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Agency for Healthcare Research Quality

The Culture of Safety

Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality (AHRQ)

Talking Points for Nurse Alliance of Service Employees International Union (SEIU) Networking Conference on Quality, St. Louis, Missouri, September 25, 2006

Introduced by Dian Palmer, R.N. & V.P., Nurse Alliance of the SEIU

Thank you, Dian, for your warm introduction. Your work in leading a team of nurses into the hardest hit areas of Louisiana after Hurricane Katrina was truly inspirational, as were the sacrifices that many of you who are here today made in heading to the Gulf Coast last year to provide hurricane relief. You once again showed the can-do attitude, spirit and commitment of the nursing community to being there when it counts the most.

The same is true with health care quality. As nurses, you see—and, in fact, probably live—the need for patient safety improvements with every shift. So, I am extremely happy to have the opportunity to speak with you about the critically important issue of taking health care quality to the next level, and glad that the Nurse Alliance of SEIU is fully engaged in this effort.

The United States is very lucky to have the world's finest nurses, physicians, and other health care workers, however, as we all know, the health care system in which they practice is not the best it can be.   There is much room for improvement in just about every area of health care. In fact, a report from the Commonwealth Fund released only last week found that the United States scored 66 out of a 100 across 37 indicators of health outcomes, quality, access, efficiency, and equity.  National performance was measures according to the rates achieved by top countries or the top 10 percent of U.S. regions, states, hospitals, health plans, or other providers.  

Clearly, we have a lot of room for improvement in just about every category of health care that can be measured. But it must also be clearly understood that we, as a nation, have the drive and the will to make the necessary improvements. And we are making progress. The pace is too slow, but we are making progress.

Accelerating the pace of improvement is a charge that the Agency for Healthcare Research and Quality takes very seriously. Our mission  is to improve the quality, safety, efficiency and effectiveness of health care for all Americans. We do this by supporting independent, user-driven research that is designed to help people and organizations at the federal, state and local levels make better decisions about health care.

The Agency, or AHRQ, as we call it, is a part of the U.S. Department of Health and Human Services. Sister agencies include the National Institutes of Health, the Centers for Disease Control and Prevention, the Food and Drug Administration, the Centers for Medicare & Medicaid Services and the Health Resources and Services Administration.

AHRQ has funded more than 225 patient safety and related health information technology projects since 2001. We have awarded more than 165 million dollars on safety related research grants and contracts. We partnered with the Veterans Health Administration to develop the Patient Safety Improvement Corps. The Corps' goal is to improve patient safety by providing training and education opportunities at the state level for field staff and partner hospitals.

We are also working with the Department of Defense to develop a new patient safety curriculum called TeamSTEPPS, that we will be announcing next month. TeamSTEPPS is a multi-media training system designed to foster teamwork in all health care settings—and an important tool that I hope all of you will look for and put to use in your facilities.

We also are working in partnership with private-sector organizations, including SEIU and nursing groups.  You are a critical ally in this nation's efforts to improve the quality and safety of health care.

During the time that I have with you this morning, I'd like to talk about the "Culture of Quality." This is the end game to all that you're doing at your facilities, and in meetings like this, to develop better health care environments for your patients. Building a culture of quality requires a broad transformation—a complete change in culture—a commitment to achieving and sustaining an effort that likely will change the way that many facilities do business.

How powerful is culture?  I recently heard a maxim that states, "When it comes to changing an organization, culture eats strategy's lunch every time."  Even the best plans made by the smartest experts are no more than academic exercises without the support of everyone in the organization. Consequently, culture change is also our biggest challenge.

Clara Barton once said, "It irritates me to be told how things have always been done. I defy the tyranny of precedent. I go for anything new that might improve the past."

Ms. Barton's nursing career started when she left the U.S. Patent Office at the outbreak of the Civil War to work as a volunteer, advertising for supplies and then distributing the bandages, socks and other goods to help wounded soldiers. In 1862, she was granted permission to deliver supplies directly to the front, and by 1881 she had successfully lobbied the government to create the American Red Cross. Clara Barton was an extraordinary woman. She too, had that can-do nursing attitude and dedication to helping patients.

Florence Nightingale also worked to address patient safety. In 1863, she said that she "...applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of comparison."

One difference between then and now is convergence: there are a number of forces pointing to the need for improving quality and seeking value for the money spent on the American health care system.  Included are:

  • The need for accurate unbiased information by all health care decisionmakers, including patients, to navigate a system which is becoming increasingly complex.
  • The growing acceptance of evidence-based practice as the foundation for health care decisions.
  • Readily available national and state data about the quality of, access to and disparities in health care services.

