How to create a culture of safety at your practice

The safest offices, naturally, are mindful of practical, day-to-day issues like hand hygiene, personal protective equipment and keeping up with infection control news. But beyond the nuts-and-bolts matters, they must also engender a spirit and culture of safety throughout the practice. It’s not necessarily a difficult task, but it’s one that does require elements of diligence, effort and teamwork.

Where to begin

“It’s a multifaceted approach,” says Joyce Moore, RDH, an infection control consultant and clinical instructor at Bristol Community College in Fall River, Massachusetts. “When you go into a practice, it’s different than going into a federally qualified health center or a healthcare system. Each office, even if they’re part of a group practice, tends to have their own ways of doing things. But I think that you have to start at the top. If you’re going to provide safe care, it depends on all of your highly trained individuals with different roles and responsibilities acting together in the best interests of the patient.”

Creating a culture of safety must start with the leadership, Moore says.

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“The safety culture has to begin with the senior leadership because it’s based on their actions and their beliefs,” she explains. “The leadership needs to model safe behavior and enforce safety guidelines so that the employees are likely to rise to those standards. They have to provide clearly defined expectations. They should have set policies and procedures that follow the regulatory mandates, the guidelines, the recommendations. So, we’re looking at evidence-based practices. And those leaders also need to allocate resources to patient safety activities, annual safety training. They should have regular staff training. There should be attendance at continuing education, not just for the staff but for the leaders as well. Leadership is a huge portion of having a safety culture because if they’re not on board, then the others aren’t going to be on board.”

Guiding philosophy

Often, creating a safe practice begins with simply embracing a mindset of safety.

Andrea Putt, patient safety coordinator at North Ridgeville Family Dentistry in North Ridgeville, Ohio, says that her practice embraced that spirit thanks to the guidance of an infection control consultant.

“What really kick started this culture of safety in our office was our consultant,” Putt says. “She did an amazing presentation with our office. She went over all the changes we can make that would increase our safety measures. There are always ways you can improve, in any office, no matter how careful you are. I still believe we have some work to do, but I feel like we are definitely more safety conscious than we were a couple of years ago when I started.

“One way that we encompassed that change was just an overhaul of our procedures and protocols,” she continues. “In-depth procedures for sterilization, room turnover and our own staff safety. It’s just having those things in mind. How you would want to be treated when you enter an office is kind of my philosophy. If I’m afraid to sit in one of our chairs to get a cleaning or have work done because I’m not sure if it has been cleaned properly, then I’m not going to want any patient coming to that same room.”

That culture of safety represents many facets both big and small.

“You think about little things,” Putt says. “For instance, stocking – you don’t want to touch anything with bare hands that will potentially be going into the mouth of anybody. So that’s where I started, with the mind shift.”

Those guidelines don’t occur in a vacuum, however. There’s plenty of official direction to get the practice started. From there, the practice can take its own initiative.

“Policies and procedures are basically a set of guidelines for people to follow,” Moore says. “They will evolve based on what’s happening in your practice. So, if you have a new piece of equipment, if you have a new technology, those will change and evolve over time. To be more specific and to give a solid set of guidelines, some policies and procedures are very basic. What you really need to focus on is the details because there’s a specific set of steps to make sure you’re doing things properly and safely.”

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For the best outcomes, practices should be willing to embrace change.

“A lot of times you do what you do because that’s what the person before you did,” Moore says. “Without clear guidelines, we really run the risk of not knowing what to do in a situation and we want to know what to do, whether it be an acute situation in the operatory or what we need to do if there’s a chemical spill. These guidelines need to be there because you don’t want to do the wrong thing in the time that you can do the research on what the right thing is.

“But I do think it’s very common that practices have not set the time to establish it,” she adds. “It might get lost in the shuffle. Larger healthcare facilities have someone that is specifically performing these services. All dental offices should have a dedicated infection prevention coordinator. That’s something that they could be doing, creating these policies and procedures or reviewing their current policies and procedures. And they need the time to actually sit down and be able to do that, especially with the changing technology and updated information that we have.”

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Power to the people

While there’s an element of leadership involved in building that culture of safety, it’s still a two-way street. That is, team members should feel empowered in their safety efforts.

“When we talk about the staff, we really need to highlight teamwork,” Moore says. “Effective teamwork plays an essential role in providing good patient care. The aviation industry has very long been recognized for their use of checklists for safety and training, and now the medical and dental fields have really grown to recognize the need for teamwork, and this has led to more teamwork training. Teamwork training, getting everyone on the same page, is really attempting to minimize the potential for error by training each team member to respond appropriately to certain situations. When the staff, when the team members, are trained to cross-check each other’s actions, offer assistance when needed, and address errors in a nonjudgmental fashion, people are more cohesive.

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“We don’t feel like we’re working separately, but we’re working together, providing feedback and making our work in what we do better and safer,” she continues. “It’s having the next guy’s back and knowing that someone else has yours. And, of course, a major part of that is effective communication. It’s something that leadership really needs to support. Leadership really needs to cultivate a culture of safety. Employees must feel safe when they provide feedback to teammates and sharing their opinions about patient safety should encouraged.”

