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In a multicultural and multilingual hospital, language can be a barrier to effective staff training. Krishnan Sankaranarayanan and Dr Steven Matarelli utilise the strength of recognition memory to overcome learning obstacles through the use of a familiar emoticon, the smile.

Most frameworks involving a culture of safety place patients at the centre of the care delivery model1. When considering health policies, Ostrom stated that frameworks are designed to organise inquiry through identification of elements and potential relationships, but are not intended to specifically test, explain, or predict the behavioural outcomes or strengths of association that a theory would test2.

In the healthcare setting patients occupy the centre prominence of our safety efforts, but we suggest that care providers play an equally important role in optimising patient safety. Furthermore, extrinsic factors such as government agencies are, at times, excluded from these discussions. Some frameworks are structurally complex, making it difficult for end users to retain, remember, and apply concepts consistently in practise.

Although the culture of safety is a serious business3, it does not have to be implemented with a grim face. Joy and spirit of care giving are also linked to patient safety. Joy comes from witnessing successful patient outcomes and seeing a patient and family experience their healing journey4. Leape offers that joy and meaning will be created when the care providers feel valued, safe from harm and are part of the solution for change5.

“although the culture of safety is a serious business3, it does not have to be implemented with a grim face”

How, then, do we approach a complex system framework, such as patient safety, with a programme that is meaningful, sustainable, and consistently recognisable - if not marketable - to the bedside care givers? We have found that the correlation of thoughts plays a significant role in the retention and recognition of information for our multicultural staff. Gigerenzer posited that the strength of recognition surpasses that of simple recall in humans – when recall is impaired, recognition often remains6.

SUPPORTING CARER'S ROLE IN PATIENT SAFETY

Putting a smile on the culture of safety framework

Krishnan Sankaranarayanan and Dr Steven A Matarelli, Tawam HospitalSAFETY CULTURE

One way to strengthen recognition and information recall is through the use of mnemonics7. Mnemonics encode complex information, in which unfamiliar material to be learned is linked with known information, pictures or symbols7. Visual cues and auditory reminders enhance meaningfulness of new information and promote overall strength of association between novel learning and known or familiar patterns8.

Healthcare settings are ideal training grounds for the use of mnemonic learning strategies, particularly when faced with novel information or step dependent procedures. Mnemonics such as SBAR, SHARQ, I PASS THE BATON and the 5 Rs have become ubiquitous in patient safety programmes and staff education throughout healthcare, as one type of aid to break communication barriers between various patient care team members9.

“in our multilingual Middle Eastern setting, we needed something with the power of recognition over recall to help drive the message of our patient safety programme”

In our multicultural and multilingual Middle Eastern setting, we needed something less complex and more in line with the power of recognition over recall to help drive the message of our patient safety programme. The SMILE culture of safety framework was created with this purpose in mind.

The use of emoticons to convey information saturates our wired world. One of the more popular emoticons is the smile. The smile is ubiquitous throughout computer generated communication such as emails, texts and social networking applications. Could we parlay its popularity in our patient safety efforts? We surmised that a healthcare provider, who is trained in the SMILE culture of safety model, would more easily recognise our culture of safety framework when this emoticon was used as a part of their daily communicating life. Here, we hope, is where the correlation of thought comes to fruition with information retention and recognition in our multicultural staff.

Through our programme implementation and staff evaluations using instruments that assess cultures of safety, such as the Pascal Metrics’ Safety Attitude Questionnaire (SAQ), the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture (HSOPS), and through deep, unit based conversations over the past five years, we have derived certain domains that we feel are inextricably linked to our programme’s understanding and implementation success.

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External constructsAs explained earlier, the key external constructs of the SMILE culture of safety framework are health policy decisions, regulators and healthcare leaders, based on a solid foundation of commitment and engagement. These external constructs balance and provide supporting boundaries to the SMILE framework.

Health policy decisions, regulators and healthcare leaders

In examining the role of state legislatures in regulating patient safety, it was found that legislation serves an important function in health policy creation, as it is an intermediate step to bringing the patient’s perspective to the table10. Hospitals and hospital leaders alone cannot establish a culture of safety; they are governed by health policy decisions and regulators as extrinsic factors. As such, health policy decisions and regulators play an important role in driving the culture of safety in hospitals.