On the question of how the nursing community works to help move this effort forward, I first want to talk about what nurses already do, which—as you all know—is pretty much everything. Nursing personnel represent the largest component of the health care workforce. The 2.8 million licensed nurses and 2.3 million nursing assistants represent about 54 percent of all health care workers in the United States. Nurses provide patient care in virtually all locations where health care is delivered. When people have reached some of their most vulnerable periods, nurses are the health care providers they are most likely to encounter. You monitor patient status, perform physiologic therapy, help patients compensate for loss of functioning, provide emotional support, and educate patients and their families to help them make informed decisions. Then there are errands, housekeeping and a host of additional tasks that no one often sees or appreciates.

As University of Pennsylvania nursing expert Linda Aiken says, nurses are the early warning and early intervention system in hospitals and many other health care institutions. Through your vigilance, you are responsible for intercepting 86 percent of all errors made by physicians, pharmacists and others involved in providing medications prior to the medication being administered.

As a physician—and at times a patient—I commend you for this vigilance.  Next to their friends and families, nurses are the best advocates that a patient can have in a hospital.  I urge you to continue to voice your concerns when you see a potential breach of quality or safety.  I know that physicians and the health care system have not made this advocacy role easy for nurses in the past, but it is a critical element in our efforts to improve safety and quality.  

AHRQ has funded numerous studies that examined the association between hospital nurse staffing and patient safety. Increasingly, the evidence suggests that the combination of the nurse shortage and increased workloads are threatening the quality of patient care. In a review of 26 studies conducted by our Oregon Evidence-based Practice Center, researchers found that, while the rates vary from study to study, lower staffing levels contribute to adverse patient events.

I know that these results are not news to you. Obviously, in the grand scheme of things, there are a number of considerations when it comes to nurse staffing. For one, there is the business case. As Jack Needleman pointed out in an article earlier this year, there are questions about whether the gains from quality enhancement reduce costs to patients, hospitals and payers. Health care facilities must also determine whether the cost savings, or revenue gains, are enough to offset the cost of improving quality. And, if the improvements result in cost increases, a decision must be made on whether the value to patients justifies spending more on care.

Getting the buy-in of leadership is critical. By leadership, I mean governing boards, especially nursing, medical, and other clinical staff, as well as management. And words are not enough. This commitment must be expressed through actions that can be observed by the staff. There must be an atmosphere of collaboration across ranks to find solutions for risks and vulnerabilities as they are discovered. Employees must have the flexibility to be active participants in the new culture. They must be encouraged to contribute in the form of activities such as developing new tools and enhancing work process.

I see nurses as the key to the success of these efforts.

This requires a flexibility that is the hallmark of nursing.  It also requires safety orientation and training. Our research shows that organizations that have fewer accidents teach their people how to recognize and respond to certain types of incidents, and then empower them to do so. Of course, it doesn't hurt to have mechanisms in place for rewarding staff involvement in safety improvements. The key is to make sure the correct people are being rewarded for developments and that their projects result in improved performance.

Organizations must also measure progress. What is measured is what gets attention, so patient safety needs to be measured periodically. AHRQ developed a tool for assessing issues of patient safety, medical errors and event reporting, as these issues relate to an organization's safety culture. The tool, called the Hospital Survey on Patient Safety Culture, enables health care institutions to understand the varying safety cultures within their facilities, how employees view the commission of errors and error reporting, and how safe the staff feels their institution is for patients.

For example, the Palo Alto Medical Foundation near San Francisco is using the survey to monitor the progress of patient safety improvement efforts at its facilities. The organization first administered the survey last September to establish baseline measurements of employee perceptions on patient safety. The response rate was 73 percent, or 855 employees.  Plans call for it to be re-administered every two years.

At AHRQ, we're currently creating a new benchmarking database using data from the hospital culture survey, and we're working on ways to use the survey in ambulatory care settings as well.

Perhaps most important, a culture of safety should be established atop a foundation of trust—a foundation which supports an open atmosphere for reporting and addressing errors. The Institute of Medicine says, "The biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve."

Several AHRQ-funded studies have found that an effective systems-level approach to a climate of patient safety fosters a blame-free, continual-learning environment where vulnerabilities are reported, and evidence is used to amend existing practices that focused on patient care. When this approach is not taken, the result can be adverse working conditions which affect patient safety and employee performance.

The "culture of blame" is one of the top seven barriers to implementing a patient safety system. The others are:

  • Competition for scarce resources in a system where patient safety is not considered to be a top priority.
  • Lack of resources: inadequate staffing and work overloads.
  • Availability and cost of patient safety.
  • Resistance to change.
  • Lack of commitment at the executive level.
  • Culture of health care workforce perceptions, attitudes and behaviors of error "cover up."

There are numerous examples of positive activity on the patient safety front. The Oregon State Obstetric and Pediatric Research Collaborative requested an AHRQ grant to help reduce the number of women and infants hurt during childbirth. The United States has the second-highest rate of newborn deaths in the industrialized with, with an average of 75 daily. Two-thirds of serious injuries and deaths in the delivery room are the result of human error. The grant in Oregon is being used for a delivery room safety project featuring Ellen D., a mannequin that is programmed to deliver a plastic baby. Ellen and her baby are being used to train obstetrics teams in Portland and at smaller hospitals statewide, and help them practice key tasks ranging from surgical techniques to basic communications.

On a different scale, a demonstration project in New York targeted three classes of adverse events at more than a dozen hospitals, with the goal of improving data collection and clinical practices within large health systems. In an attempt to determine why some adverse events were not showing up in the state's Patient Occurrence reporting and Tracking System, researchers in this AHRQ-funded demonstration project analyzed admissions data to find out whether patients arrived with a condition or developed one in the hospital. After gathering this information from the computerized system, they could then compare how many times adverse events actually occurred and see how often they were reported. They developed interventions for PE/DVT, AMI and post-operative wound infections because each has significant patient outcome, and because they are also events where evidence-based medicine suggested that positive impacts could be made.

While they found significant resistance to more detailed reporting on evidence-based protocols, they learned that the best way to change behavior is to make it easy for people to do the right thing. When results are difficult to ignore, it is easier to implement the tools necessary to improve patient safety.

At AHRQ, we believe Health Information Technology [IT] can save lives, and improve care and efficiency in our health system. Our belief is based on a growing amount of evidence.  For example, studies have shown that adverse drug events have been reduced by as much as 80 percent by targeted programs, with a significant portion of the improvements stemming from the use of health IT.

I am sure you are aware of a recent study published in the Journal of the American Medical Association which showed that clinical information is frequently missing at the point of care, and that this missing information can be harmful to patients. This study also showed that clinical information was less likely to be missing in practices that have electronic reporting systems.

Nurses need to be involved early on in health IT system design and development. In a Nursing Economics magazine article last year, Dr. Norma Lang, an icon among nurses, said that, "embedding nursing language within informatics structures is essential to make the work of nurses visible, and articulate evidence about the quality and value of nursing in the care of patients, groups and populations."

It is clear that health information technology will not achieve its promise without the input and involvement of nurses, and it is becoming increasingly clear that the adoption of health IT in clinical settings addresses a lack of time and shortage of nurses, which—I certainly don't need to tell you—are two of the biggest problems in nursing.

Not long ago, AHRQ supported a study that examined changes in ICU [intensive care units] nurse activity after the installation of a computerized medical information management system. One of the things we learned was that having these systems significantly reduces the time ICU nurses spend on documentation. By using the system, nurses were able to save 52 minutes in an eight-hour shift.

And while we're on the topic of increasing efficiency, I'd like to talk with you for a moment about a new federal initiative that will have far-reaching implications. Last month, President Bush signed an Executive Order to promote federally led efforts to implement more transparent and high-quality health care. The purpose of the order is to ensure that health care programs managed by the Federal Government promote quality and efficient delivery of health care.  Since the U.S. government spends 40 percent of all health care dollars in the U.S., its influence in this area is enormous.

As the Federal government uses its health care purchasing power to make cost and quality information more transparent, and more health care consumers start choosing health care providers on the basis of value and quality, this initiative promises to be a real game-changer, especially as it harnesses the power of the internet to disseminate information.

At AHRQ, we've been using the Web for years as a tool for gathering and sharing valuable information on many important topics, such as patient safety. I am sure that many of you know about AHRQ's free Web-based tool that helps hospitals enhance their patient safety performance by quickly detecting potential medical errors in patients who have undergone medical or surgical care.

Earlier, I mentioned the Hospital Survey on Patient Safety Culture. The survey and the accompanying took kit give hospitals the basic knowledge and tools needed to conduct a safety culture assessment. The survey examines patient safety from a hospital staff perspective. Thus, it can and should be completed by virtually anyone whose work affects patient care. This survey, and our other patient safety products and tools are available on the AHRQ Web site at, or by calling our publications clearinghouse at 1-800-358-9295.

We have also been designated as the agency to determine how the provision of the Patient Safety and Quality Improvement Act of 2005 will be implemented. This includes the process of certifying organizations that want to become Patient Safety Organizations (PSOs). This program encourages providers to identify and correct patient safety events by:

  • Ensuring that their work with PSOs cannot be used against them in court or in disciplinary proceedings.
  • Promoting aggregation of non-identifiable cases through a network of patient safety databases.
  • Identifying and rapidly distributing patient safety improvement strategies.

