed performance reviews, including career development plans, for
leaders and the workforce?
Does the organization use, evaluate, and define action plans related to
measures of just culture on employee surveys?
Is there an existing measure that is regularly evaluated for assessing frontline
knowledge of just culture algorithm?

Establish Organizational Behavior

Expectations
GOAL: CREATE ONE SET OF BEHAVIOR EXPECTATIONS THAT APPLY TO EVERY INDIVIDUAL
IN THE ORGANIZATION AND ENCOMPASS THE MISSION, VISION, AND VALUES OF THE
ORGANIZATION.
Much of the work involved in creating a culture of safety in healthcare is intrinsically linked to the everyday behaviors
that characterize an organization (PSNet Patient Safety Primer: Safety Culture 2016). In fact, culture is often defined as
“the way we do things around here.” CEOs set the tone and have the power and responsibility to establish behaviors,
set expectations, and promote accountability for these behavioral norms for everyone, including both employed and
non-employed individuals. It is essential for Board members, the CEO, and leaders at every level to model the behaviors
they aim to cultivate throughout the organization.
Strategies 3 CEO creates, communicates, and 3 CEO prioritizes resources for
models an organizational climate of professional accountability
Overarching strategies personal and professional framework and programs to ensure
for implementation at accountability for behavior and sustain behavioral excellence
the CEO level
3 CEO establishes systems to recognize 3 CEO ensures that succession
and reward desirable behaviors planning and talent management
3 CEO activates organization to develop, programs prepare future leaders
implement, and evaluate programs with competencies in organizational
that address and improve personal, behavior and accountability
professional, and organizational 3 CEO works with licensing bodies
behavior and accountability and medical executive committees,
3 CEO engages Board by sharing metrics where applicable, to ensure
and dashboards related to behavioral expectations and
organizational behavior accountability practices are consistent
3 CEO engages and holds all leaders 3 CEO and leaders at all levels of
and workforce accountable for the organization encourage
defined behaviors questions, increasing the likelihood
that the right question will be asked
at a critical time


Expectations
Chief among the behaviors that contribute to an environment of physical

and psychological safety are transparency, effective teamwork, active
communication, just culture, respect, and direct and timely feedback. Each Importance of Physical
of these can be learned, and the workforce should be educated about what
and Psychological Safety
is expected and why. For example, educating health professionals in effective
communication with patients and families, whether disclosing an error, of the Workforce
seeking informed consent, or practicing shared decision making, is a key part
of cultivating teamwork, communication, and respect. An environment that protects the
physical and psychological safety
One of the first responsibilities of a CEO is to understand the current accepted of the workforce is fundamental
behaviors within the organization. One way to achieve this understanding to a culture of safety. Yet many
is through use of validated surveys of patient safety culture, which can help healthcare workers suffer from
identify areas of strength as well as areas for improvement at organizational, harm, including bullying, burnout,
departmental, and unit levels. Surveys can also reveal the strength or and physical injury and assault,
weaknesses of organizational culture and “subcultures,” and provide leaders during the course of providing
a better sense of where they may need to focus attention. In this manner, care. Under these conditions, it is
leaders are able to better connect with the frontline workforce on a regular
difficult for care providers to find
basis, whether through leadership rounding, safety huddles, briefings/
joy and purpose in their work, and
debriefings, or other tactics, so they can hear about challenges firsthand.
patient safety is jeopardized. The
A Board, leadership, physician and other clinical professional, and workforce
“credo” or compact also helps to communicate behavioral expectations. Such prioritization of safety behaviors
a compact can frame discussions and maintain accountability when someone including respect, transparency,
violates the standard behavioral code (Webb et al. 2016). and teamwork is at the foundation
of safety for the workforce,
It is also important to have a mechanism for escalating concerns when and therefore for patients. The
behavioral codes are violated and for dealing with disruptive and unsafe workforce needs to know that
behaviors. Everyone within the organization should understand what that their safety is an enduring,
procedure is, and that it will be applied consistently across the organization, non-negotiable priority for the
regardless of rank, department, revenue, or other considerations. It is CEO and Board. This commitment
essential to remember that the process of changing behavioral norms is demonstrated when action plans
across an organization or system can be a long and challenging one. That is are developed and implemented to
why it is equally important to ensure that there is also a system to reward
ensure the workforce feels valued,
individuals who are identified as modeling desired behavior. True progress
safe from harm, and part of the
can be accomplished with the dedication of a highly engaged, unwavering,
and courageous CEO. solution for change (NPSF LLI 2013).


