Creating a safe learning organization

THE FEATURE ARTICLES in this issue of Frontiers of Health Services Management by Bagian at the Veterans Health Administration and by Winokur and Beauregard at William Beaumont Hospital highlight improvements in patient safety that need to be made by healthcare professionals and their organizations. We can learn several specific lessons from the articles based on what they have accomplished, such as creating a vision for safety, providing strong visible leadership, and finding the right mix of tools for analysis and actions for change. In general, these articles bring into focus the need to create a culture of safety and, more broadly, the need to create a learning organization. Bagian asserts that "very little has changed since patient safety burst into the public's and general medicine's consciousness." Indeed, when we think of how far we must go to achieve the level of patient care currently provided by the few "ultrasafe" healthcare organizations, it does seem that very little has changed. However, the small changes to date have been consequential changes, as observed by Leape and Berwick (2005). They summarize the progress we have made as occurring in the following three broad categories: 1. Viewing the task of error prevention (i.e., how health professionals think and talk about medical errors and injury) 2. Enlisting the support of key stakeholders 3. Changing practices Leape and Berwick acknowledge that while key stakeholders exist at multiple levels, from the federal government to accrediting bodies, the most important stakeholders are the physicians, nurses, therapists, and pharmacists who have answered the call to improve safety in their own hospitals and clinics for their own patients. The Veterans Health Administration has become a national example of safe practices and training programs through its patient safety program. Bagian's article illustrates that it is possible to bridge the gaps between the macroorganization, the mesoorganization, and the microsystem. In this case the macroorganization is the Veterans Health Administration, the mesoorganization represents the departments within individual VA medical centers, and the microsystem is the front line of care where patients and providers meet. A CULTURE OF SAFETY During the past several years of the growing patient safety movement, it has become increasingly clear that assessing and transforming the organizational culture is a key component toward realizing potential improvements in quality and safety of care. The Institute of Medicine (2001) holds that "the biggest challenge in moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are not treated as personal failures but as opportunities to improve the system." How do we create an environment in Healthcare that fosters safety? Whereas national cultures arise largely out of shared values, an organizational culture is shaped mainly by shared practices. Culture can be defined as the collection of individual and group values, attitudes, perceptions, and assumptions that guides the group members' behaviors (Schein 1990; Helmreich and Merrit 1998). Characteristics of a strong safety culture include a commitment of the leadership to discussing and learning from errors, founding all communications on mutual trust, sharing perceptions of the importance of safety, encouraging and practicing teamwork, and using systems for reporting and analyzing adverse events (Pronovost et al. 2003). Striving toward a safety culture is a process of collective learning-personal learning as well as organizational learning. A classic model of safety culture describes the elements or subcultures as reporting, learning, flexible, and just (Reason 1997). Providers must know what to report, how and why to report it, and do so safely with rapid-cycle feedback to keep the reporting coming. The organization must honor learning above blame and improvement over the status quo and use all available means to learn, including "safety imagination" about what could happen given known risks and near-miss data. …