The health care sector must make a fundamental shift to equate worker safety with patient safety. It must also make this shift a strategic priority if it is to deliver exemplary patient care and ensure the health and safety of workers, patients and the public. Failure to do so puts the sector at risk and makes it vulnerable to crises. The author of this article makes the vital connection between worker and patient safety and recommends a strategic, systemic approach.
Health care is a high-risk, high-demand, high-stress industry in perpetual change, one with unique health and safety challenges. It operates 24/7/365 and much of the time is involved in matters of life and death. Nurses, who make up 77 per cent of health workers, are on average 46 years old or older. Like other health workers, they work in fast-paced environments which have high physical work demands and require constant mental astuteness to oversee the needs of fragile, complex, compromised, very ill people, often in unpredictable settings.
In such stressful and often hazardous work environments, the health and safety of patients are the first priority. This has long been the traditional focus of health care providers and one that has been embedded through education and reinforced throughout their careers. Patient priority is also the cultural norm and management practice of conventional health-care organizations that invest in systems, processes, equipment and controls. Resources are primarily allocated to meet the needs of patients and medical technology, often leaving the safety of staff and quality of work-life issues unaddressed.
With the significant growth of the 60+ demographic, health care consumers, as well as workers, are at great risk of injury and their adverse effects. Now is the time for change, because the safety and well-being of the patient and worker are inextricably linked. Safe workers mean that a cohesive, experienced work team is available and able to provide safe, exemplary patient care – the prime mission and core business of this industry.
Health-care errors and resulting injuries – unlike those in the aviation industry, for example – are usually not immediate and catastrophic. The impact is often invisible and delayed but it can be just as devastating – a crisis in the making. As a result, the potential for human error often goes unrecognized. Staff are expected to perform flawlessly at all times without the necessary management system controls or support devices designed to prevent or mitigate potential hazards or untoward events. This article focuses on the pivotal connection between worker and patient health and safety, the barriers to change, and what leaders can do to create a culture of safety in their organizations. It also highlights the benefits of developing a holistic approach to employee and organizational health, engagement and productivity that applies across all industry sectors.
Over the past 15 years, three high-profile events have indicated the need for more thorough due diligence and effective safety systems in health-care organizations: the 1993 Krever Inquiry into Canada’s tainted blood system, the Campbell Commission Report on the 2003 SARS outbreak, and the 2008 findings of the Dupont – Daniel inquest following the death of nurse Lori Dupont at an Ontario hospital in 2005. Spring of Fear, the final report of the Campbell Commission, in which 44 people died and 330 others were infected, concluded that: “This was a system failure. The lack of preparation against infectious disease, the decline of public health, the failure of systems that should protect nurses and paramedics and others from infection at work –all these declines and failures went on through three successive governments …”
Post-SARS, the need to change health and safety practices in health care has become increasingly urgent. Workplace health and safety issues are emerging as key priorities in OSACH‘s partnerships with government, universities, employers, research agencies, unions, health care and community care organizations. Extensive work with sector group members confirms this trend. Creating a culture of safety has become absolutely critical because staff safety and consumer care are connected.
In the article Patient Safety –Worker Safety: Building a Culture of Safety to Improve Healthcare Worker and Patient Well-Being, Annalee Yassi and Tina Hancock note that: “Patient safety and access to high quality patient care are the top priorities for the healthcare system. However, according to the Canadian Adverse Events Study approximately 7.5 percent of Canada’s 2.5 million hospital patients experienced at least one adverse event in 2000 and up to 23,750 patients died as a result…Many of these events were potentially preventable.” (Healthcare Quarterly, October 2005). Yassi and Hancock’s research connects the dots between safety in the workplace, the safety of workers and patients, and workplace conditions:
“Workers in high -injury rate facilities had more negative perceptions of their job demands and workload pressures than workers in low injury facilities. They were more likely to report that they did not have time to get their work done, to work safely, to find a partner, or to use a mechanical lift. Workers in high-injury rate facilities also reported more pain, more burnout, poorer personal health and less job satisfaction. Conversely, workers at facilities with low injury rates were more likely to agree that their facility had enough staff to provide good quality care and did indeed provide good to excellent care.” (Healthcare Quarterly, October 2005).
Researchers Heather Laschinger and Michael Leiter affirm: “The link between negative working conditions and employee stress is well known. Work stress and burnout are also associated with quality of patient care and patient safety.”(“The Impact of Nursing Work Environments on Patient Safety Outcomes”, JONA, May 2006). As well, days lost due to workplace injuries, disabilities and high sick-time rates, along with burnout and constant stress, are more than a major financial cost to an organization. They also destabilize experienced and knowledgeable work teams, thus creating a higher probability of errors.