Expectations
Organizational safety behavior expectations are the daily demonstration of a true culture of safety. CEOs work with
leaders and the workforce to develop these expectations and to personally demonstrate expected behaviors, while
holding the leadership team accountable for doing the same.
Encourage open
Define organization-wide reporting and safety Recognize and reward
required processes and discussions and provide workforce engaging in
expected behaviors transparent feedback defined safety behaviors
Define organizational Hold all leaders and Engage patients in

response to disrespectful workforce accountable all team activities
or disruptive behavior for organization-wide and communication
expected behaviors processes

Readiness Level
Examples of tactics that 3 Complete culture of safety surveys 3 Require annual signatures on compacts
may be implemented to every 12-18 months and review for Board members, leaders, and the
create change at each of with Board, leadership team, and workforce that clearly define expected
these levels workforce; set targets for professional accountability behaviors
improvement and take deliberate 3 Educate and explain to your
action to achieve them organization and the public what
3 Stratify and track culture and safety you will be transparent about, and
metrics by sociodemographic what limits may exist on transparency
variables that are important to 3 Design and implement a crisis
the organization’s community and communications policy and plan for
develop plans to address any gaps both internal and external audiences
3 Develop required processes for 3 Align and integrate organizational
teamwork, communication, and safety and respectful behaviors with
handoffs among the workforce and all departments across the
with patients, using tools like SBAR, organization
read back, “stop the line,” briefings, 3 Provide feedback to employees when
and de-briefings they report a safety issue, closing the
3 Require, participate in, and give loop and demonstrating how
context for existing safety processes, frontline callouts improve safety
including safety huddles and 3 Recognize and reward individuals
operational briefings, and use these and teams for demonstrating positive
opportunities as forums to build safety behaviors and reporting
better teamwork and safety culture


Expectations

Readiness Level
Tactics To engage your organization (cont): To engage your organization (cont):
Examples of tactics that 3 Define organizational safety behavior 3 Ensure the existence of measurement
may be implemented to expectations and respectful tools and/or report cards for
create change at each behaviors, as well as the individual performance
of these levels organizational response to 3 CEO requires and accepts notification of
disrespectful behavior and conflict any serious safety events within 24
3 Proactively promote and encourage hours, without exception
teamwork by implementing a formal 3 SBAR for all serious safety events is shared
team training program with full administrative and clinical
3 Break down hierarchical policies and leadership teams and with the Board
systems for reporting, and encourage 3 Leadership distributes awards for teams
reporting without fear of punishment and organizations based on culture of
or retribution safety metrics
3 Break down power gradients by To engage clinical leaders:
communicating and rewarding a
policy that requires all staff to speak 3 Recognize and reward physicians, nurses,
up for safety concerns and other clinical leaders who actively
participate in teamwork and
3 Develop and abide by leadership communication initiatives
behaviors, including appreciative
or humble inquiry 3 Create (and require signatures on)
physician and leadership compacts that
3 Celebrate and recognize clearly define behavioral expectations
individuals and teams who excel
at key safety behaviors 3 Commit to and train the workforce on
communication and resolution programs
3 Work with key stakeholders to clearly
communicate and enforce the same To engage patients and families:
behavioral standards for both 3 Include patients in the development of
employed and non-employed required processes for communication
practitioners and staff with patients, using tools like AskMe3®
and shared decision making
3 Encourage and enable patients and
families to report safety concerns, and
follow up with families who have reported
3 Ensure that safety behavior expectations
are centered around the patient, and
involve patients in setting these expectations
3 Create, supply, and use understandable
tools for patient involvement and shared
decision making
3 Invite patients to utilize versions of
communication and reporting tools (e.g.,
SBAR) and to participate in team processes
3 Have a designated team available to
provide support to patients, families, and
the workforce when an error has occurred


Expectations

Readiness Level
YES / NO
Assessing
Execution Does the organization have a clearly defined reporting system and measure
utilization of this system (including follow-up and feedback processes)?
List of questions that Are organizational behavior expectations, such as use of huddles and briefings,
should be asked to with follow-up plans and identified owners of action items, implemented and
further assess and reviewed regularly?
measure progress
Are professional accountability standards (e.g., a process to address disruptive
behaviors) in place, used, and regularly evaluated?
Are specific tools to encourage teamwork and clear communication in place,
used, and regularly evaluated?
Are communication and resolution/reconciliation programs in place, utilized,
and regularly evaluated?

Appendix
Key Terms Related to Patient Safety and a Culture of Safety

Based on AHRQ PSNet Glossary [nd], Runciman et al. 2009, and others as noted.
Adverse Event: Any injury caused by medical care. An undesirable clinical outcome that has resulted from some aspect of
diagnosis or therapy, not an underlying disease process. Preventable adverse events are the subset that are caused by error.
Clinician: A health professional qualified in the clinical practice of medicine, such as a physician, nurse, pharmacist, or
psychologist who is directly involved in patient care, as distinguished from one specializing in laboratory or research techniques
or in theory.
Error: An act of commission (doing something wrong) or omission (failing to do the right thing) that leads to an undesirable
outcome or significant potential for such an outcome.
Harm: An impairment of structure or function of the body and/or any deleterious effect arising therefrom, including disease,
injury, suffering, disability, and death. Harm may be physical, social, or psychological, and either temporary or permanent.
Inclusion: Positively striving to meet the needs of different people and taking deliberate action to create environments where
everyone feels respected and able to achieve their full potential (National Institute for Health Research 2012).
Just Culture: A culture that recognizes that individual practitioners should not be held accountable for system failings over
which they have no control. A just culture also recognizes that many individual or “active” errors represent predictable
interactions between human operators and the systems in which they work. However, in contrast to a culture that touts “no
blame” as its governing principle, a just culture does not tolerate blameworthy behavior such as conscious disregard of clear
risks to patients or gross misconduct (e.g., falsifying a record, performing professional duties while intoxicated).
Patient Safety: Patient safety refers to freedom from accidental or preventable injuries produced by medical care. Thus,
practices or interventions that improve patient safety are those that reduce the occurrence of preventable adverse events.
Psychological Safety: Individuals’ perceptions about the consequences of interpersonal risks in their work environment. These
perceptions include taken-for-granted beliefs about acceptable interactions with co-workers, superiors, and subordinates,
and how others will respond when one puts oneself on the line, such as by asking a question, seeking feedback, reporting a
mistake, or proposing a new idea (Edmondson 2011).
Respect: The treatment of others with deference in daily interactions, weighing their values, views, opinions and preferences
(Sergen’s Medical Dictionary 2012).
Safety Culture/Culture of Safety: The safety culture of an organization is the product of individual and group values, attitudes,
perceptions, competencies, and patterns of behavior that determine the characteristics of the organization’s health and safety
management. Organizations with a positive safety culture are characterized by communications based on mutual trust, by
shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures (Health and Safety
Commission 1993).
Total Systems Safety: Safety that is systematic and uniformly applied (across the total process) (Pronovost et al. 2013). A
systems approach can help with the design and integration of people, processes, policies, and organizations to promote better
health at lower cost.
Trust: The collective expectations by the public and other clinicians that health care providers will demonstrate knowledge,
skill, and competence, and will act in the best interest of both patients and colleagues with beneficence, fairness, and
integrity (Calnan 2008).
Workforce: Health professionals and all other workers employed in health service or other settings, including but not
limited to clinicians, administrators, medical records personnel, and laboratory assistants.
Workforce Safety: Healthcare workforce safety refers to freedom from both physical and psychological harm for all those
who work with patients as well as those who oversee or provide non-clinical support for those who work with patients.
Zero Harm/Free from Harm: The total absence of physical and psychological injury to patients and the workforce.
Appendix 30
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Bibliography 32
Self-Assessment Tool
Culture of Safety Organizational Self-Assessment
Please Note: The questions in this self-assessment represent a selection of elements from the report,
“Leading a Culture of Safety: A Blueprint for Success.” This brief assessment may not accurately represent
the full environment or state of each organization. It is recommended that teams review all strategies, tactics,
and information in the full document for additional clarity and guidance.
Instructions:
Select a diverse team to lead the safety culture review and improvement process. It is recommended that this
team include key C-Suite executives, clinical leadership, patient safety leadership, and a patient and family
representative.
Share the guide, Leading a Culture of Safety: A Blueprint for Success with your team. Review the full document
as a team or independently.
Ask each team member to complete this self-assessment independently. Conduct a series of meetings to:
A) Review self-assessment responses and scoring for each category as a team, and finalize your
organizational score.
B) Develop action plans, metrics/dashboard, for assessment, and follow-up plans for low scoring domains
(Refer back to Leading a Culture of Safety: A Blueprint for Success for assistance)
Note: if your team records low scores in Establish a Compelling Vision for Safety or Value Trust, Respect,
and Inclusion, it is recommended that you begin with action plans for improvement in these domains.
C) Review improvement metrics, revisit action plans, and make adjustments as necessary. You should
include additional team members and/or consultants where applicable.
Notes on Scoring:
Each statement should be scored on a scale of 1-5 based on the following:
1 – Never true for my organization

2 – Rarely true for my organization
3 – Sometimes true for my organization
4 – Almost always true for my organization
5 – Always true for my organization
If you are unsure of the response, please check the box titled unsure. When adding responses for a total score, this
box should be recorded as a 0. For any item where a member of the leadership team is unsure of the response, it
is recommended that he or she spend time speaking with frontline staff and other appropriate individuals in the
organization to determine the best answer.
Reviewing Responses:
The total score is the sum of the response for each of the three questions. The total score will correlate with one
of the three ranges in the boxes below, 0 – 4, 5 – 9, or 10 – 15. Confirm that the organizational state box accurately
describes the current state of your organization. If it does not, you may need to reevaluate your responses, or speak
with additional individuals to better understand the current state of your organization.
Use the recommended next steps box in the column that correlates with your total score as a quick reference
when developing action plans for improvement. For additional information and recommendations, refer to
Leading a Culture of Safety: A Blueprint for Success.
Scoring:
1 – Never true for my organization 4 – Almost always true for my organization
2 – Rarely true for my organization 5 – Always true for my organization
3 – Sometimes true for my organization 0 – Unsure of the response
Establish a compelling vision for safety

MEASURABLE ELEMENTS SCORE OBSERVATIONS
Key questions to ask about your 1 2 3 4 5 Unsure Please provide a brief description of
organization’s capabilities and processes. 0 why you chose this score, considering
all parts of each question.
1. My organization’s safety vision statement
and aspirational end state are clear and
consistently communicated.
2. My organization completes and reviews
culture of safety surveys every 12 – 18
months with evidence of improvement.
3. My organization’s CEO and leadership
team effectively build enthusiasm for
and understanding of my organization’s
safety vision statement.

Total Score = ______
Score: 0 – 4 Score: 5 – 9 Score: 10 – 15

Organizational State Organization’s vision statement Organization has a defined vision Leaders and the workforce
Brief description of current does not reflect an end state of with a clear, aspirational end effectively communication the
state of the organization zero harm and is not regularly state. Leaders communicate organization’s vision to patients,
communicated to the workforce. this vision consistently to the families, and the public. The
Leaders and staff may have a workforce, and understand workforce is motivated by
difficult time understanding how their work fits into the the vision statement and can
or communicating how their organizational vision statement. clearly tie their daily work to
daily work contributes to All members of the workforce are the advancement of this vision.
advancement of the vision able to effectively communicate Metrics to benchmark progress
statement. the vision statement. toward vision are in place and
regularly evaluated.
Recommended Next Steps Begin with review of Review Foundational and Review Foundational and
Recommended next steps Foundational tactics Sustaining tactics Sustaining tactics
for improvement and Share vision and action plans
Develop a vision statement Encourage leader visibility on
implementation are based for change transparently with
with a clear end goal; Educate front lines and communication
on domain and included in patients, families, and the
leaders and the workforce on about how daily work advances
Leading a Culture of Safety: public; Benchmark progress
the meaning of safety culture vision; Hold leaders accountable
A Blueprint for Success and zero harm; Host information for regularly and consistently towards zero harm and share
sessions to build understanding communicating vision to all units goals and strategies with similar
and enthusiasm for the vision and departments organizations; Develop and
support programs that recognize
growth and adherence to vision
Scoring:
Value trust, respect, and inclusion

1. My organization uses and regularly
evaluates formal respect programs that
provide education and support to patients
and the workforce.
2. My organization implements workforce
safety programs to reduce physical and
psychological harm to the workforce.
3. My organization transparently shares
information and metrics around harm
events and action plans for improvement
across our organization.


