First, Do No Harm (to Yourselves): The Role of Leadership in Creating a Culture of Employee Safety in Healthcare

Introduction
As the push for improving patient safety in healthcare continues, leading healthcare systems in the United States are expanding safety initiatives to incorporate employee safety. Employee safety is both cost-effective for the organization as well as serving as a contributor to patient safety (Organizational Safety Culture-Linking Patient and Worker Safety, n.d.). In order to improve both patient and employee safety in healthcare institutions, a culture of safety is a requirement. A culture of safety may be defined as an organizational ideology, which prioritizes safety over financial gain or benefit (Creating and sustaining a culture of safety, 2004).

This chapter will explore best practices for creating a culture of safety in healthcare institutions. We examine the primary components of creating a culture of safety including a just culture, in which employees are treated in a supportive rather than punitive manner when it comes to safety concerns, a safety reporting system to capture safety concerns and therefore intervene to improve concerns, a transparent approach to safety in which all employees are made aware of safety concerns and efforts to improve these concerns, and finally engagement by both leaders and frontline staff to improve safety. Additionally, this chapter will examine the importance of extending safety practices to incorporate employee safety. To illustrate these best practices, this chapter will examine the Zero Hero Employee Safety program at Nationwide Children’s Hospital in Columbus Ohio.

Background and Context for a Healthcare “Culture of Safety”
In 1999 the Institute of Medicine (IOM) published a report titled: “To err is human: building a safer health system” (Poillon, 1999). The paper reported groundbreaking statistics, which identified hospitals as one of the most dangerous places in the United States due to medical errors. The report detailed the detrimental impacts of medical errors including patient deaths, financial impacts, and loss of trust in the healthcare industry.

The IOM report identified major issues in medical systems including: lack of communication among providers, lack of incentives for improving quality and safety, and flawed systems. The report distinguishes that rather than individual person errors, most medical errors are a result of system issues. The report encourages national level changes including: a federal level focus on improving patient safety, mandated reporting of medical errors, improvements to standards of care on a national level, and a culture of safety across all medical institutions. As learned through the IOM report, system-wide initiatives are crucial to creating a culture of safety in healthcare institutions.

After the publication of the IOM report healthcare research related to patient safety increased. Along with an increase in safety literature, the IOM report also propelled a shift in the kind of safety research conducted. Whereas before the release of the IOM report most research centered on individual blame and malpractice cases, research began to focus on system-wide causes for a lack of safety (Stelfox, Palmisani, Scurlock, Orav & Bates, 2006). Although the IOM report brought attention to the issue of patient safety, much like at the time the report was published the healthcare industry continues to struggle today in improving safety (Free from harm, 2015). Later in this chapter, we discuss how employee safety is the next crucial step in healthcare safety, a step that may improve patient safety as well (Organizational Safety Culture-Linking Patient and Worker Safety, n.d.).

Best Practices for Creating a Culture of Safety
In current literature, there are several practices identified to be contributors to producing a culture of safety. The presentation of these practices in many unique research articles demonstrates that these practices are evidenced-based and serve as best practices for improving safety. The particular practices, which will be examined here, were selected because they are broadly accepted as manners in which to improve safety. The following section address the themes found across the literature related to creating a culture of safety in healthcare institutions.

Just Culture
Literature underscores the importance of a “just culture” (Gandhi, 2018), in which healthcare workers are supported when they bring up safety concerns rather than punished. Dr. Mark Jarrett, the chief quality officer at Northwell Health in New York, points out that in order for employees to feel comfortable expressing safety concerns or reporting safety events, they must feel that their reporting will not lead to negative repercussions (Jarrett, 2017). A just culture focuses on accountability for all members of the healthcare team, from the frontline staff up to executives.

