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This month’s Patient Safety Congress (28–30 May 2012) sees the launch of the first in a new series of Health Foundation thought papers, providing an opportunity for leaders in the field to share their views, experience and expertise about particular aspects of healthcare. Here, we summarise key themes from the paper by Dr Michael Leonard and Dr Allan S Frankel, which looks at how leaders can influence a safety culture.

Leonard and Frankel argue that leaders can ensure the systematic delivery of safe and reliable care by developing a culture of safety and continuous learning. They suggest that great leaders are the ones who learn to wield attitudinal and behavioural norms to best protect against the inevitable risks inherent in healthcare. They can do this in these key ways:

Build psychological safety

The ability of caregivers to raise safety issues is an essential component of safe care. Building psychological safety is about creating an environment where no one is hesitant to voice a concern about a patient or anything that puts the organisation at risk. Speaking up should not be associated with being perceived as ignorant, incompetent, critical or disruptive.

Leaders contribute to building psychological safety and a collaborative care environment in a few important ways. High-performance safety cultures hire individuals with positive attitudes with regard to collaboration, treating others with respect, and working toward a common goal. While technical skill is necessary, healthcare is a profound social process for patients and caregivers. Leaders need to continuously reinforce the cultural values of the organisation.

Measure and understand the safety culture

There is a fundamental need to measure and understand safety culture at a local level. The use of surveys that reflect the perceptions of staff at clinical unit level is important and produces data about important safety issues which can be debriefed and acted on.

Units where caregivers have very positive perceptions of psychological safety, teamwork, and leadership, and feel comfortable discussing errors, provide safer care environments. The adoption of consistent teamwork behaviours is also a powerful mechanism to improving safety.

Support organisational fairness

Leaders need to make it safe for members of the team to discuss errors and near misses so that the organisation develops a strong learning culture. A ‘Just Culture’ is one where caregivers know they are accountable for being capable, conscientious and not engaging in unsafe behaviour, but are not held accountable for system failures. This can only be successful when supported by leadership. Leaders need to create the safe space to have these conversations, model the right behaviours, and act in response to these events for organisational fairness to work.

Develop a learning system

Leaders can profoundly influence a culture of safety through their support of a learning system. This is a visible structure that captures any concerns from front-line caregivers and demonstrates that leadership is interested in these issues. The information must be acted upon, and, when the issue is resolved, systematic feedback needs to be given to the people who gave them information.

A learning system that captures information and tracks improvement builds trust and the capacity to drive improvement.


In summary, leaders have a profound opportunity to enhance a safety culture:

  • Creating an environment of psychological safety enhances the ability of caregivers to voice concerns – an essential component of safe care.
  • Reflecting the perceptions of unit-level caregivers by debriefing safety culture data identifies opportunities that are important and actionable.
  • Organisational fairness, or ‘Just Culture’, makes it safe for members of the care team to discuss errors and near misses so that the organisation develops a strong learning culture.
  • The learning system is an effective mechanism to capture defects and opportunities and visibly demonstrate that concerns are being addressed and resolved.
  • Effective leadership is an essential component in every aspect.

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