Organizational State CEO and organizational leaders Formal respect and teamwork Open and honest reporting
Brief description of current understand the criticality of trust, programs are in place across is standard across the
state of the organization inclusion, and respect, but may the organization, and all staff organization and includes
not model these values in all participate in regular trainings. defined feedback cycles. Both
situations. The workforce fears The workforce reports errors patients and the workforce
punishment from reporting and and close calls anonymously are empowered to speak
disclosing errors to patients. and without fear of retribution. up about safety concerns.
Hierarchies based on rank Leaders across the organization Robust communication and
and role exist throughout the embody behaviors that focus on support programs are in place
organization. trust, respect, and inclusion in all for patients, families, and the
interactions. workforce.
for improvement and Develop organization-wide Educate leaders and workforce Publically share information
implementation are based about harm events and plans
respect for people programs; on inclusion, diversity, and
on domain and included in to prevent recurrence; Enable
Train all leaders, staff, and communication with both
Leading a Culture of Safety: and encourage patients and
clinicians on respect program; patients and co-workers;
A Blueprint for Success families to speak up for safety
Develop, implement, and train on Develop and implement
anonymous reporting systems; disclosure and apology program; through available tools and
Establish a patient and family Include metrics for trust, respect, education programs; Provide
advisory council and inclusion as part of annual cultural competency training for
review process for all leaders leaders and workforce; Regularly
evaluate metrics on disparities in
patient care
Scoring:
Select, develop and engage your Board

1. At all Board meetings in my organization,
the amount of time spent reviewing and
discussing a transparent dashboard on
safety and culture is equal to or greater
than time spent reviewing financial
performance.
2. My organization’s Board members are
required to complete regular self-
assessments and education related to
safety culture and quality principles.
3. Performance assessments and
incentives for my organization’s
leadership are inclusive of safety
culture metrics and performance.


Organizational State Organization’s Board Organization has a quality and Organization’s Board and
Brief description of current members have strong financial safety committee that reviews all committees include experts in
state of the organization backgrounds, but lack quality serious harm events, but these safety, clinicians, and a patient
and safety expertise. Safety are rarely presented to the full and family representative.
metrics are presented briefly at Board. Time spent on safety Patients are invited to meetings
each Board meeting, and few during Board meetings includes a to present their experiences
questions are asked. The majority story of harm told by the safety/ directly to the Board. Safety
of the meeting focuses on quality manager, and some is a top priority and Board
financial review. questions are asked about the members understand how safety
event. Board meetings prioritize impacts the bottom line and feel
financial review over safety empowered to ask questions.
review.
for improvement and Link CEO compensation and
Provide educational Consider including a patient/
implementation are based bonuses to performance on
opportunities in safety science family representative on Board
on domain and included in safety and culture metrics;
and culture for all Board and all committees; Provide
Leading a Culture of Safety: Provide opportunities for Board
members; Include a safety expert opportunities for all Board
A Blueprint for Success members to learn from other
on the Board; Develop a patient members to participate on
and workforce safety dashboard guided leadership rounds; Share organizations and industries;
for regular review; Establish a all serious safety events and Bring frontline teams to Board
quality and safety committee action plans with the full Board meetings to tell their stories and
be recognized for exemplary
performance
Scoring:
Prioritize safety in the selection and

development of leaders
1. All leaders in my organization receive
education and review opportunities in
safety science and safety culture.
2. My organization has defined roles,
safety competencies, and development
programs for leaders at all levels.
3. My organization allows leaders
opportunities for learning across
departments and from outside
organizations and industries.


Organizational State Organization’s leaders are Organization’s executive leaders Leaders at all levels of the
Brief description of current considered for development are provided basic safety organization are required
state of the organization opportunities and promotion science and culture educational to complete safety culture
based on business and opportunities. Leadership training. Regular reviews for
financial competencies. Leader development programs are in all leaders include safety and
development programs focus on place at all levels and throughout culture metrics. Leaders are
executive leadership. All leaders the organization. Both current provided opportunities to learn
have semi-regular reviews that and emerging leaders have access from outside organizations
focus on financial performance. to peer coaching and mentoring and industries and are able to
programs. transfer among departments
and units based on interest and
organizational needs.
for improvement and Provide leaders at all levels
Define required leadership Provide continuing education
implementation are based opportunities for learning outside
competencies in culture and opportunities in safety and
on domain and included in the organization; Define talent as
safety; Conduct regular gap culture for both new and
Leading a Culture of Safety: analyses for CEO and senior emerging leaders; Develop an organizational resource; Tie
A Blueprint for Success leader competencies in safety systems that support leaders at performance on safety culture
culture; Develop and implement all levels, including opportunities to leadership development
an organization-wide leadership for cross-departmental training priorities and promotional
development program opportunities
Scoring:
Lead and reward a just culture

1. My organization uses a defined just
culture policy during all review processes
and decisions (e.g. not just harm event
review).
2. My organization regularly reviews
metrics for just culture education and
understanding and defines
improvement opportunities.
3. My organization has one set of defined
and employed behavior standards and
accountability guidelines in place for
all individuals, regardless of department,
rank, or role.


