When it comes to ensuring a safe environment for both employees and customers, healthcare lags behind other industries, as evidenced by the alarming rate of medical errors that persist despite the warnings and mandate for change outlined in the Institute of Medicine report more than 15 years ago. Drawing on our expertise in developing safety programs for the nuclear power and airline industries, as well as insights derived from a decade of work in partnership with more than 800 healthcare organizations, we have identified eight cultural barriers in healthcare that inhibit the industry from making meaningful and sustained progress toward reducing medical errors and achieving high reliability.
Acceptance of errors as system complexity grows
Healthcare is a high-stress environment where caregivers care for vulnerable people with complex conditions. The pressure to provide the best care possible to each patient with the resources available can create an acceptance of “short cuts” and a reliance on staff’s ability to work around obstacles. When caregivers feel overwhelmed by the complexity of healthcare or operate outside established processes, a medical error is much more likely to occur.
Dysfunctional external accountability
There are many regulatory agencies in healthcare—The Joint Commission, the Centers for Medicare & Medicaid Services, state agencies and various payers, for instance. While most share the objective of improving the delivery of safe, high-quality care, each has a different mandate and set of metrics that can cause an organization to focus on the near horizon of process and accountability rather than on the ultimate shared goal of zero harm.
Regulations focused on embedding safe behaviors and high-reliability principles into practice, as well as more emphasis on the root cause rather than the symptom of dysfunction or error would help organizations create a strong sense of accountability for safety.
Lack of comprehensive internal oversight
In high-reliability industries, risk management is focused on preventing errors and detecting and correcting high-risk situations. In healthcare, risk management tends to be reactionary, with a focus on mitigating loss after an error rather than on preventing error before it can occur. Proactive oversight of processes and guiding principles creates a strong mechanism for internal enforcement on high reliability.
Slow introduction of high-reliability principles
Healthcare is unique in many ways. That said, the standard principles of high-reliability science directly apply. As a complex environment with high-stakes outcomes, it is critical that healthcare providers look outside the industry for operational solutions. To be successful, healthcare organizations should focus on behaviors rather than outcomes, establish proven best practices that help providers make the right decisions, and create a culture with a shared focus on patient safety.
Fear of retribution
The perceived consequences for identifying serious safety issues can sometimes overshadow the goal to eliminate avoidable patient harm. Internal and external pressures can negatively impact the goal of creating a high-reliability culture. Internally, peer review systems can be punitive and focus on individuals rather than system accountability. No one wants to be responsible for a co-worker losing his or her job. Externally, caregivers are faced with regulatory, legal and licensing pressures that can affect their accreditation and ability to practice. If a fear of negative repercussions exists, a culture of transparently reporting errors will never take hold.
Personal failure is unacceptable
Perfectionist personalities and professional pride can perpetuate an attitude that “only bad doctors or nurses make mistakes.” We must embrace a culture of full transparency and reporting of errors.
Overly developed sense of urgency
Healthcare providers have a tendency to escalate emerging issues to urgent issues. Factors like impatience, too little time, higher likelihood of proceeding in the face of uncertainty, and patient demands that can be so intense that the “end justifies the means” can provoke caregivers to move ahead too fast when intervention at an earlier stage could prevent a safety event.
Standardization is perceived as a burden
For organizations that embrace a culture of personal authority and individualism, introducing protocols, guidelines and regulations can be seen as bureaucracy. Some clinicians can view process controls as “cookbook medicine,” or feel that dictating care delivery undermines their expertise. Organizations must collaboratively get past those barriers and focus on the shared purpose of ensuring safe, high-quality, patient-centered care.
To improve safety performance and sustain improvements, healthcare organizations must understand and address these eight cultural barriers. High reliability is dependent on strong processes but moreover, on the people who are expected to implement the processes as intended. Influencing behaviors is grounded in a strong culture driven by leadership and governance, with the commitment to zero harm the No. 1 priority. Only through the industry’s commitment to change can we eradicate avoidable medical errors as the leading cause of death.
Kerry Johnson is partner at Press Ganey Strategic Consulting and was a founding partner of Healthcare Performance Improvement, which was acquired by Press Ganey in 2015. Mr. Johnson has more than 25 years of experience improving reliability in nuclear power, transportation, manufacturing and healthcare. He specializes in designing and implementing human performance reliability programs for large organizations.
Craig Clapper PE, CMQ/OE, is partner at Press Ganey Strategic Consulting and was a founding partner of Healthcare Performance Improvement. Mr. Clapper has more than 25 years of experience improving reliability in nuclear power, transportation, manufacturing and healthcare. He specializes in cause analysis, reliability improvement and safety culture improvements. He now is the lead consultant on several safety culture engagements for healthcare systems.