So, today we're going to talk about safety culture. And we'll begin by defining what safety culture really is. And when we talk about culture, it really helps for us to take a step backwards and disguise what is culture in a broader context. And so, when we think about broadly what culture is, it is the learned, shared, and tacit assumptions of folks who are contributing to a meaningful social group. And so, what that means more simply is, especially within organizational context, it's the compass that team members use to guide their behaviors, attitudes, and perceptions while they're on the job. And so, when we are trying to get a sense of what a culture of an organization, it looks like, and what it is, we can ask them simple questions such as what is it that I'll get praised for, what am I getting reprimanded for, and what is the right thing to do in this context? I bet that many of you have worked in a number of different organizational environments, and that most of those environments slightly differ from one to the next. And that's because their cultures are slightly different. Even within hospitals. What we find is that organizational cultures within hospitals aren't so different across hospitals. But when we start to look at within the units, we start to see a lot of variation across how things are done within different units. And these three simple questions: what do I get praise for, reprimanded for, and the right thing to do, begin to give us that surface layer understanding of what culture is within any particular context. And so, understanding that safety culture within this more global organizational culture is, really comes down to understanding the bigger goal organizational picture. We have many different assumptions and policies and values as an organization, even as a society. So, safety culture really refers to the perceived priority of safety relative to other goals within our organization. And even more specifically the subculture of patient safety is that priority of patient safety as opposed to health care worker safety or the safety of other folks who work in the organization. So, we can start to think of culture as a layer. And so when we start to think about safety culture specifically, it gets even more hairy because safety culture as one single thing is a little bit of a misnomer. Sometimes you maybe have heard people say, well, our safety culture is really weak here, or we have a really strong culture of safety here in our organizations. But I wonder if you ever stopped to wonder, well, what does that really mean? What makes your safety culture strong? And it's a really good question because so much of what composes safety culture is also layered or piecemeal. And so, what we see here is a couple of different core aspects of safety culture as they've been defined and showcased in the literature. And so, our communication and language patterns are one element of our safety culture, how we speak to one another, the words that we use, the mechanisms that we use, whether it's email or face to face or hard copy, office memos or white boards. These are all elements that relate to our language and communication patterns that ultimately then also inform how we think about and approach safety within our organizations. Feedback, reward and corrective practices, another element of safety culture. How is it that we are taking information that we garner on the job from our experiences and learning to improve our performance over time? What are we being rewarded for? What are we being penalized for? And how are we going about doing those things? Are our corrective practices more about penalizing folks for making mistakes or are they about learning from our mistakes? And these are all questions that we can ask that are related to how it is that we approach safety and with a learning lens. And of course we know that leaders are super critical and provide a lot of messaging for what it is that is important in our organizations. And of course that, related to safety, is no exception. And leaders can be formal, they can be informal, so, I'm sure we all have examples of folks that we know who aren't necessarily in a position of power, but who have maybe been on the job for ages and are just somebody that people look up to as an informal leader. We can think about leadership in terms of what is it my unit management is saying? What are the messages I'm getting from my unit management? What does the C-suite saying in terms of our greater organizational priorities? And then what are the priorities within my unit that my local leadership is showcasing? And that's how sometimes we can see safety culture differing among units even within the same organization. Our team work practices. How is it that we interact with one another? Is it normal for us to offer back-up behavior? Is it considered appropriate for me to ask for help if I'm in the weeds or having a really busy day and need some assistance, or will somebody roll their eyes at me for asking for additional assistance? These are all elements that are also related to how we approach safety in our organization. And of course resource allocation practices; the way that we use our people, our time and our money, those are all big points and priorities in how we approach safety. Where are our resources going in terms of these things? And of course our error detection and correction systems. We are all human, we all make mistakes. And so how it is that we handle those mistakes, how we detect those mistakes, how we are logging and tracking those mistakes, and then making efforts to make improvements within our organizations to correct those mistakes and reduce the likelihood that mistakes are going to happen in the future. And as I'm speaking I bet you're thinking that so many of these things are overlapping and related. How we speak to each other is probably highly related to our team work practices and the examples that our leaders are setting. Our corrective practices are probably highly related to how we go about monitoring for errors and what we do in the event of an adverse event. And you're absolutely right. It's important to remember that while these are different components of a safety culture, they all are highly interrelated, because they are all integral to the ultimate subculture of safety. So, let's take a moment to talk about the components of different culture, because as I said before, when we think about culture, we can ask ourselves questions such as what have I've been reprimanded for, what am I praised for, and what's the right thing for me to do here in my organization or in my unit or in my department? And those are all great ways to get at that surface level manifestation of culture. However, when we think about culture in that way, we can also be oversimplifying it. So, Edgar Schein, who is a leading organizational researcher on culture from the Sloan Business School at MIT, has reminded us to think about culture as layers. And we have our cultural artifacts, which is exactly what I was just describing. And in many ways are many of the things in that wheel, that puzzle wheel that we just saw a moment ago, it is the visual manifestations. And if we think about this in terms of a water lily, it's the beautiful flower that sits on the surface. However, that flowers is connected to stems and roots that are below the surface, that aren't necessarily immediately visible. So, let me talk about what that means. So, again, that flower, it's the behavior, norms and processes that we do on the job. It's our reward systems that we just talked about. So, we can walk into any unit, we can walk into any organization, and we immediately get a feel for what their culture is like. We can get more of a feel by asking folks, what is your experience here, what is it that you're getting reprimanded or praised for, and in any given context, what would you say is the right thing to do? As an example, if you have a linens shortage on your unit, is it part of your organizational culture that the right thing to do is to call up housing and maintenance and ask for more linens to be delivered, or do you just walk down the hall and steal more linens from another unit? What is considered appropriate behavior? Maybe for many of you stealing linens sounds like absolutely the wrong thing to do, but maybe for many of you that's normal practice. That's just one element of your culture that can be easily observed. However, why do we do the things that we do? Why do we engage in these behaviors and these norms and these processes? And the answer comes that we're really trying to live our espoused values, our goals and philosophies, the formal policies that are presented in our organization. And these are the stems that support our flower, our water lily there on the surface. And so that's just one deeper layer. And these are a little bit harder to see sometimes, but when you ask people, why do you do it that way, they can sometimes begin to articulate, well, we do it this way because really we're very much focused on throughput here in the labor and delivery unit. We want to make sure we're doing our work as quickly as we possibly can. That's valuable to us. That's our work philosophy here in labor and delivery. And so, to match that we go and we borrow linens from down the hall quite often. And yet these espoused values where do they come from? So really we go a little bit deeper and we find that the root, our underlying assumptions. And here it gets really tricky because people don't necessarily find it easy to articulate their underlying assumptions. So, there at the top, we see this flower, it's really obvious, it's really beautiful, it's easy to observe, perhaps maybe we stick our hand under the water and we are able to feel out the stems of the flowers. But then as we get down to the bottom the assumptions, they're more tangly, they are harder to unlock, they're harder to understand, and people don't always articulate very well those assumptions. And so, when we think about culture, we have to try not to forget about these underlying assumptions that really drive our behavior in the long term.
