Creating a “Just Culture” for Patient Safety

A message from Debra Poskanzer, M. D., Vice President of Medical Management and Quality

According to a recent survey conducted by the Harvard School of Public Health, almost one in four Massachusetts residents reported experiencing a medical error in the past five years, with over half of those errors resulting in serious health consequences.

Barbara Fain, executive director of the Betsy Lehman Center for Patient Safety and Medical Error Reduction, cited that survey in a January article in the Boston Globe. Noting that while there is an increased awareness in the health care community of medical error, and that strategies have been developed to prevent many of those errors, Ms. Bain also pointed out that there continues to be a lack of relevant data about medical error — how often it occurs, where are the areas of greatest risk, and whether the situation is improving.

Patient safety efforts have until now been hospital-based and have focused on isolated priorities such as decreasing readmissions, reducing hospital-acquired conditions, and improving adherence to medication regimens. While those efforts have been important, patients assume that they will receive care in within a culture of safety that will be maintained across the health care continuum. As a result there is increasing emphasis on extending patient safety initiatives to integrated care delivery, including ambulatory surgical centers, nursing and rehabilitation facilities, dialysis centers, and working with patients and their families to support care in the home. But extending patient safety efforts across the health care continuum carries inherent difficulties because episodes of care often occur across longer periods of time and may involve real barriers to identification, reporting, monitoring and oversight.

Creating and maintaining a culture of patient safety begins with accurate reporting to identify problem areas and performing root cause analysis as a basis for developing metrics for accountability and improvement. Ongoing reporting and measurement are also needed to assess success in activities that make a difference in improving patient safety.

Many health care organizations are now developing policies and procedures to foster a “just culture.” A just culture is one that encourages individuals to report mistakes and offers non-punitive response to reporting adverse events so that the factors contributing to error can be better understood. Analysis of preventable lapses in safety reveals that errors in patient care are often related to systemic failures and not the fault of individual providers. A just culture also enables and encourages staff to openly identify patient safety issues, share information and facilitate the implementation of meaningful changes based on accurate data to further promote a safe patient care culture.

The Institute for Health Care Improvement's website has a number of training and other useful resources to support and guide the creation of a culture of safety. The National Patient Safety Foundation also offers programs, online webcasts, and other resources related to improving patient safety for patients, families and health care professionals. And led by the National Patient Safety Foundation, Patient Safety Awareness Week™ is an annual campaign to foster education and awareness around patient safety. In 2015, Patient Safety Awareness Week was March 8-14. This year’s campaign focuses on patient engagement and emphasizes the importance of the relationship between providers and patients and their families.

In support of this campaign, Tufts Health Plan’s Clinical Quality Improvement Department is helping to raise awareness of patient safety among Tufts Health Plan employees, encouraging them to adopt specific steps to effectively communicate with their providers when receiving health care services.

Tufts Health Plan demonstrates its commitment to maintaining a “just culture” through our regular reporting to state and federal agencies, which not only provides data on medical errors and patient safety but also helps to identify what constitutes great patient care. We also support initiatives to improve patient safety. Through our annual Provider Quality Innovation Awards, we publicly recognize providers for efforts aimed at improving patient safety and quality of care.

March 10, 2015
Revised June 29, 2015