Patient safety results from a strong culture among health care providers, and a strong culture rests on an active dialog among members. People who are admitted to hospital have problems that go beyond the capacity of a single person within a limited time. Treatment requires integrating information and procedures from doctors, nurses, technicians, dieticians, etc. Treatment spans shifts; personnel continually change over the course of treatment. The points where people transfer information and responsibility for treatment to one another are especially vulnerable to error.
The foundation of an organizational or a workgroup culture is a set of shared values. The pathway to a healthcare profession is long and complex. It does not work to assume that everyone thinks the same. In fact, one sign of a particularly effective health care team is that it can bring distinct perspectives to a patient’s problem and then integrate those perspectives into an action plan.
Shared values do not go without saying. They only become shared—and members only know that they are shared—when members of the team have talked them through. Those conversations occur in the abstract as well as in the nitty-gritty of actual practice.
In a strong patient safety culture:
- Colleagues develop shared values at work through open, honest communication.
- Providers overcome professional and hierarchical boundaries to communicate effectively.
- Learning as a value takes precedence over reprimanding.
Developing a strong culture requires a serious commitment from a health care organization. It requires solid procedures for reporting incidents, integrating that data, and taking action to avoid future mistakes. Those procedures only work within a strong culture.