Devers, Pham, and Liu described three general mechanisms for stimulating hospital staff to reduce medical errors: professionalism, regulation and market forces11. Organisational participation in quasi-regulatory organisations such as the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) was found to be the primary driver for hospitals’ patient safety initiatives11.

These domains were aligned to fit the SMILE conceptual framework as follows:

S - Systems and support

M - Morale and motivation

I - Information and open communication

L - Leadership and commitment

E - Empowerment and engagement

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Government agencies must participate to create atmospheres and environments that foster the implementation of safety culture in hospitals – punitive approaches to patient safety have done little to contribute to a safer environment12. Health policy decisions must be created in the spirit of patient safety and regulators must pledge commitment to the cause of a culture of safety. Healthcare leaders must exhibit their commitment by engaging themselves in practise and being active participants where health or organisational policies are created.

Commitment and engagement

When medical errors occur, patients may be harmed and qualified healthcare providers may seek new positions or leave the organisation prematurely, rather than face the consequences often associated with errors13. Leadership commitment and engagement are critical success factors that drive a culture of safety. Our experience illustrates that we can achieve great improvements in clinical and operational outcomes if our leadership becomes a strong advocate of patient safety, and if our commitment and engagement is evident throughout the organisation.

One way healthcare leaders may showcase their commitment and engagement is by conducting walkarounds in patient care areas in order to engage, first hand, with frontline staff, thereby providing a workplace forum to discuss their safety concerns14. Use of open forums and open door policies in order to listen to staff concerns are other effective tools. While these are not unique behaviours to other leadership engagement models, at the time of implementation they were unique behaviours for our organisation. Regular walkarounds have become a trusted forum in which staff can speak up.

Further, we found the importance in leadership commitment and staff engagement through demonstrated safety awareness throughout the organisation, in areas such as intimidating and disruptive behaviours as a complementary path to patient safety. Commitment and engagement are manifested by creating a code of conduct and procedures to establish zero tolerance for disruptive behaviours. We empower staff to speak up and voice their concerns.

“if leadership fails to challenge unsafe behaviours, then it means we have inadvertently reinforced the notion that such behaviours are acceptable ”

We found that if leadership fails to challenge unsafe behaviours, then it means we have inadvertently reinforced the notion that such behaviours are acceptable in our healthcare setting. Leadership's decisions and actions must match its words – congruence of words and actions is one of the external constructs we used to create a shared vision of the importance of safety within our organisation.

Internal constructsAs detailed right, the key internal constructs are the patient and the care providers, respect, information and care for the patient, and systems, empowerment and support for the care providers. These internal constructs are a lens best viewed through the patient’s eyes, thus their strategic placement in the SMILE image.

Patient

Edgman-Levitan and Cleary asked patients what was important to them and what affected them, either positively or negatively, concerning their hospitalisation. Collectively, patients indicated that coordination of care, information, communication, and respect for patients’ values formed important dimensions of viewing a hospital as ‘safe’15.

“while very new in our culture, open disclosure is gaining strength as an effective part of our patient safety programme”

Respect, information and care are three primary expectations we found in our patients, operationally defined as:

1. Respect - Patients treated with respect, being treated equally without any discrimination of nationality or religion, and care providers being courteous to patients. Respect is further refined as understanding the feelings and needs of the patient, and care providers respecting the patient’s values and beliefs even if different from their own.

2. Information - Care providers communicating with patients clearly and in an easily understandable manner, using layman’s language and avoiding excessive use of medical terms. Information provided in the patient’s native language is preferred. Information is further refined as telling patients about their actual conditions and giving them appropriate hope and support where needed. While very new in our culture, open disclosure is gaining strength as an effective part of our patient safety programme.

3. Care - Patients having unrestricted access to care that is needed to treat their illness.

Care provider

Organisational leaders have long realised that engaged employees are linked to providing good patient care services16. There is growing evidence that supports connections between employee engagement and patient loyalty. Concepts such as loved ones taking care of loved ones, and caring for those who care for the patients are emerging trends in the healthcare industry and should be incorporated into patient safety programme planning.17

“organisational leaders have long realised that engaged employees are linked to providing good patient care services”

Patient safety is accurately defined as a systems' issue in which the care provider is one aspect of a highly complex structure. As such, interventions to improve patient safety should be made at the system level and through a systems' lens, in addition to individual care giver education and commitment. Individuals in an organisation must feel empowered to report errors.

Organisations’ leaders must implement ways to discover errors and learn from defects, by employing process improvements that passively and actively create opportunities for

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sustainable error reduction. Part of the solution is to ensure that providers have the proper tools to address system issues18.

Systems, empowerment and support are three primary expectations we found in our organisation, operationally defined as:

1. Systems - Human beings are fallible and care providers are at the sharp end of error19. It becomes the binding duty of the regulators and healthcare leaders to create systems that make it both easy for care providers to do the right thing, and which make it difficult for them to do the wrong thing. This can be accomplished by creating forced functions in many healthcare delivery processes20.

2. Empowerment - Creating opportunity for providers to speak up when things go wrong. There must be zero tolerance to bullying and disruptive behaviours, while making providers accountable and involving them as process owners for employee engagement21. We have adopted a fair and just culture22, where care providers are responsible for their professional conduct. We embrace the fact that systems’ issues lead good healthcare professionals to make unwanted errors.

3. Support - Regulators and hospital leaders supporting care providers when they become a second victim due to an error23. We offer affected staff a fair and just investigation as principles of natural justice24, and we do not dismiss employees due to errors linked to systems’ issues. We do hold staff accountable for their professional conduct. Finally, staff must be given tools and training to do their work effectively and efficiently in a culture of safety.

ConclusionThe culture of safety is a serious business and current frameworks are structurally complex, making it difficult for bedside care givers to remember and apply in practise. The SMILE framework provides an opportunity for users to understand and replicate the various components that influence organisational factors for patient safety. By putting a smile on the face of patient safety we are able to tap into a contemporary cultural movement strengthened by remembrance, rather than information recall alone.

While patients are clearly the centre focus in healthcare delivery, we submit that care providers themselves hold equal prominence in the patient safety movement. Care providers play an important role in delivering safer care, but this requires

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a right and a safe environment in which to practise. Delivering safer care is linked to external and internal constructs that influence and drive a new philosophy. Throughout this article we have portrayed those constructs we found most meaningful along our journey.

AcknowledgementsThe authors wish to thank Mamoon Abu Haltem, Carole L Hemmelgarn and Theresa A Morris for contributing their views in designing the framework, and Bachar Mamich for his computer skills in bringing the SMILE framework to life.

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leader’s role. The Online Journal of Issues in Nursing, 16(3), Manuscript 3.

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5. Lucian Leape Institute at the National Patient Safety Foundation, 2013. Through the eyes of the workforce: Creating joy, meaning, and safer health care. Retrieved: www.npsf.org/wp-content/uploads/2013/03/Through-Eyes-of-the-Workforce_online.pdf

6. Gigerenzer G, 2007. Gut feelings. London, England: Penguin Books.

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12. Latter C, 2009. And justice for all. Prevention Strategist, 2(4), 46-53. Retrieved from: legacy.justculture.org/media/Prevention_Strategist-_Justice_For_All.pdf

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AuthorsKrishnan Sankaranarayanan is the senior safety officer at Tawam Hospital. He holds a Master of Science degree in patient safety leadership from the University of Illinois-Chicago, as well as a master of business administration degree from Annamalai University. Krishnan is a Certified

Professional in Healthcare Quality (CPHQ) and a founding member of the patient safety team at Tawam Hospital.

E: ksankara@tawamhospital.ae

Dr Steven A Matarelli works for Johns Hopkins Medicine International and serves as the chief operating officer for Tawam Hospital. He holds a dual master’s degree in medical surgical nursing and nursing administration and a PhD in public health. Dr Matarelli is a founding patient safety

team executive at Tawam Hospital.