Organizational State Organization may have just Organization has a robust just Just culture algorithm is
Brief description of current culture policy but it is not robust culture policy that is well- embedded in all reviews and
state of the organization or embedded in decisions communicated internally decisions across all departments.
and processes across the and utilized in processes The Board, leaders, and the
organization. Patient safety and and departments across the workforce are held accountable
risk management professionals organization and/or system. All for utilizing the just culture
are systematically trained in just staff are trained on just culture policy. Patients and the public
culture principles. principles and use of just culture are educated on just culture
algorithm. and transparency around events
through their providers and use
of the media.
for improvement and Treat gaps in culture as adverse
Develop a robust just culture Work with the Board and
implementation are based events requiring review with
policy; Educate the Board, organizational leaders to align
on domain and included in the just culture algorithm;
leadership team, and workforce just culture policies across all
Leading a Culture of Safety: Educate providers on transparent
on just culture principles and professions and departments;
A Blueprint for Success communication of errors; Work
the daily use of the just culture Develop and review metrics
algorithm; Ensure utilization of for just culture; Hold workforce with the media to educate
just culture principles in all event accountable for the utilization of and inform the public about
reviews just culture algorithm just culture and plans for
improvement
Scoring:
Establish organizational behavior expectations

1. My organization uses and regularly
reviews a formal training program and
defined processes for teamwork and
communication.
2. Professional accountability standards,
including processes to address
disruptive behavior and disrespect,
are implemented uniformly across my
organization.
3. My organization has a program for
recognition and celebration when
individuals or teams excel at key safety
behaviors and culture metrics.


Organizational State Behavior expectations vary Behavior expectations are All members of the organization
Brief description of current across the organization, often consistent across care providers, are held accountable for the
state of the organization based on department, unit, or but organizational response same behavior expectations and
role. Leaders and the workforce to disruptive behavior may have the same consequences
are not aware of defined vary. Non-clinical departments, for disrespectful behavior.
standards of respectful behavior including finance and human Organization provides
or consequences for disrespectful resources, may not utilize transparency of these
behavior. Best practices and common behavioral standards. expectations through patient/
standard processes also vary. Leaders are held accountable for provider compacts. Leaders and
modeling expected behaviors. the workforce are rewarded
for exceptional teamwork and
communication.
for improvement and Implement a formal team Measure implementation and Work with key stakeholders to
implementation are based ensure identical processes for
training program; Develop and compliance of teamwork and
on domain and included in employed and non-employed
communicate organization- communication programs;
Leading a Culture of Safety: clinicians and staff; Develop
wide behavioral expectations; Develop compacts detailing
A Blueprint for Success required processes for
Develop and implement standard behavior expectations for
processes for teamwork and signature by leaders and the communication and teamwork
communication workforce; Ensure measurement with patients and families;
tools and report cards for Develop standard tools for
individual performance exist and patient and family involvement
are utilized in teamwork and communication
processes
Members and Staff

Members of the National Patient Safety Foundation’s
Lucian Leape Institute
Gary S. Kaplan, MD, FACMPE Gregg S. Meyer, MD, MSc, CPPS
Chair, Lucian Leape Institute Ex-Officio Member
Chairman and CEO Immediate Past Chair, NPSF Board of Directors
Virginia Mason Health System Chief Clinical Officer
Partners HealthCare
Tejal K. Gandhi, MD, MPH, CPPS
President and CEO, NPSF Lucian Leape Institute David Michaels, PhD, MPH
President and CEO, National Patient Safety Foundation Professor
President, Certification Board for Professionals in Patient Safety Milken Institute School of Public Health
George Washington University
Lucian L. Leape, MD
Adjunct Professor of Health Policy Julianne M. Morath, RN, MS
Harvard School of Public Health President and Chief Executive Officer
Hospital Quality Institute of California
Donald M. Berwick, MD
Former Administrator Charles Vincent, PhD, MPhil
Centers for Medicare and Medicaid Services Professor of Psychology
President Emeritus and Senior Fellow University of Oxford
Institute for Healthcare Improvement Emeritus Professor of Clinical Safety Research
Imperial College, London
Susan Edgman-Levitan, PA
Executive Director Robert M. Wachter, MD
John D. Stoeckle Center for Primary Care Innovation Professor and Chair, Department of Medicine
Massachusetts General Hospital Director, Division of Hospital Medicine
University of California San Francisco
Amy C. Edmondson, PhD, AM
Novartis Professor of Leadership and
Management
Harvard Business School
ACHE Staff NPSF Staff

