1. Smith, Joan R. PhD, RN, NNP-BC
  2. Director

Article Content

Since the seminal public health report by the Institute of Medicine1 revealed thousands of people die as a result of preventable errors, healthcare organizations have been striving to improve patient safety. Unfortunately, medical errors continue to be the leading cause of death in the United States, second only to cardiovascular disease and cancer.2 Although much attention has been given to reducing preventable harm and protecting patients, less attention has been paid to ensuring a safe system for both patients and workers within the healthcare environment. Healthcare workers concerned for their safety in an environment in which their health and safety is not perceived as a priority are unable to deliver error-free care to patients.3 Worker and patient safety are inextricably linked: efforts to reduce medical errors and improve patient safety must be linked with efforts to prevent work-related injury and illness.4,5 Healthcare workers must have their most basic needs met (eg, protection, respect, and support) in order to safely care for patients. The basic foundation of a safe workplace is protection of the physical and psychological safety of the workforce.4 Yet, many healthcare workers suffer from physical and emotional/psychological harm in the course of providing care to patients. Physical harm (known and preventable environment risks) includes needle stick injuries, back or musculoskeletal injuries (from straining and overexertion), slips/falls, body fluid exposures, and violence; emotional/psychological harm includes not being treated with respect, being bullied, harassed, demeaned, and ultimately working within a culture of intimidation, mistrust, and burnout.4 In fact, healthcare workers encounter some of the highest rates of nonfatal occupational illness and injury-exceeding construction and manufacturing industries.5-7



If organizations are committed to driving down patient harm, worker safety must be prioritized in equal measure with patient safety. It is well documented that disrespectful treatment of healthcare workers increases the risk of patient injury.3,6 Therefore, healthcare organizations and local teams need to create and support an environment that encompasses mutual respect and teamwork-both essential in providing safe practices. To create a safe and supportive work environment, healthcare organizations are seeking to become high-reliability organizations (HRO8) and/or using manufacturing processes such as the Toyota Production System (TPS9) to value their employees, improve efficiency, and continually improve. HROs are intensely concerned with the possibility of failure and strive to create systems and processes that prevent errors or mitigate their impact.6,8 Some of the most basic tenets of both HRO and TPS include respect for people, teamwork, transparency, and continuous improvement. Organizations who are striving to provide a safe environment for both patients and workers can embrace these basic tenets and neonatal leaders and those at the frontline can integrate these tenets into their daily work:


1. Respect. Virginia Mason Medical Center10 and ThedaCare11 have transformed their operating system based on Lean principles12 and the TPS, which is characterized by respect for people and continuous improvement. Respect for people is more than being nice or civil to one another-it is about challenging people to perform to their peak ability. Respect means making every effort to understand, to actively listen, and to take responsibility to build mutual trust. Unfortunately, this takes time and is often overlooked when pressures mount. Respectful communication among all levels of staff is essential for individuals to be truly valued and respected.13 Neonatal leaders can incorporate worker and patient safety rounds into their daily processes and standard work by routinely going to where the work is being done (eg, the neonatal intensive care unit [NICU]). During these rounds, leaders can actively listen and encourage staff to identify potentially high-risk situations that result in prevention of unsafe conditions and ultimately foster a culture of respect. A key component of respect for people is to invest in workers, whether in showing concern for their well-being or in professional development and education. Creating work that is meaningful and safe is the mark of profound respect for people.11 Members of interdisciplinary neonatal teams need to demonstrate respect for one another because respect is the foundational element in creating a healthy work environment and is the precursor of teamwork.14


2. Teamwork. Teamwork is built once respect is established. Elimination of hierarchical models, lateral bullying, and violence that are missing from respectful relationships and teamwork is essential. Interdisciplinary teamwork is integral to providing safe care, but cannot be achieved without respect-including respect for one another, authority, experts, and institutional aims. Team Strategies & Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an example of an evidence-based teamwork approach aimed at optimizing patient outcomes by improving team communication and teamwork.15 Effective communication is key in establishing interdisciplinary partnerships by engaging team members in information exchange that develops mutual understanding and shared knowledge resulting in a shared mental model to ensure quality patient outcomes and safety.16 It is imperative for neonatal leaders to invest in development of partnerships and relationships among team members because effective interdisciplinary teamwork has a direct impact on patient and worker safety.6,17 In addition, individuals who are part of a team that respect, appreciate, support one another, and focus on positivity rather than negativity are more likely to find meaning and joy in their work, think more creatively, and be more productive, satisfied, engaged, resilient, and retained.18