A sector at risk
Along with changing demographics, economic uncertainty and rising costs, organizational health and well-being is at the top of the agenda for most organizations. Paradoxically, however, the very sector that is dedicated to the health and well-being of others is itself among the most hazardous. In Ontario, health care is among the top four sectors in the frequency of lost-time injuries, well ahead of mining and construction. There are measurable human and financial costs and repercussions for the quality of care if such risks are not managed. The top two sources of lost-time injury in health care are musculoskeletal disorders (54 per cent), and slips and falls (17 per cent). In Ontario, health care has the highest rate of violence and client aggression –even higher than police work. Compounding these risks are bullying in the workplace, increased workloads with fewer resources, burnout and fatigue. Ample evidence exists to show correlations between high rates of injury and illness, absences from work and adverse outcomes for patients and workers. Related impacts are increased costs and diminished resources for patient care.
In Ontario, between 2002 and 2008, the average direct cost of a lost-time injury increased by 97 per cent (WSIB Premium Rates Manuals 2002-2008). The 2007 average premium paid by a hospital (excluding surcharges) $89,726, 397 increased by 10.7 per cent. In 2008, the average direct cost of an injury was $24,133, a 13 per cent increase over 2007. This number excludes the indirect costs, estimated to be four times this value. All these costs are potentially preventable.
A compelling case for change
For more than 20 years, other industry sectors have recognized that there is a connection between a safe, engaged workforce and excellent customer care. These sectors have pursued systems and processes to ensure employee safety and well-being. Attention to health and safety are routinely seen as part of the strategic oversight that good corporate governance provides, and integrated into the core business, risk management and due diligence practices.
This is not standard practice in the health care sector. There are a number of reasons for this:
Workplace health and safety is not widely understood or addressed as a strategic priority by health care boards of directors, leadership and management
There is limited sustained leadership commitment and allocation of adequate health and safety resources
Health and safety resources are not aligned with the corporate planning and budgeting cycle
Health care has a well-entrenched, hierarchical and tradition-bound professional and organizational culture
There is fragmented accountability and inadequate communication of health and safety matters in health care settings.
There is an absence of comprehensive corporate analysis to identify, monitor, mitigate and manage health and safety risks
The health care workplace has complex, trained groups of professionals who have had different training and who are used to working independently and in silos
There is limited cross-enterprise communication on solution management.
While none of these barriers to change is insurmountable on their own, they constitute a powerful deterrent when taken together. They prevent health care leaders from recognizing the connection between worker safety, engagement and well-being, and high-quality patient care – the health care sector’s raison d’etre. Change is necessary. As noted in HealthForceOntario’s 2007/2008 year-end report Opening Doors: “Improved communication reduces medical errors, in one study lowering emergency department clinical error rates from 30 percent to 4.4 percent”
So what can health care leaders do to drive the required positive changes in their organizations?
Take a management-like approach
The OSACH Health and Safety Management System (HSMS), customized for health care, refines the organization’s management structure to address the complex inter-relationships of worker, patient and public safety. Launched in 2007 in partnership with HealthForceOntario, HSMS is currently being piloted at 18 sites, including the Hospital for Sick Children in Toronto, the Ottawa Hospital, the Norfolk and North Bay General Hospitals, the Region of Halton Services for Seniors, and the West Park Healthcare Centre. The system is based on the premise that quality health care depends upon a healthy and safe workforce and environment. Aligned with the CSA Z1000 standard for occupational health and safety, HSMS is the blueprint for building a culture of safety and health for all key stakeholders – workers, patients and the public.
As Anne Marie Malek, president and CEO of West Park Healthcare Centre, explains: “The key benefit to a management system approach is that it creates a disciplined road map for assessing and monitoring risks, and for identifying opportunities to improve. What impressed me most about the OSACH system is the thoroughness of the self-assessment process. It was very gratifying to systematically and thoroughly review various aspects of health and safety in our workplace.” (Hospital News, August 2008).
HSMS takes a comprehensive and integrated systems approach to assess, measure, evaluate, manage and mitigate risk. The approach cuts across programs, departments and silos, and brings key stakeholders to the table to develop system solutions that are integrated into enterprise-wide core business practices. The approach consists of five management system pillars:
- Leadership and commitment
- Risk identification and analysis
- Risk management and control
- Evaluation and corrective action
- Strategic review and continuous improvement
Its primary goals are to provide coordinated, integrated, sustained risk management, and effective health and wellness solutions across the spectrum of workers, patients and the public. HSMS is designed to help health care leaders and managers establish health and safety priorities and objectives, define roles and responsibilities, processes and measures, and to evaluate effectiveness and efficiency.