Everyone in the organization must embrace this just culture; particularly those who hold a leadership role, as they ultimately are the individuals who will (or will not) enforce punishments for involvement in safety events. Leaders must also lead by example when responding to safety events, such as responding by initiating positive change instead of reprimanding involved staff members (Conduct patient safety leadership walkrounds™ , 2018). Along with executive leaders who often do not serve in clinical roles, frontline leaders who do serve in clinical roles are crucial in implementing a just culture. Frontline leaders such as nurse managers or charge nurses are intricately involved in patient care, and thus, have a strong understanding of safety needs and barriers to safety. When frontline leaders respond in a supportive manner after safety events, they demonstrate a just culture through their actions and thus contribute toward a supportive safety culture in their clinical area (Tarantine, 2017).

Safety Reporting Systems
Additionally, literature emphasizes the importance of implementing safety reporting systems to achieve a culture of safety. Dr. Mary Gregg, the chief medical officer of MAG Mutual Insurance, reported the importance of learning from safety incidences reported through safety reporting systems (Gregg, 2013). Dr. Gregg emphasizes the importance of documenting “near misses,” (Gregg, 2013) which are circumstances in which a negative safety event could have happened but was avoided. A safety reporting system alone is not enough; leaders who review safety data must act quickly to make changes after safety events. By responding quickly, leaders demonstrate their focus on safety as well as provide encouragement to employees to report safety events (QAPI leadership rounding guide, n.d.). Leaders who respond efficiently to safety concerns reported will demonstrate to employees that reporting can lead to positive outcomes. Additionally, it is crucial that leaders continue to assess the data in order to avoid complacency and to move toward continued improvement (The essential role of leadership in developing a safety culture, 2017).

Transparency
Further, literature discusses the benefits of transparency (Creating and sustaining a culture of safety, 2004). In order for a widespread culture of safety, leaders must be transparent regarding safety occurrences and initiatives. In conjunction with the previously discussed safety reporting systems, transparency allows for all members of the healthcare team, from frontline staff to executives, to be aware of safety events. Transparency has a two-fold benefit. The initial benefit may seem rather obvious: transparency provides all staff members with information regarding safety events. While it may seem overly simplistic, knowledge of safety events is crucial for all staff members. When armed with knowledge regarding the number and types of safety occurrences, all members of the healthcare team can be aware of potential safety issues and therefore act to reduce safety incidences. Additionally, transparency encourages accountability among all employees related to safety occurrences. When safety data is regularly shared, everyone shares the responsibility of improving safety at the institution (The essential role of leadership in developing a safety culture, 2017). Shared responsibility and accountability go hand-in-hand with the ever-important just culture, as all within the institution share the burden of improving safety rather than pointing fingers at individuals. Along with transparency about the type and number of safety events, transparency also includes sharing information about initiatives made toward improving safety at the institution. Information regarding safety improvement efforts again encourages everyone to be accountable and responsible for implementing improvement initiatives (Creating and sustaining a culture of safety, 2004).

Leadership and Frontline Staff Engagement
A just culture, a safety reporting system, and transparency are all requirements for a safety culture; however, without leadership engagement, a culture of safety is impossible to attain. The Joint Commission, a national accreditation organization for healthcare organizations, implores healthcare leaders to focus on a culture of safety just as much as a focus on any other leadership topic such as finance or business growth (The essential role of leadership in developing a safety culture, 2017). While human errors may occur, the literature emphasizes that the majority of safety issues stem from systematic issues. From their vantage point, leaders are in a unique position to approach safety from a whole systems approach (Gandhi, 2018).

It is necessary that leaders focus on separating human errors from systematic errors to allow for appropriate interventions (Gandhi, 2018). A culture of safety must be a conscious effort on the part of employees, and leaders are encouraged to incorporate safety into all daily activities. It is essential that leaders utilize an adaptive leadership approach. Adaptive leaders conduct themselves in a manner in which their behaviors reflect their goals for the organization and motivate followers to conduct themselves in a manner that will achieve these goals (Northouse, 2016). Additionally, adaptive leaders encourage their followers to think for themselves to create positive change (Northouse, 2016). In healthcare, the leaders’ behaviors must reflect a mission toward improving safety, so they can encourage followers to participate in safety measures and feel empowered to accomplish safety goals. As leaders incorporate safety into all activities, this behavior serves as a model to followers (Creating and sustaining a culture of safety, 2004).