We're in the final stages of drafting proposed regulations to implement the law and hope to publish them for comment soon.

When the PSOs are up and running, and we start obtaining, sharing and understanding more and better data about medical errors, we'll have a powerful new tool to help us improve patient safety and the overall quality of health care in the United States.   Because even though we're making strides in improving the quality of health care in America, we need to do more and we need to accelerate the rate of improvement.

According to the latest National Healthcare Quality Report, a report we publish every year for Congress, the quality of health care in the U.S. continues to improve at a modest pace across most quality measures. The median rate of annual improvement is about 2.8 percent, about the same as what we reported in the previous Quality Report.   This is far too slow for any of us to accept.  At this rate, it will be lifetimes before we have a health care system of which we can be proud.

The question is, what do we do from here?

Dr. Lucian Leape, the father of the patient safety movement in the United States, says the primary reason to continue on the current path is our obligation to the patient. And, he says, within the last year, we have moved from saying there are safe practices that make difference to saying there are safe practices that everyone can use to make a difference.

The nurse's role in this movement is evident: nursing and patient safety are inseparable. With nurses responsible for intercepting the majority of potential errors, one could almost make the case that creating a culture of health care safety without the contributions of nurses would be unlikely at best.

And, as a group, I applaud how you have embraced this challenge. The SEIU is leading Americans for Health Care, a national grassroots network that brings together working families, small business owners, seniors, health care workers, community leaders and elected officials in support of affordable quality health care. You have also established Patient Care Committees. These panels of labor and management representatives have been instrumental in giving SEIU nurses opportunities to put their advocacy of patient safety into action.

And while we're on the topic of advocacy, there are three additional areas where I see terrific opportunities for nurses to contribute to the improvement of quality and safety in health care:

  • First, we need to create more opportunities for nurses to help design and develop long-term followup programs for patients with chronic conditions such as heart disease. In a recent study funded by AHRQ in New York, we found that patients with heart failure whose care was directed by nurse managers could perform everyday activities better, and had fewer symptoms of their condition than patients who managed their own care. 
  • Second, we need to create more opportunities for more nurses to do health services research, to put their practical, everyday experience and insight to work in identifying and understanding many of the key challenges facing our health care system, especially in the areas of patient safety, quality, and organizational culture change.
  • And finally, we need to create more opportunities for nurses to teach other nurses, and to become instructors without having to take a pay cut.  Finding ways to do this will make a critical difference in our ability to train more nurses, and help alleviate the nursing shortage in this country.

While we are making improvements in many areas, and we are gathering valuable data to inform our policymaking, the rate of improvement falls considerably short of where we need to be, and where we know we can be. But even as we measure our performance, there are many underlying forces at work in our society that are not only changing the health care landscape, but also impacting the future of primary care.

First and foremost is the rapidly escalating cost of health care in America, which has doubled over the last decade to over $1.9 trillion dollars, a figure that exceeds the gross domestic product of a country as large as Russia. Health care expenses account for one-sixth of the U.S. economy, and continue to grow at unsustainable rates. If you think cost pressures have been tough before, they're going to pale in comparison to the cost cutting and cost shifting that's going to happen, and is, in fact, happening now.

There is, however, reason to be optimistic. Dr. Leape says he is energized by the fact that people are talking more about the quality of culture, and learning how it is accomplished. There are also growing lists of safe practices and there are results, not only in the form of saved lives, but of money saved.

Research will continue to provide key insight into how various aspects of working conditions for nurses can be changed to improve patient safety. As we learn more about what causes errors, we will be able to develop a more solid evidence base to support patient-safety-driven working conditions. The evidence on working conditions continues to demonstrate what needs to be done to lower threats to patient safety. We already know that major inroads can be made by proactively reducing the effect of human factors, improving the flow of information with enhancements including health IT, and incorporating patient safety processes and clear-cut, continuously improving patient safety goals in everything we do.

Yet, we are in the formative stages of an evolution that ultimately will require completely different ways of thinking about standards and practices that have been in place for long periods of time. As practitioners on the "sharp edge" of patient care, you can serve as drivers of this evolution—as indispensable leaders in building a culture of quality for your hospitals, for your patients, and for your future at the forefront of patient care in America.

Current as of September 2006

Internet Citation:

The Culture of Safety. Speech by Carolyn M. Clancy at the Nurse Alliance of Service Employees International Union (SEIU) Networking Conference on Quality, St. Louis, Missouri, September 25, 2006. Agency for Healthcare Research and Quality, Rockville, MD.


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