Patient safety culture: accountability

Accountability to patients and families in the face of medical accident is a hallmark of a safety culture. The organization committed to creating a patient safety culture, through its board and its CEO, has in place pohcies, processes, and... 

Watching teams and teamwork quickly reveals that a group of weU intentioned individuals does not make a team and furthermore, that teamwork has to be planned and organized. In this section we will review some apparently simple interventions, which turn out to have quite profound effects. Daily goals, preoperative and post-operative checklists seem mundane, and this partly accounts for clinicians resistance to their use. However, a checklist is not a piece of paper or even a list it is a team intervention which, used well, can affect the wider team functioning, the relationships across professions and hierarchies and even the values and safety culture of the team. To my mind, the impact of these simple tools on clinical processes and patient outcome suggests that their effect can only be fully understood by appreciating their wider impact on team performance. 

Leadership accountability is at the heart of culture change to create patient safety. 

A safety culture is an accountable culture, and the overarching accountability is to those served. Accountability is the specihc translation of responsibility. Whereas responsibility involves the authority and ability to make decisions and act independently, accountability entails the requirement of responsibility for specific conduct, behaviors, and duties. Mechanisms of accountability help create a culture of patient safety. It is the role of leaders to ensure that the following mechanisms are established ... 

Before discussing specific mechanisms, it may be helpful to emphasize that accountability must be understood as a dynamic, reciprocal concept, one that is foundational in the transformation to a culture of patient safety. 

An exemplar of accountability is the Veterans Affairs system that, under the leadership of Dr. Ken Kizer, established the Veterans Affairs National Center for Patient Safety. Kizer chose physician and former space shuttle astronaut James Bagian to lead both the center and a relentless, evidence-based campaign to eliminate harm across the 170-hospital VA system and to test new technologies and interventions to make health care safer. While at the VA, Dr. Nancy Wilson developed a culture survey. This leadership tool evaluates whether specific tactics are in place to advance the culture of safety. The survey measures leadership and strategy, and it includes the following dimensions (Wilson, 2000) ... 

The specific tactics listed under strategies provide a road map to follow in the pursuit of establishing a safety culture. Evidence of the leader gaining personal knowledge related to patient safety is an important demonstration of accountability in nurturing a safety culture. Several areas have been identified as crucial to the leader s learning about safety ... 

Leadership actions are required to build the culture for transparency and learning, prerequisites for safety to be successfiil and sustained. These actions are in pursuit of a patient safety cultme, which is an accountable culture, a just culture, a learning culture, and a culture of parmership. 

Organizations that achieve high levels of safety performance find ways to engage staff from all disciplines and at all levels. True engagement requires well-functioning processes and systems. It also creates personal commitment and personal accountability, both of which are critical in improving patient safety and creating a performance-oriented culture. 

The leader s responses in the face of a medical accident are crucial to determining whether an organization advances or retreats from a culture of safety. Understanding how a leader should respond to a medical accident requires a detailed discussion about the leader s accountability to the patient and family, to staff members, and to external agencies. The leader s role in managing the inevitable tensions between accountability and blamelessness in an organization, and the leader s... 

Medical accident, especially when it harms a patient, is a defining moment for an organization. How such an event is managed both expresses and shapes the culture of the organization. When we mean to do well but harm results, we have failed the patient and the patient s family. An accident also affects the care providers at the sharp end, the point of care where technical work is done. It is a devastating event. How the organization responds can reinforce a culture of secrecy and blame, or it can advance a culture of safety, characterized by open disclosure, analysis, learning, prevention, and face-to-face accountability. 

We used to think that individual human error was a major cause of medical accidents. We learned that this is rarely the case. The human tendency to assign error as cause and place blame is universal and cross-cultural, a tremendous barrier to safety. When an accident does occur, aU the victims—the patient, the family, and the providers need support, disclosure, and accountable leadership. The focus of investigating accidents is on system breakdowns, not on individual error. 

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