In order to demonstrate active engagement in safety efforts, literature encourages leaders to have regularly scheduled time to interact with and shadow frontline workers.

The literature describes an emphasis on the importance of leaders engaging frontline staff in order to gain the best understanding of safety concerns in all areas of work. It is recommended that this interaction with frontline workers be systematic and regularly scheduled. The Institute for Healthcare Improvement (IHI) calls regularly scheduled interactions with staff “leadership walkroundsTM” (Conduct patient safety leadership walkrounds™ , 2018). Leadership walkroundsTM provide an opportunity for leaders to directly interact with frontline staff to discuss important safety topics. Other institutions such as the Center for Medicare and Medicaid Services (CMS) and local healthcare systems engage in similar rounds with a variety of names including “rounding to influence” (Rounding to influence, 2008) and “leadership rounding” (QAPI leadership rounding guide, n.d.).

In addition to rounding by leaders, regularly scheduled safety briefings should be conducted. During conversations with executives, any identified issues should be discussed. However, the staff member who identified the issue should remain anonymous, another essential component to creating a just culture (Conduct patient safety leadership walkrounds™ , 2018). As previously discussed, it is necessary for leaders to quickly address and respond to concerns that are identified, which serves as another manner to demonstrate to frontline staff that leaders are receptive and responsive to safety feedback.

Next Steps: Employee Safety
As advancements in patient safety continue, this goal of a culture of patient safety can be expanded to incorporate employee safety. The Federal Occupational Safety and Health Administration (OSHA) reported a strong relationship between a culture of safety and employees following appropriate infection control precautions, which is a contributor to both patient and employee safety (Organizational Safety Culture-Linking Patient and Worker Safety, n.d.). Along with safer patient care, the literature shows that safer employees have higher morale and therefore create a stronger and more motivated workforce (Barr, Miller, Principe, Merandi, & Catt, 2016). Additionally, safer employees are more cost-effective as they require fewer days off, reduce healthcare costs, and may have fewer turnovers due to their higher morale (Barr, Miller, Principe, Merandi, & Catt, 2016).

Case Study: Nationwide Children’s Hospital Zero Hero Employee Safety Program
The following case study will examine the Zero Hero program at Nationwide Children’s Hospital, beginning from the program’s inception as a patient safety program and the expansion to incorporate employee safety. The reader will gain understanding of the actions and steps taken to create this successful safety program. Additionally, a comparison is made between the literature on best practices and the Zero Hero program.

Zero Hero Program Background
Nationwide Children’s Hospital in Columbus, Ohio is a nationally ranked, freestanding children’s hospital, which services patients and families from all 50 states of the United States and patients and families from 52 countries (Nationwide Children’s Hospital-About Us., n.d.). In 2009 under the leadership of Chief Medical Director Dr. Richard Brilli, Nationwide Children’s Hospital created the “Zero Hero” program (Zero Hero, n.d.). The Zero Hero program aimed to create a culture of patient safety at the hospital. The goal of Zero Hero was simple yet incredibly complex to achieve: zero instances of preventable harm to patients at the hospital (Zero Hero, n.d.). While leaders at the hospital knew that zero instances of harm was a very lofty goal, they believed that the hospital needed to aim high as the ultimate goal is to avoid all preventable patient harm. This type of goal follows a quality improvement method of creating “big hairy audacious goals” (BHAG) (Collins, 2018)3, which can serve as motivators for change as they serve as “clear and compelling” (Collins, 2018) goals for the organization.

Incorporating Employee Safety
While a leader in patient safety following the initiation of the Zero Hero program in 2009, Nationwide Children’s senior leaders determined that to truly reduce preventable harm, employee safety must also be prioritized (D. Barr personal communication, February 9, 2018). In 2012, the hospital had 179 OSHA reportable incidents; these incidents caused 846 days of lost employee work time and cost the hospital approximately $1.2 million (Barr, Miller, Principe, Merandi, & Catt, 2016).

