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Accounting for Culture in Patient Safety
A four-part series on 'Culture' in patient safety
Satyan Chari
July 30, 2024
Mural of Bob Dylan in downtown Minneapolis- Photo by Nikoloz Gachechiladze on Unsplash
The order is rapidly fadin'
And the first one now
Will later be last
For the times they are a-changin'
Introduction
A key quality of the global patient safety movement has been its willingness to co-opt a diverse range of ideas and toolkits from other fields. These have sometimes retained a level of fidelity upon arrival.
More often though, such assimilations have led to remodelling of core constructs - to better align with the specific needs of clinical governance and safety management.
This refashioning of ideas into more palatable forms has created problems of discontinuity and dissonance between how they are applied in healthcare and the scientific contexts that birthed them. The notion of ‘culture’ within patient safety is a prime example.
From its roots as an abstract and elusive idea, evoked in diverse (yet complementary) ways across the social sciences and the arts - ‘culture’ has come to represent something entirely different in patient safety.
This issue of The Human Stream provides a brief overview of how healthcare typically approaches questions of culture, drawing out some key differences between our current perspectives and those held by disciplines with deeper expertise on the topic (mainly social sciences & anthropology). The rest of this issue deals with one pillar of our current approach - measurement.
The next issue will examine popular interventions employed across the sector to address various dimension of safety culture.
The last instalment in the series will be in the form of a pragmatic practice guide for leaders and practitioners attempting to navigate questions of culture in patient safety.
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Patient Safety as a Cultural Output
In the previous issue, we noted the recent origin of the term ‘Safety Culture’, specifically in the aftermath of Chernobyl Disaster. While the term caught on quickly, it was not initially offered as a clear causal diagnosis for the disaster. Rather, it served as a type of a ‘Deus Ex Machina’1 - an explanation that had to be invoked because of the lack of a compelling alternate thesis.
Photo by Genny Dimitrakopoulou on Unsplash
The emerging Safety Culture concept was treated with much suspicion by sociologists and anthropologists as it sought to appropriate the concept with “little of the theoretical edifice sociologists and anthropologists have built for cultural analysis”2 . Not only that, the initially subjective (and heavily couched) statements about safety culture were quickly replaced by a more confident ‘functionalist’ orientation3 - defining safety culture as something quantifiable and controllable by organisations. After all, if the cause of accidents:
“..could indeed be put down to a ‘poor’ safety culture, then there might surely be something, for want of a better word, called a ‘good’ safety culture, which safety managers might then promote, design, or encourage in order to head off some of the worst consequences of organizational-system failure (Pidgeon 1998)”4 .
Silbey3 referred to this shift as the ‘instrumentalisation’ of the concept of culture - treating it as something that can be manipulated and put to service of organisational goals (see resources below).
While the functionalist trend touches nearly every aspect of the culture conversation in healthcare, its deep integration into the patient safety is clear from the following quotes that cut across jurisdictions:
Quote | Source | Embedded ‘functionalist’ perspectives |
|---|---|---|
“In the end, culture will trump rules, standards and control strategies every single time, and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime.” | Berwick and Shojania. National Patient Safety Foundation. Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. Boston: National Patient Safety Foundation; 2015. | -Culture precedes outcomes. -Culture can be intentionally manipulated. -It is valid to talk about culture as something homogenous, spanning the entire organisation or even the whole sector. |
“Measurement of patient safety culture enables the identification of strengths and areas for improvement. This information can be used to develop appropriate interventions.“ | The Australian Commission on Safety & Quality in Healthcare | - Culture change programs can be implemented and suspended in planned & episodic ways. - Culture is sufficiently stable and ‘tractable’ to be probed with top-down standardised measures. - Outcomes from standardised measures can quantitatively establish whether safety culture falls below objective norms. |
“The key ingredients for healthcare organisations that want to be safe are: staff who feel psychologically safe; valuing and respecting diversity; a compelling vision; good leadership at all levels; a sense of teamwork; openness and support for learning.” | NHS National Patient Safety Strategy page 8 (Box 1: Features of a Patient Safety Culture) | - Cultures are decomposable (or may be factored) into a stable set of discrete dimensions. - Intervening across those dimensions will produce a positive safety culture. |
The functionalist perspective tends to frame culture as something that organisation’s ‘have’, rather than as something organisations are and ‘do’. This further lends credibility to the growth we see in formalised & empirical approaches to culture measurement and change in patient safety today. But are we really measuring and improving culture through these efforts?