Deborah Bowen, FACHE, CAE Tejal K. Gandhi, MD, MPH, CPPS
President and CEO President and CEO
Eva Chess, JD Joellen Huebner
Vice President, Communications and Marketing Program Manager, NPSF Lucian Leape Institute, Grants,
and Special Projects
Anita Halvorsen, FACHE
Vice President, Professional Development Patricia McGaffigan, RN, MS, CPPS
Chief Operating Officer and Senior Vice President,
Allison Romer, MBA Program Strategy
Vice President and Chief of Strategic Alliances
Patricia McTiernan, MS
Megan Silverman, MHSA, CPPS Assistant Vice President, Communications
Strategic Project Manager
© Copyright 2017 by the American College of Healthcare Executives.

All rights reserved.
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Leading A Culture of Safety-A Blueprint For Success

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What is the purpose of the document?

What is the purpose of the document?

What are the six domains of a culture of safety according to the document?

What are the six domains of a culture of safety according to the document?

Leading a Culture of Safety:

A Blueprint for Success

The Culture of Safety Imperative iii

Recommendations for Use of This Guide 4

A Culture of Safety: The Six Domains 5

Appendix: Key Terms Related to Patient Safety and a Culture of Safety 30

American College of Healthcare Executives

The National Patient Safety Foundation’s Lucian Leape Institute

Letter from the Project Co-chairs

Gary S. Kaplan, MD, FACMPE Charles D. Stokes, RN, BSN, FACHE

Letter from the Project Co-chairs i

Culture of Safety Roundtable Participants

The Culture of Safety Based on data from James and

The Culture of Safety Imperative iii

A Case Study in Culture:

The Culture of Safety Imperative iv

A Note about Disparities in Care

A Note about Learning Systems

Whether an organization is just beginning the journey to a culture of safety or is working to

Recommendations for Use of This Guide 4

A Culture of Safety: The Six Domains 5

Establish a Compelling Vision for Safety

GOAL: COMMIT TO DEVELOP, COMMUNICATE, AND EXECUTE ON AN ORGANIZATIONAL

Establish a Compelling Vision for Safety 6

Establish a Compelling Vision for Safety

Complete and review Clearly communicate

Establish a Compelling Vision for Safety 7

Establish a Compelling Vision for Safety

Organizational Foundational Sustaining

Establish a Compelling Vision for Safety 8

Value Trust, Respect, and Inclusion

GOAL: ESTABLISH ORGANIZATIONAL BEHAVIORS THAT LEAD TO TRUST IN LEADERSHIP AND

Value Trust, Respect, and Inclusion 9

Value Trust, Respect, and Inclusion

Value Trust, Respect, and Inclusion 10

Value Trust, Respect, and Inclusion

Provide education and Develop and share

Implement workforce Implement Participate in full transparency

Organizational Foundational Sustaining

Value Trust, Respect, and Inclusion 11

Value Trust, Respect, and Inclusion

Organizational Foundational Sustaining

Value Trust, Respect, and Inclusion 12

Select, Develop, and Engage Your Board

Select, Develop, and Engage Your Board 13

Select, Develop, and Engage Your Board

Effective Patient and Family Representation on Boards and

Culture of the Board encourages total engagement and involvement of patient/family

Patient/family member(s) are representative of the community the organization serves

Patient/family member(s) have representation on quality and safety committee(s) and

Patient/family representative is provided with ongoing learning opportunities in safety

Select, Develop, and Engage Your Board 14

Select, Develop, and Engage Your Board

Board completes regular Include a patient/ Bring patients to the

Organizational Foundational Sustaining