In order to reduce these negative effects, beginning in 2012, hospital senior leaders expanded the Zero Hero program to include employee safety (Barr, et al., 2016). Tackling employee safety at Nationwide Children’s was no easy task, particularly due to the magnitude of employees; nearly 13,000 employees work for the organization (D. Barr personal communication, February 9, 2018). The priority of the hospital to encourage safety is evident as the Zero Hero program is introduced during hospital orientation for new employees and new employees are required to attend a Zero Hero training course during their on-boarding process (D. Barr personal communication, February 9, 2018).

Through the patient safety initiatives, a safety reporting system called CS Stars was implemented. The CS Stars system provides a simple process for employees to directly report safety occurrences, including occurrences in which staff members correctly intervene to avoid potential harm. In order to hold safety at the forefront of all employees’ minds, all hospital computers have a direct link to the CS Stars form on the desktop. To begin the employee safety component of the Zero Hero program, baseline data related to employee safety was collected through the CS Stars reporting system. Leaders took this data to create a preventable harm index for employee safety. The preventable harm index allowed leaders to prioritize safety initiatives in order to have the most effective impact on reducing employee harm. The preventable harm index is reassessed annually to realign safety priorities and to assess the previous year’s progress (D. Barr personal communication, February 9, 2018).

The employee safety initiatives incorporate frontline staff members to ensure that all perspectives are included. One component of engaging frontline staff members is through assessing CS Stars entries. When a CS Stars report is entered, the report is shared with the employee safety team as well as with the department manager. In order to remedy systematic issues associated with the reported event, hospital leaders respond within one week to begin steps toward improving the issue. If events are severe, however, leaders will respond to the event immediately in order to quickly work toward reducing future such incidences. Additionally, safety initiatives are regularly shared with employees thorough a variety of channels. Electronic signage in the hospital is regularly updated to report messages regarding continuing safety initiatives as well as to remind staff members of steps they can take to improve safety (D. Barr personal communication, February 9, 2018).

Frontline staff members are also incorporated through the hospital’s safety coach program. Departments within the hospital identify certain staff members to serve as their representative in the safety coach program. Safety coaches serve as leaders for improving safety among the staff members in their departments. These coaches receive training on ways in which to notice, report, and intervene when safety events could or do arise. Additionally, safety coaches participate in monthly meetings to discuss best practices related to improving safety within the hospital (D. Barr personal communication, February 9, 2018).

Frontline staff members are encouraged to participate in “focus effort teams” (D. Barr personal communication, February 9, 2018) related to safety topics. These focus effort teams allow for frontline staff members to have autonomy and leadership in creating safety solutions. These teams are formed when staff members identify a safety concern and work together to create a solution. The focus effort teams typically consist of an executive level sponsor, frontline staff members who either work in an area with a high-level of the type of harm being addressed or have a passion for the topic, and members of the hospital’s Business Process Improvement (BPI) team (D. Barr personal communication, February 9, 2018).

Daniel Barr serves as the Vice President of Operations for the Hematology, Oncology, and Bone Marrow Transplant program as well as serves as the Co-Director of Employee Safety at Nationwide Children’s Hospital. Mr. Barr played a crucial role in the expansion from patient safety initiatives to include employee safety initiatives. Mr. Barr reported that leaders initially considered creating new tools and procedures for improving employee safety, however, leaders decided that hospital employees were already familiar with and appropriately utilizing the Zero Hero tools. Therefore, leaders decided to expand current Zero Hero programs and initiatives to incorporate issues assessed from the preventable harm index for employees.

To gain a system-wide awareness of all safety concerns at the hospital, leaders at the hospital participate in a daily organizational safety phone call each morning. The daily safety call allows leaders to assess any safety events from the previous day. During the call, leaders assess if the harm event was preventable and how to best intervene to prevent similar future occurrences. Mr. Barr reported that one of the most important benefits of this phone call is that it forces safety issues to “stay at the top of the mind” of leaders (D. Barr personal communication, February 9, 2018).

Case Study Example: Reducing Employee Harm with Combative Patients
With the rising numbers of patients seen at the hospital for behavioral health diagnoses, the number of injuries to staff members due to combative patients also increased. Utilizing the preventable harm index, the employee safety team determined the importance of reducing staff member injuries due to combative patients. Patients admitted with behavioral health diagnoses are serviced in the hospital’s Emergency Department, in-patient behavioral health unit, and in-patient crisis stabilization unit. In addition to these areas with a dedicated behavioral health focus, patients with other health conditions along with their behavioral health diagnosis may be serviced on other medical units. Due to the large range of locations where patients with these diagnoses are admitted, it was necessary to provide expansive training and services to reduce employee injuries (Barr, Miller, Principe & Milliken, 2017).

In order to reduce the number of injuries by combative patients, the hospital created a focus effort team with this goal in mind. The focus effort team utilized data from the CS Stars reporting system to ascertain where to focus their safety interventions. Through the data, the team learned that it is necessary to improve employees’ knowledge in how to keep themselves safe and to improve how employees utilize de-escalation techniques. To remedy these issues the team worked to change the culture and mindset, as it was noted that many employees felt that injuries from patients was simply a part of the job when working with behavioral health patients (Barr, et al., 2017).

Additionally, the team noted that incidences with combative patients occur in an unpredictable manner. Therefore, preventative actions must be used to reduce staff injuries. For any patient or caregiver who becomes escalated or violent, staff members are able to activate a “Code Violet” (Barr, et al., 2017).

During a Code Violet, mental health professionals, as well as security officers, assist in de-escalating the patient and keeping the patient and staff members safe. In order to proactively support patients with a history of Code Violets, the team created an update to the hospital’s electronic medical record (EMR) system. This update causes a purple banner to appear at the top of the screen in any patient’s medical record when the patient has a history of a Code Violet. Through this identification, staff members are able to be prepared for the patient’s potential triggers and behaviors and can anticipate potential incidents. Additionally, every week hospital leaders and the security team review the previous week’s Code Violets and prepare for upcoming outpatient appointments for patients with a history of a Code Violet. A similar conversation occurs for inpatient unit managers related to hospitalized patients with a Code Violet history (Barr, et al., 2017).

In order to better respond to Code Violet situations, the team also implemented Code Violet simulations. During these simulations, employees are able to practice de-escalation techniques and safety interventions. By allowing staff members to practice in advance, they are better armed and more confident when interacting with patients during a true Code Violet (Barr, et al., 2017). Following the implementation of a new behavioral health unit, the hospital saw an increase in about 30% of harm incidents for staff working with behavioral health patients. After about one year of utilizing these initiatives, however, the hospital saw a 60% decrease in harm due to combative patients (D. Barr personal communication, February 9, 2018).

How Does Zero Hero Line Up?
In comparison to the best practices identified by the literature, the Zero Hero Employee Safety program implements many of the suggested activities and behaviors. The below section will discuss the Zero Hero program in relationship to best practices learned from the literature.

Creating a Just Culture at Nationwide Children’s Hospital
Daniel Barr, who serves as the co-director of employee safety at Nationwide Children’s Hospital, identified that the hospital’s rate of safety incidents reporting demonstrates the hospital’s just culture. According to Mr. Barr, at the beginning of the hospital reporting system, the program received approximately 30-40 reports per month. Currently, however, CS Stars receives up to 120 reports per month (D. Barr personal communication, February 9, 2018). Mr. Barr believes that if staff members felt there was a punitive component to reporting safety concerns, these reports would not continue to increase over time and would instead slow down. The hospital incorporates a “200 percent accountability” (Barr, et al., 2016) mindset. This mindset means that all employees are responsible not only for their own engagement in safe behaviors, but also are responsible for their peers engaging in safe behavior.

This accountability is created through a culture of utilizing what has been coined a “questioning attitude” (L. Kappy, personal communication March 12, 2018). The questioning attitude is a philosophy in which staff members are expected to intervene when they notice a safety concern. Beginning from the new employee Zero Hero training, this idea is reinforced and encouraged. Staff members are taught that regardless of the hierarchy of professionals in the hospital, everyone is expected to provide and accept a questioning attitude.

