Editor’s note: Our Safety Leadership column is written by experts Michael Greene, Blair Bigham and Daniel Patterson. Following is part eight of a 12-part series.
An effective and successful safety management system (SMS) requires leadership, plain and simple. To quote the Institute for Healthcare Improvement’s Guide to Patient Safety, “Leadership is the critical element in a successful patient safety program and is non-delegable.”
As we’ve discussed, leadership is the roof in the organizational house of SMS, held up by the four pillars—policy, assurance, risk management and promotion—built on a strong foundation of safety culture. To continue the metaphor, the roof—leadership—shields, protects and insulates all that lays inside. As part of this, the leadership has two primary roles: design safe systems and manage employee behaviors.
- Drawing on a field study of eight hospitals, researchers at Stanford University and the University of Pennsylvania have found that strong safety leadership requires six actions:
- Setting and communicating a clear, compelling safety vision
- Valuing and empowering personnel
- Engaging actively in the effort to improve patient safety
- Leading by example
- Focusing on system issues
- Continually searching for improvement opportunities
Data from this same study suggest that substantial variation in these key safety behaviors exists among senior hospital leaders. Let us—you—in EMS leadership change that! But how?
Developing a vision of the future
A leader must develop a vision of the future to serve as the guide for current activity, as well as a strategy to achieve that vision. The vision should not be a solitary or individual perspective, but a broad organizational visualization conceived by many. (The greater the participation, the broader the buy-in.)
When developing this vision, keep in mind that successful visioning, alignment and commitment require good communication, facilitation and coalition building—and that inspiration, motivation and enthusiasm are key to successful implementation. In fact, according to a 2008 study, inspirational motivation by the health care leader is a primary predictor of job satisfaction, organizational commitment and workplace empowerment. Top-of-mind awareness can be achieved by daily safety topics, safety items leading meeting agendas and timely feedback on safety issues.
Leadership fosters and nurtures the growth and development of a safety culture. According to Kilmann, Sexton and Serpa, culture is the invisible force behind any organization, a social energy that moves people to act. Soon the culture is embedded within the organization and may be difficult to recognize, as it becomes deeply ingrained in everyday routines. As my co-author and noted safety expert Daniel Patterson and others have said, a strong safety culture is exemplified by what people do when no one is watching.
As has been widely reported, three leadership processes support the creation of a safety culture in a high reliability organization: migrated distributed decision making (MDDM), management by exception (MBE) or negotiation, and fostering a sense of the big picture. MDDM gives local control of decision-making, the point where the event is occurring. MBE allows for the quick identification of a problem—and solution—and an environment where senior leadership doesn’t have to make all decisions while providing checks and balances. The big picture helps the staff make decisions in context of the whole organization, not just the individual department or team.
- Leadership and safety culture have additional benefits to the organization. The following characteristics have been identified in high reliability organizations:
- People are helpful to, and supportive of, one another.
- People trust one another.
- People have friendly, open relationships emphasizing credibility and attentiveness.
- The work environment is resilient and emphasizes creativity and goal achievement, providing strong feelings of credibility and personal trust.
Approximately 80 percent of medical errors are system-derived, so good people simply working harder will be insufficient to overcome the high complexity inherent in EMS. Errors will occur; the key is to design systems so that harm does not reach the patient. James Conway, former executive vice president and chief operating officer of the Dana-Farber Cancer Institute, has said, “Our systems are too complex to expect merely extraordinary people to perform perfectly 100 percent of the time. We as leaders have a responsibility to put in place systems to support safe practice.” So add a healthy dose of system evaluation and design skills to your leadership toolbox.
I highly recommend the “double diamond” model developed at the Design Council as a simple, graphic way of describing a design process.
While not directly developed for safe system design, it offers a simple yet effective approach. Divided into four distinct phases—discover, define, develop and deliver—it maps the divergent and convergent stages of the design process, showing the different modes of thinking that designers use. Thinking as a system designer, use the following steps developed by the Design Council (adaptations for our market are in italics).
Discover
The first quarter of the double diamond model marks the start of the project. This begins with an initial idea or inspiration, often sourced from a discovery phase in which user (safety) needs are identified. These include: market-user research (risk assessment), information management (documentation) and design research groups (empowered workforce).
Define
The second quarter represents the definition stage, in which interpretation and alignment of these needs to business objectives are achieved (risk analysis). Key activities during this stage are project development, project (risk) management and project sign-off.
Develop
The third quarter marks a period of development in which design-led solutions are developed, iterated and tested within the company. Key activities and objectives during this stage are multi-disciplinary working groups, visual (WalkRounds) management, development methods and testing.
Deliver
The final quarter represents the delivery stage, in which the resulting product or service is finalized and launched in the relevant market. The key activities and objectives during this stage are final testing, approval and launch, targets, evaluation and feedback loops (continually searching for improvement opportunities).
It all sounds like safety management leadership to me. So lead on!
Michael Greene, R.N., MBA, MSHA, is a senior associate at Fitch & Associates. He has served in numerous front-line and leadership positions throughout his career, working in volunteer and paid search and rescue and as a paramedic, county EMS director and air medical/critical care transport director. He is the author of numerous articles and chapters on EMS and air medical transport topics. He can be reached via e-mail at mgreene@fitchassoc.com or by phone at 816-431-2600.