After a careful review of international health and safety management systems and standards, the OSACH Health and Safety Management System was based on the Canadian Standards Associations CSA Z1000 Standard for occupational health and safety, primarily because it is aligned with Canadian legislation and best practices in Canada. As well, CSA Z1000 is used by organizations of every size and sector in Canada.
Focusing on root-cause analysis and system variables
HSMS tracks and analyses four key system variables to measure their impact on worker, patient and public health and safety:
Are working conditions, work organization and processes and workplace design optimal for worker and patient health and safety?
What equipment is available and is being used to mitigate health and safety risks for worker, patient and the public?
Are human capabilities and limitations for health care tasks appropriately identified and addressed, e.g. stress, knowledge, physical attributes?
What is the level of commitment and the priorities, policies, standards, procedures in place to address health and safety?
Are health and safety issues openly communicated and routinely reported? Are employee engagement, empowerment and teamwork encouraged, measured and rewarded?
Leading the process
Leadership commitment and engagement are critical success factors that drive, and flow through, the entire HSMS process. What can health care leaders do to consider and implement HSMS in their own organizations? They can adopt a systematic approach by making health and safety a strategic priority and aligning it with the corporate vision, values, goals and resources. They can also make health and safety an intrinsic part of their corporate culture, and lead, model and reward health and safety initiatives and celebrate progress. They can recognize, reinforce and continuously evaluate the health and safety policies, standards, processes and programs of their organizations. Finally, organizations need to recognize that this is a journey and that the development of a sustained culture of health, safety and wellness will take time.
Health care leaders committed to creating a culture of safety typically follow this process:
- Sign a commitment and get their senior team on board
- Select a steering committee representing key stakeholders from all parts of the system
- Using the OSACH HSMS tools, assess the five pillars noted above
- Communicate the case for health and safety openly and often, across the organization
- Provide HSMS educational workshops
- Identify and implement one major prevention program/initiative from pillar three, risk management and control
- Lead the steering committee in adopting a reporting and action plan
- Facilitate the OSACH process and committee engagement
- Regularly follow up action plan initiatives.
The OSACH implementation design and structure provide health care leaders with vital data that can ensure their health and safety, and support their due diligence responsibilities and requirements. HSMS also helps leaders to identify gaps and vulnerabilities so they can take appropriate steps to mitigate and manage risks of key stakeholders – health care consumers, employees, and the public. Unlike traditional workplace health and safety programs which tend to be fragmented and reactive, HSMS is proactive and has strong feedback and evaluation mechanisms. It integrates health and safety into health care’s core business of patient, client and resident care.
A prescription for success
Improving worker health and safety by taking a systems approach can have many positive results. First, there are clear financial benefits. Consider that the average cost of lost-time injury is increasing every year – by 13.3 per cent from $ 21,300 in 2007 to $24,133 in 2008 – with no significant injury-rate reduction. Reducing the number of lost -time injuries through improved health and safety practices has a measurable impact on available resources. Time and cost savings can then be redirected to patient care and services, the core business of health care.
Indirect costs are four times the cost of a lost-time injury and have a negative impact on recruitment, replacement and patient safety. Workforce retention strategies can also significantly reduce recruitment and replacement costs. This is particularly critical in the health care sector with an aging workforce and a severe worker shortage.
Creating a culture of health and safety also increases employee engagement. The Towers Perrin 2007 Global Workforce Study of 90,000 employees in 18 countries stressed that leadership commitment to worker well-being is the key driver in retaining and engaging a high-performing workforce – a critical necessity for health care.
Other benefits of implementing a proactive, coordinated system for sustainable health and safety management include:
- Increased quality of patient care and service
- Decreased absenteeism and overtime
- Improved communication and teamwork
- Higher work satisfaction and productivity
- A healthier, stable workforce
- A safer work environment
As well as financial, human resources and patient care improvements, HSMS strengthens an organization’s risk management and corporate governance by meeting national, cross-sector health and safety standards and embedding best practices.
Funded by HealthForceOntario, Dr. Andrea Baumann of McMaster University and Dr.Linn Holness, Chief of Occupational Medicine at Toronto’s St. Michael’s Hospital are leading an HSMS process review. The results will be used to further refine HSMS before rolling it out in the broad health care sector in 2009.
To survive and thrive in the future, health care must create a culture of safety: “The culture of the future must be a culture of safety and of quality; a culture of openness and of accountability; a culture of public service; a culture in which collaborative teamwork is prized; and a culture of flexibility in which innovation can flourish” (Milligan and Davis, 2005).
Based on a standard used across organizations of all sizes and sectors, the OSACH Health and Safety Management System differs from traditional models by combining assessment results and root cause analysis of problems to achieve better long-term and sustainable solutions. It is a prescription for success, not only for health care leaders, but for managers in any environment or setting.