A frontline registered nurse is expected to intervene when an attending physician does not correctly complete a safety procedure. The attending physician is expected to be gracious and accept the feedback provided. Alternatively, when the situation is reversed, the attending physician is also expected to question the registered nurse, and he or she is expected to respond graciously and implement the feedback. The questioning attitude philosophy encourages accountability and responsibility among all staff members and assists in creating a culture in which it is an expectation that safety concerns are identified and addressed (Zero Hero, n.d.).

Safety Reporting System at Nationwide Children’s Hospital
In alignment with literature recommendations and as discussed previously, Nationwide Children’s has a safety reporting system called CS Stars. In addition to employees regularly reporting concerns through CS Stars, many departments also incorporate safety discussions into team meetings. For example, Lisa Kappy, a child life specialist in the Family and Volunteer Services department, reported that at the beginning of their department meetings staff members report “safety catches” (L. Kappy Personal communication March 12, 2018). Safety catches are times in which staff members notice potential safety concerns and intervene appropriately. Managers within the department lead a brief discussion regarding the Zero Hero tool utilized when intervening, which serves as a way to assist in reporting data to the employee safety team and to assist other staff members in knowing how to respond in similar situations.

Creating Transparency at Nationwide Children’s Hospital
Nationwide Children’s also incorporates the previously discussed literature recommendations related to the importance of transparency. In order to maintain open lines of communication with staff members about safety occurrences, the hospital’s intranet page includes a daily tracker of time since serious safety events. The intranet includes two counts one which indicates the number of days since the last serious patient harm event and one with the number of days since the last employee harm event. This transparency is intended to maintain awareness for staff members at all levels and serves as a regular reminder about engaging in safe behavior (D. Barr personal communication, February 9, 2018).

Leadership and Frontline Staff Engagement at Nationwide Children’s Hospital
Nationwide Children’s engages in practices in alignment with the literature cited and does so through leadership and frontline staff engagement in safety initiatives. Mr. Barr, the co-director of employee safety stated that hospital leaders aim to “lead by example” through their behaviors and actions (D. Barr personal communication, February 9, 2018). Mr. Barr stated that leadership buy-in is crucial and requires leaders to hold themselves and those around them accountable for improving safety. As recommended by the literature, Nationwide Children’s leaders regularly visit with employees to assess their engagement with the Zero Hero program. These regular visits called “Rounding to Influence” (Zero Hero: Rounding to Influence, n.d.) allow managers to have an increased understanding of safety concerns and an awareness of safety needs of frontline staff. Nationwide Children’s aims to incorporate frontline staff members into safety improvement efforts through the safety coach program and focus effort teams. Through these endeavors, Nationwide Children’s utilizes a multidisciplinary approach to improve employee safety.

Conclusion
Creating a culture of safety is necessary to improve patient outcomes as well as to improve safety for healthcare workers. The literature identifies several important factors for creating a culture of safety in healthcare institutions. These factors include creating a just culture in which all are accountable for safety and the response to safety concerns is to focus on problem solving rather than punishment. Another factor, which is crucial for a culture of safety, is a strong safety reporting system.

A safety culture requires hospital leaders to be transparent in their efforts for safety as well as to incorporate employees into efforts for safety improvement. Finally, leadership behavior of executive and frontline leaders is crucial to model engagement in safety. While many safety efforts are focused on patient safety, there is a great need for improvements to employee safety as well. Safer employees provide better care to their patients and also contribute to better financial outcomes for the healthcare institutions where they work.

We presented a case study of the safety program at Nationwide Children’s called Zero Hero. The program was initially aimed to improve only patient safety, but later efforts were expanded to include improving employee safety. Many recommendations provided by the healthcare safety literature, including incorporating a just culture, a strong reporting system (titled CS Stars), transparency, as well as staff and leader engagement, were demonstrated by the Nationwide Children’s Zero Hero Program.