Initiative Encourages Communication over Blame in Enhancing Safety for Patients

Mistakes can – and do – happen in any workplace. That’s true in health care, where our responsibility is the well-being and safety of our patients.

Alameda Health System leadership is deeply aware of how important it is to do our jobs with care and precision. They also know it’s important to foster an environment that recognizes human fallibility, with a never-ending emphasis on patient safety.

AHS seeks to create a Just Culture – one that promotes the understanding of inevitable errors, while helping us learn more about how we can ensure our patients’ safety. Adrian Smith, AHS director of risk management, is spearheading the initiative, which is accompanied by an upcoming survey and a training program called BETA HEART.

“Just Culture is about how leadership and staff interact in their day-to-day work,” he says. “It’s underpinned by trust, promoting a culture of learning, and constantly trying to improve. One of the really important things it considers is human factors – a concept of how people make mistakes.”

For example, Adrian says a Just Culture acknowledges degrees of mistakes and provides for appropriate responses. The first level is simple human error, “an inadvertent action, a slip, a lapse.” In a Just Culture, the manager’s task is to analyze the error and assess whether it could be avoided through improved procedures, training, design, resources or some other factor.

“If that’s the case, we can solve the problem, and we support the person,” Adrian says, “It doesn’t call for coaching or counseling, it’s not really the person’s blame.”

At the second level, the error stems from a faulty choice or decision, perhaps a calculated risk that seemed justified at the time.

“We’ll coach that person,” Adrian says. “We’ll look at how we can make the process simpler, or better. What might we need in terms of more training or more knowledge? We’re not blaming, we’re helping the staff member improve.”

Adrian stresses that third-level errors originate from a tiny percentage of the workforce – perhaps one percent – and result from willful suspect behavior, undeterred by possible consequences. Such instances are subject to disciplinary measures, Adrian says, but the response must be fair.

Manager training through the BETA HEART (healing, empathy, accountability, resolution and trust) program has already launched, and leaders will soon pass along what they’ve learned via in-house presentations. Trainings seek to improve communications and sustain our dedication to patient safety.

Keep an eye out for an upcoming (anonymous) survey, to be emailed to everyone between mid-March and mid-August. It’s essential that we all participate in this chance to share our successes and concerns about patient safety at AHS.

“It gives employees a voice, and the results will help leadership put together action plans,” Adrian says. “Your answers are really important and will be listened to.”