Building and Sustaining a System-wide Culture of Healthcare Safety: Getting It Done Chapter 4


(Note: this is a very brief summary of a chapter that is packed with practical strategies, tactics, and tools to improve healthcare quality and safety)

Sentara Healthcare is an integrated healthcare system in southeastern Virginia. Frustrated by the pace of change, Dr. Gary Yates hypothesized that the missing piece was a stronger organizational culture focused on patient safety, so he partnered with Performance Improvement International because of their reputation for safety improvement in the nuclear power and airline industries. 

In 2002, they launched the Sentara Safety Initiative at Sentara Norfolk General Hospital (SNGH), a 543-bed, level-one trauma center located in Norfolk, VA. A baseline assessment of adverse events identified inadequate communication, inattention to detail, noncompliance with policy, and failure to recognize high-risk situations and use error-reduction techniques as the principal sources of errors. They implemented four strategies to promote the practice of safe behaviors:

  • Expectation setting: developing three sets of behavior-based expectations (BBEs)linked to techniques for error prevention for all hospital staff, hospital leaders, and physicians
  • Operational focus: establishing “red rules” to focus employees’ attention on high-risk procedures that can result in patient harm if not followed exactly (e.g., positive identification prior to any action with a patient, site verification before surgery)
  • Effective tools: developing an enhanced root-cause and common-cause analysis process that was more timely and geared toward producing long-term, systems-oriented changes
  • Streamlined rules: adopting an approach for simplifying policies and procedures (e.g., identifying and standardizing key steps in a checklist)


Staff increased their use of expected communications behaviors (such as using repeat-backs and clarifying questions) by 42 percent. Ventilator-associated pneumonias were reduced by 92 percent (6.15 to 0.42 per 1000 ventilator days) from January 2002 through December 2009, and the device-associated bloodstream infection rate fell 93 percent (3.68 to 0.42 per 1000 central line days) from January 2002 through December 2009.

Additionally, symptomatic catheter-associated urinary tract infections within the critical care units fell 66 percent (1.86 to 0.60 per 1000 foley catheter days) from January 2007 through December 2009. Total compliance to proper hand hygiene increased to 96% by December 2009.

Case Analysis

Sentara’s experience models the idea that culture change is enhanced by embedding specific tactical safety improvement processes and activities within a larger organizational strategy. Organizational culture drives behaviors, and behaviors drive outcomes. The process also works in reverse, in a self-reinforcing circular fashion. Hence, an organization can use behavioral observation, coaching, and feedback as a form of social engineering to promote the practical learning of new safety-enhancing skills and behaviors that, over time, can become internalized norms of a safety culture.

Four steps that organizations can take to build and sustain a healthcare safety culture include:

  • Conduct a baseline survey of adverse events and near misses over the past year
  • Look for patterns and common causes that suggest recurring systems issues
  • Gather employees and medical staff to review the data and brainstorm improvement strategies; have physicians present data to the medical staff
  • Discuss and evaluate what behavior-based expectations (BBEs) might decrease adverse events and near misses

As always, I welcome your input to improve healthcare collaboration and get it done.

Kenneth H. Cohn

© 2011, all rights reserved

Disclosure: I have not received any compensation for writing this content.

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