One of the guiding principles in healthcare is, “First, do no harm.” This tenet is essential to American psychologist Abraham Maslow’s hierarchy of needs, introduced in a 1943 article published by Psychological Review. This hierarchy is often portrayed as a pyramid: Safety is the foundation—the most basic need for human survival. And this structure prevails in healthcare. Patient and employee safety is a fundamental need for healthcare organizations, when their very purpose is rooted in well-being. 

The only way to actively prevent harm is to cement a solid culture of safety—one that routinely considers the physical and psychological safety of patients and workers alike. Doing so strongly correlates with positive safety outcomes, while intersecting with a better patient experience and employee experience. 

Reducing preventable harm to both patients and employees must be the goal of every healthcare organization. But achieving this goal isn’t possible unless healthcare organizations make creating a culture of safety a core value—not just a priority. Priorities change, but values are fundamental to an organization’s makeup. 

The impact of COVID-19 on safety culture 

Even before the pandemic, the data around safety culture wasn’t encouraging. Although safety culture was on the upswing, improvements were slow and limited. But COVID-19 forced healthcare organizations to quickly shift gears, directing their attention on battling the virus and the sudden crisis wreaking havoc on a global scale. The singular focus on COVID-19 caused an increase in routine patient safety issues—like medication errors, falls, and central line-associated bloodstream infections (CLABSI). 

Since then, routine safety performance hasn’t improved. A more recent analysis of 2021 data suggests that hospitals haven’t fully recovered from 2020’s spike in safety event rates. In addition, safety culture has worsened during the pandemic. Although the downward trends are slowing, troublingly, senior leaders and physicians are still showing declines.  

The key to creating a culture of safety

An unsafe health system means less optimal clinical outcomes, as well as worse patient and employee experiences. How can patients trust healthcare professionals if they don’t feel safe and secure? How can employees take care of people when they don’t feel taken care of themselves? 

Across healthcare, safety cultures need to rebound—and understanding Human Experience is the key to creating this culture of safety. 

“Patient safety and quality of care drive everything we do. We always make decisions based on quality, safety, the best interest of the patient, and how to pull in the family and make sure everyone is supported. Press Ganey plays a big role in that by helping us get actionable feedback to do the right things.”
 

— Caitlin Stella, CEO, Joe DiMaggio Children’s Hospital and Pediatric Services¹

Reversing negative safety trends, and driving improvements through an HX lens 

When safety is a core value, it’s so ingrained in the culture that it guides everything the organization does. Top-decile healthcare organizations put safety at the center, whether the organization is operating during a global healthcare emergency, emerging from a crisis, or enjoying a period of relatively “normalcy” (whatever that might mean now, and in the future).  

Of course, a robust, ironclad culture of safety can't be created overnight. But pairing deep and innovative patient and employee listening strategies with industry-leading expertise can streamline—and even accelerate—this process. 

Top-performing healthcare organizations make safety a core value, and they reach for three overarching strategies to continually meet their safety goals and create a collaborative culture of safety. By assimilating these mindsets, and practicing them in tangible, measurable ways, we can reverse negative trends and drive improvements not only in safety, but in patient and employee experience too. 

Make safety visible. Leaders must be forthcoming and transparent—with employees and patients—about their commitment to safety and their efforts to improve it. It’s not enough to just be safe. Data shows that patients who don’t feel safe are also unlikely to recommend a healthcare organization. For example, one hospital switched cleaning products during the pandemic because what they had been using was too pungent. But patients complained that it didn’t smell: The scent left behind by the original product provided a psychological cue that their room had been cleaned sufficiently. Even though the new products worked just as well, patients’ perception of cleanliness, and the safety of their environment, had changed—and it had changed for the worse. And patient perceptions of safety are strongly tied to “Likelihood to Recommend"—and therefore their trust in organization. 

Prioritize employee engagement. Employee engagement had been on the decline since 2018, but the stressors of COVID-19 caused it to further plummet, while, at the same time, driving unprecedented levels of employee burnout. This is, and should be, cause for concern. The data suggests a strong correlation between employee engagement and patient safety. A patient’s experience should comprise safe, high-quality, and Compassionate Connected Care®. But that experience can only be delivered if the workforce itself is safe, engaged, and resilient—creating a “virtuous cycle” in which engagement and safety impact experience, quality, and efficiency.

Organizations should also view employee engagement through the lens of diversity, equity, and inclusion (DEI). Too often, efforts to improve healthcare safety culture and employee engagement are siloed—and DEI work is left out of the conversation. But national data suggests that a positive safety culture strongly correlates with higher performance in both employee engagement and inclusion. 

Focus on organizational resilience. The COVID-19 pandemic highlighted the importance of organizational resilience—i.e., the ability for an organization to bounce back from a crisis. We read a lot about individual resilience and burnout during the pandemic, but it is equally important for organizations to be flexible enough to pivot in the face of new challenges, and resilient enough to absorb any obstacles that come their way. 

“Our high reliability foundation prepared our team to be battle-ready for any crisis. We developed safety and high reliability muscle memory and habit formation. Skills that have been put into practice day in and day out, year over year, situated our organization to be prepared when crisis hit rather than preparing for the crisis at its start.”
 

— Sandy Cox, Director of Safety, Novant Health²

To achieve organizational resilience, healthcare organizations must adopt a high reliability organizing (HRO) mindset. High reliability organizations are those that succeed in avoiding serious accidents or catastrophic events, in an environment where unintended safety events can be expected. Healthcare organizations must implement the four fundamentals of high reliability organizing when transforming safety culture and focusing on organizational resilience.  

The four fundamentals of high reliability organizing are:  

1. Adopt the goal of zero harm. 
2. Measure harm and make harm visible. 
3. Foster a fair and just culture.
4. Practice daily check-ins for safety. 

By nature, healthcare will always involve some degree of uncertainty and risk. Even the most informed, precise, and well-executed efforts can fail to achieve the desired outcome from time to time. But to the degree that we can reduce preventable harm to patients as well as employees, we will become that much more proficient at fulfilling our purpose: improving patient outcomes and, by extension, the Human Experience of healthcare. 

At Press Ganey, we’ve spent decades helping the nation’s top healthcare organizations cultivate a collaborative culture of safety and stay on the leading edge of high reliability best practices. To take your safety culture to the next level, reach out to a member of our safety team.

1. "How Joe DiMaggio Children's delivers award-winning PX." Joe DiMaggio Children's Hospital and Press Ganey, 2022.

2. "High reliability organizing: The pathway to organizational resilience." Dr. Tejal Gandhi, 2022.