Part 4 - What Got Us Here Won’t Get Us There — BROWN EMERGENCY MEDICINE BLOG

“The institutions we are in shape our behaviors. When institutions shape our behaviors such that our behaviors are no longer in line with our values we experience burnout.”

When we look at ways of dismantling institutionalized “-isms” in healthcare we can learn much from the successes and struggles of the creation of safety culture in hospitals.

“Several studies have found organizational factors to be the most significant predictor of safe work behaviors” - Occupational Health and Safety Administration (OSHA) [1].

The institutions we are in shape our behaviors. When institutions shape our behaviors such that our behaviors are no longer in line with our values we experience burnout. Burnout is a problem with the company not the individual” (Harvard Business Review) [2]. How we approach remediating harms, whether it be from workplace accidents to healthcare inequities, we must remember that our institutions hold the power and the responsibility of our culture. They can empower our successes or set us up to fail.

Healthcare safety culture is an example of an approach to culture change for patient safety that has led to many successes, but is limited by operant conditioning and thus punitive processes. Unfortunately, in addition to punitive processes, safety culture doesn’t include the resources necessary needed to comply. For example, when the hand sanitizer is empty but we are punished for not sanitizing our hands.

“An AHRQ benchmarking study, Hospital Survey on Patient Safety Culture: 2008 Comparative Database Report, analyzed data from 519 hospitals that conducted a culture of safety survey with 160,000 staff members nationwide. It found the following: 64% worried that the mistakes they made would be kept in their personnel file, 49% felt mistakes were held against them, 55% felt like the person, rather than the mistake, was being reported”. [3]

The implementation of safety culture in hospitals is taught by OSHA through operant conditioning. Despite the research to support non-punitive workplace environments by the Agency for Healthcare Research and Quality’s (AHRQ) Center for Quality Improvement & Patient Safety, OSHA still teaches punishment as part of safety culture.

We now live in a healthcare system where anonymous reporting, which was created as part of a safety culture to learn from mistakes and near-misses, has become a way for staff to punish each other. “Compared to nonpunitive reports, punitive reports were more likely to focus on communication and employee behavior issues, policies/procedures, and staff training or competency issues. Punitive reports commonly involved adverse reactions or complications and communication errors”[4]. Often institutions will implement anonymous reporting or policies for written feedback in an attempt to facilitate change. However, these anonymous reporting or written feedback systems inevitably just create more leverage for institutions to control.

We can only manifest our own growth and support others growth if we are within institutions that create safe spaces for growth. Growth is often not linear. Along the path of change there are failures and mistakes that often teach us the most. Punishment (negative reinforcements) as a response to behavior changes motivation away from improvement to avoidance of punishment.

Obvious punitive processes are easy to identify, but those that exist under the invisibility cloak of gaslighting, microaggression, and stereotype threat can be insurmountable for those targeted. Gaslighting, microaggressions, and stereotype threat amplify the challenges faced by those with less institutional power. Top-down leadership within hierarchical systems increases the threat and challenge of speaking ones truth to power. (look for future posts on all of these)

Dismantling “-isms,” and patient safety, start with eliminating obviously punitive processes and prioritizing time/space for coaching and practice working through interpersonal conflict.

A roadmap solution to dismantling institutionalized “-isms” is Cultural Humility. Cultural Humility was coined by Dr. Melanie Tervalon and Dr. Jann Murray-Garcia in 1998 as a roadmap towards multiculturally equitable healthcare. Their framework emphasizes that we learn and grow from listening to each other. Cultural Humility is built on the following principles [5]: