Mr. Isaacks' Insider: July 2022 HRO Theme of the Month - "Support a Culture of Safety"

“Support A Culture of Safety”

?Dear Colleagues,

In Healthcare, fostering a Culture of Safety is vital, as it can impact the difference between life or death. As an organization, it is so important, that we made it one of the three foundational pillars of a High Reliability Organization. In fact, it is the center pillar, surrounded by Leadership Commitment and Continuous Process Improvement.

For those of you that have gone through HRO Baseline and CTT training, we know that human error is ubiquitous. No one is immune to it. Our role as healthcare professionals, regardless of your specific duties (ie, EMS, logistics, nurse, physical therapist, ect.) is to review past errors, learn from them and establish processes to help make sure the errors don’t occur again. In order to do this though, we have to establish a culture of safety in which errors are reported. We can’t review if we don’t know.

One of the ways in which we learn about errors or close calls is through incident reports (JPSR). These reports provide opportunities for improvement by documenting the errors and close calls. On the call we walked through how to enter a JPSR and the process by which they are reviewed.

We have also talked about the importance of establishing and promoting a Just Culture. Organizations with a Just Culture encourage staff to report safety concerns without a fear of reprisals or punitive action. Having a Just Culture promotes psychological safety for staff and in turn creates a safer environment for our Veterans. When reporting errors and or close calls results in punitive actions with no regard to review of processes, the result is continuation of hazardous behaviors and potentially adverse events. Why? Because staff are not willing to report their mistakes due to fear of punitive action.?These mistakes go unnoticed and are bound to be repeated – eventually leading to patient harm.

It is all of our responsibility to support a safety culture. As a leader in this organization, I want to thank you for speaking up. Thank you for raising concerns and working to improve the care of our Veterans.

David Isaacks

Executive Health System Director

Follow the North Florida/South Georgia Veterans Health System

“Patient Experience and Employee Experience/Employee Engagement is WHY Veterans and Employees Choose Us, High Reliability is HOW we organize, and Whole Health is WHAT we deliver.”