3. Transparency. Transparency helps drive improvement and is a core tenet of HROs. In order to reduce harm to both patients and workers, full transparency of all accidents and incidents of harm to patients and workers must be acknowledged and displayed. Transparency also sets the tone within an organization for every aspect of care, daily operations, and consistent communication/messaging. Given the vast changes and complex nature of healthcare, organizations need to collect and share data efficiently and effectively for quality reporting and to help drive process improvement, which will ultimately reduce unsafe conditions for both patients and workers. This will result in highlighting where the improvements are needed. Transparency of senior leaders telling safety stories of events that have occurred within the organization, or even within the NICU, can be powerful. These safety stories can include both worker and patient safety events that reinforce a persistent focus and relentless pursuit of eliminating harm and providing safe work environment. Organizations can incorporate daily house-wide and unit-based huddles with visual displays of data to focus on worker and patient safety hazards, both within and across units, and optimize real-time identification of actual or potential problems.6 These huddles can be integrated both at the unit (NICU) and at the senior leader level for problems to be identified in real time and solved at the local level by the staff. If unable to solve at the local level, the problems can be quickly escalated and solved with support from executive leaders.


4. Continuous improvement. Continuous improvement focuses on making small incremental improvements in processes at the frontline. This goes back to the tenet of respect. Respect is at the core of continuous improvement because it relies on encouraging and supporting frontline staff to apply a standard process, or scientific method, of problem solving that engages, encourages, and excites staff to find solutions to achievement improvements.11 Examples of structured or standard improvement models include Plan-Do-Study-Act (PDSA19) or the model of Robust Process Improvement (RPI20) that provide a systematic approach to solving complex problems and help guide improvement teams to examine why processes failed to achieve their desired results.6 The purpose is to apply a rigorous methodology to improvement, and in order to be successful, entire teams (from unit clerks, to managers, providers, patients/families, and others) need to engage those doing the work so they can be empowered to change the work. In order for teams to know whether they are improving, metrics provide quantitative evidence of improved safety outcomes.6 PDSA or RPI methods do not only apply to patient safety problems (eg, blood stream infections) but can also be applied to worker well-being and safety. For instance, measuring and reporting healthcare worker falls and strategies to reduce these falls can be powerful in communicating concern for and recognition of the important contributions of those at the frontline. Measuring performance and realizing the benefits of multiple small tests of change can be done through real-time feedback. For example, if the primary improvement metric is to reduce preventable injuries for both workers and patients, performance measurement data for both process and outcome metrics can be displayed via dashboards. This visual display of data may be on the hospital's intranet (with the ability to display unit-specific data) or at the unit (NICU) and hospital levels using visual management and metrics board to allow people at all levels of the organization to clearly visualize whether the performance met the daily target on any given day. It also helps identify any deviation from the target so all members of the healthcare can make adjustments to "fix" the deviation. The goal is to focus on the root cause of problems and make adjustments to eliminate recurrence.


Healthcare organizations are recognized as a high-hazard and high-risk industry for both patients and workers.6 HROs have learned to be mindful and constantly aware of creating a culture that invests in the safety of both patients and workers. Although there are specific strategies aimed at improving patient and employee safety (eg, training programs, safety committees, patient handling and ergonomics, security, and work place prevention), these 4 basic HRO and TPS tenets can help create foundational stability necessary to build safe systems that support the health and well-being of both our workers and patients. Although pursuing high reliability must be prioritized at all levels of an organization (from the frontline to the top executive) and requires commitment from senior leaders, neonatal teams and leaders can integrate these 4 basic HRO and TPS tenets into everyday work processes. The integration of these tenets will result in safer work environments within the NICU and throughout the organization, which in turn will result in optimal patient care outcomes.


-Joan R. Smith, PhD, RN, NNP-BC




Clinical Quality, Safety & Practice Excellence


St Louis Children's Hospital, Missouri




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