When corrections are necessary, Putt says she uses a soft touch.

“I don’t take an authoritative approach to it,” she says. “I try to lead by example, and I try to address the staff – I try not to single anybody out. If there is a change that needs to happen, then my role is to not make anybody feel like they’re being singled out. I have a medical background. I went to nursing school, so that is a big emphasis for me on the infection control. It was pounded into my head during nursing school, so just the thought of cross-contamination is always on my mind. Instead of thinking, ‘Oh, it’s okay to set the stuff up just before the patient comes,’ I have to do gentle reminders of, ‘Well, what if this happens and that stuff is already set up? So, let’s just think about it that way.’”

Putt adds that she’ll let the doctor step in to be the heavy hand if necessary

“I don’t want them to be constantly, ‘Ugh. Oh great, she’s watching me,’” Putt says. “What I just want you to do is follow the procedures that we did and you don’t have to worry about it. If I see you doing something that’s super dangerous, I will bring it up at that time. But other than that, it’s just reminders.”

Expectations

Practices should have clearly defined guidelines to ensure that team members know what’s expected of them.

“We have a great state guideline that we can go by,” Moore says. “We’ve got our CDC guidelines, we’ve got CDC recommendations, so we have a lot that is provided to us in the dental realm by the FDA, CDC and other agencies that can really help us with those standards.”

Expectations should start with the practice’s leadership.

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“The doctors have made it known to the staff any of the new procedures, protocols, whatever, they have made it mandatory that people follow those,” Putt says. “I haven’t seen anything that’s just blatantly being ignored. Some of it is continuing to build new habits and kind of getting a new mindset. I haven’t seen anybody that’s blatantly defied that. The doctor set the precedent that ‘This is what we need to do.’ I do take suggestions from people who have a background in dental. I sat with the hygienists and we went over room turnover and what they feel would be the best protocols from their end. And I spoke to the dental assistants as well. So, I did coordinate with most office staff on what their ideas were and how we could implement something just a little differently.”

But, once again, that culture of safety is a two-way street.

“I think it does come from both,” Putt says. “I heard some grumblings like, ‘Oh, this is so extreme,’ over the past year, but we established that this is the precedent of how it’s going to be done. I also offer the flexibility of ‘If you can think of a better approach, keeping safety in mind, then I am totally fine with that. I don’t mind.’ I’ve been flexible enough that we have rewritten a couple things over time, forgot new products that changed things. There’s definitely a two-way street there. We work as a great team, so I think that’s really important.”

Up next: Resources to use...

Resources

There are a number of diverse resources that practices can turn to for help to develop that culture of safety.

“An outside resource that I think is becoming more and more prominent is called TeamSTEPPS,” Moore says. “It is a program that was developed in collaboration with the United States Department of Defense and the Agency for Healthcare Research and Quality (AHRQ). This is done to support effective communication and teamwork in healthcare. This is a program that does have tools to help you measure the impact that you’re having and it has increased emphasis on the role of effective communication in team training.”

Another popular resource is getting help from an infection control consultant.

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“Consultants can step in and have an overview, look at the policies and procedures, and see what’s happening within a practice in a way that is different than the leadership for the employees,” Moore says. “We can help set the standards so you have references to use. It’s like when you get in your car and you try to figure out how to use all the features without the owner’s manual. We help them create their owner’s manual, so to speak, and help provide the documentation they need so that they can work efficiently and have a reference if they need to know something. As well as, of course, helping them make sure they have the right references, resources and training in place to help support their practice and of course their teamwork and their cohesiveness.”

Putt also recommends referring to magazine articles and online resources. A best practice, she advises, is to make sure the practice has a thorough, effective system in place.

“In order for the entire office systemically to follow a culture of safety, there needs to be good systems in place that are supported by the doctors or managers,” she says. “It needs to be 100 percent supported by the doctors. Before it’s presented to the office, it needs to be gone over with the supervisory people for that office. I really believe it needs to be a systemic safety mindset. That’s a big thing. Because I’m not going to get anywhere if the people who are overseeing the staff really don’t have that mindset of change for safety.

“And it needs to be a team effort,” she adds. “What I try to do is give positive reinforcement instead of negative criticism. Last week, for example, I saw somebody stocking a room and they had their gloves on, touching all the clean stuff. So, I said, ‘Oh, I’m so excited to see you wearing gloves right now.’ It’s just those little things. I think it’s really important for staff to know that safety is the culture in the office, and if it’s not followed or it’s not modeled, then things are going to fall by the wayside.”

There isn’t any one thing that embodies a culture of safety. Rather, it’s a pervasive atmosphere.

“The safety culture should just be part of your day,” Moore says. “When staff members are happy because they can communicate well and are respected, this builds trust and it promotes safety. If we’ve got that positive attitude and that safety culture, not only is it good for the leadership, but it’s good for the staff members, it’s good for the patient. Ultimately, it reduces the risk of incidents that can bring us to legal action. It’s a good situation for all.”