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Leadership, foundation of a patient safety culture

With the spotlight being shown more and more these days on the health care profession, one area that has received particular attention is that of patient safety. An increase of patients going home from hospitals with bacterial infections is one reason for the concern. Another is that patients are becoming more educated and sophisticated when it comes to health care, and they want to be sure that their treatment is effective – and safe. As such, any health care organization delivering health care services needs to stress an environment of safety.

But a safety culture doesn’t just happen – it requires a measurable plan, and leadership willing to drive the organization toward the goal of a safety culture. Without a commitment from the top down, a safety culture will end up being little more than just a lot of words.

Today’s Healthcare Environment

Once upon a time, delivery of healthcare was pretty simple. An individual would go to the doctor for a checkup or to get rid of an illness like the flu. If there was a terminal illness, that individual would likely go home to die. If a child contracted the measles, he or she would just have to ride it out. Things like childhood vaccinations, the AIDS virus, chemotherapy, radiation – these were not a part of the healthcare culture.

Technology, however, has led to some wonderful things in healthcare, from the polio vaccine to many treatments for cancer. But these things come with a price – if misused, they can be just as dangerous – if not more so – than the disease. Horror stories abound about the nurse who accidentally stuck herself with a needle from an HIV-positive patient; about the radiation machine that malfunctioned, causing burns among patients receiving treatment; about potential allergic reactions to vaccines and so on.

The point here isn’t to scare people or healthcare providers but rather, to point out that these cures, while very effective, also require a more intelligent approach to safety for the protection of both staff and patients.

The most successful systems that protect patients (and staff) from potential side effects of medical technology are those that offer solid metrics, careful handling and, of course, leadership that is on board. The goal of leadership, in this case, is to ensure that safety parameters are put into place for patients, that they’re followed and, if there is a collapse in the system, to determine what happened.

Literature Review

Back in 2004, Fosina pointed out two theories when it came to understanding patient safety in an organization. Normal accident theory, he noted, tends to occur from system failures, while high-reliability organization theory puts the blame on individuals for failure (Fosina, 2004). Not that individuals are stupid, or ignorant or willfully destructive, but rather, they may not have the training or understanding to operate within complex systems (Fosina, 2004).

But let’s break this down somewhat further to discuss how, exactly, organizational culture can be defined. According to Schein (2004), organizational culture represents shared assumptions that a group picks up and shares, as a result of their history together. These “assumptions” are very important; they are the way in which people create their own reality; as they also tap into the organizational members’ ability to think, feel and react (Schein, 2004).

The visible aspects of an organization’s culture involve policies, procedures, language and symbols (Carillo, 2010). Then there are the “invisible” aspects of organizational culture; the beliefs and assumptions about how people behave and act (Carillo, 2010). Sometimes the invisible aspect is a lot more difficult to change – no one likes to be told that their long-held beliefs and systems are actually wrong (Carillo, 2004). For example, any nurse floor manager who has tried to change the way his or her floor is run with new safety procedures understands the collective groan that comes about when the staff is informed that things are going to change to make processes easier on the patient. But it isn’t just nurses who might be resistant to change – people, in general, have the belief that “if it ain’t broke, don’t fix it.” Even if a situation IS broken, people can stubbornly refuse to really do much about it.

Going back to our two organizational theories – normal accident theory and high-reliability theory – the former occurs in the “visible” area of the organization while accidents in the latter theory can be found in the very belief systems of an organization.

Furthermore, in any organizational culture, the leader’s challenge is to both perceive the limits of a particular culture, and then go beyond those limits to help make it more successful (Schein, 2004). There are an abundance of leadership theories to help in this endeavor – there is, for one, the autocrat who demands compliance. On the other side, there is the participative leader, who seeks frequent input from employees. In between these two types of leadership are a variety of others when, used judiciously, can help move an organization toward a more safety-conscious culture. Transactional leaders reward change, transformational leaders encourage it and managers ensure everything gets done from an operational perspective.

Ginsburg et al (2010) also point out the importance of leadership and patient safety. The authors, in conducting an empirical research study about the link between safety and leadership, found that both formal and informal leadership is required to ensure that an organizational safety culture is formed and maintained. In addition, leadership has been important when it comes to overall organizational improvement, and not just safety factors (Ginsburg et al, 2010).

We would be remiss, however, if we didn’t mention external forces in our thesis – everything from the external environment to rules and regulations has an impact on an organization’s culture. For example, in the health care setting, regulations and accreditation are just two external forces that have an impact on patient safety in a health care organization (University of Michigan Health System Patient Safety Toolkit).

Leadership in the Health Care Setting

Carillo (2010) points out that leaders, by their very nature, are able to help (and persuade) others through both language and action; and in doing so, these leaders also help change culture. But McSween points out that there is more to developing a safety culture then by just mandating it. This, in fact, is what can get leaders into trouble – they say something needs to happen, and then leave it to others to get it done. The result is – nothing gets done.

McSween points out there are five steps to developing effective safety leadership; creating alignment, communicating, building support, monitoring the process and shaping/reinforcing the behavior. Alignment, in this regard, means creating behaviors and actions consistent with values-based safety, while communicating focuses on ensuring the message of safety is repeated again and again (McSween). Building support focuses on creating coalitions among management and employees to ensure safety parameters; monitoring the process involves understanding how to measure implementation and shaping and reinforcing behavior means that behaviors are changed, and reinforced, so they become habit (McSween).

The guide entitled “Patient Safety First” from the United Kingdom’s National Health Service, is more specific with a graphic, noting that a safety culture requires a mandate from the organization’s board of directors. While the board develops goals and priorities, provides leadership and ensures executive accountability, delivering improvement requires the monitoring of progress, establishing and monitoring system-level measures and building patient safety/improvement knowledge and capabilities.

Meanwhile, the guide entitled “Leadership and Organisational Safety Culture” provides 10 principles of safety leadership behavior which include safety as a top priority; a visible management commitment to safety; increasing visibility around safety; reporting; staff involvement; creation of a learning culture; providing recognition; creating an open culture; communicating effectively and putting into place an effective system for safety.

Needless to say, this is not a short-term process. Shifting behaviors into a desirable mode takes time, commitment and perseverance. It also takes patience, as people don’t easily, or readily, change. But it can be done, as we’ll see in the recommendations below.

Recommendations for creating a strong safety culture

Ensure specific goals and objectives. Simply saying “let’s launch a safety culture!” won’t do it. People need to understand what, specifically, they need to strive toward.

Ensure accountability and transparency. An important part of any kind of safety initiative is assigning responsibilities, and ensuring that all actions are transparent and can be viewed by everyone. This also establishes a culture of honesty and forthrightness.

Ensure cooperation and collaboration. Everyone needs to be on board with a move toward a safety culture. Resistance can throw a wrench in the plans (and it’s the skilled leader who knows how to deal with that resistance).

Develop, implement and monitor plans. Forming a safety culture requires metrics to compare where the organization has been, and how much it has improved. Furthermore, plans, in the form of timelines, goals and processes, also need to be in writing, either on paper, or online.

Instill patient safety improvement and capabilities. This means communicating, driving and insisting on safety procedures every step along the way, from covering one’s mouth when coughing to ensuring that the caliber on the radiation equipment is set to manufacturers’ specifications. If there are any questions at all, it’s important for the individual to ask.


In this paper, we pointed out that patient safety is a major issue being faced by health care organizations today. We also pointed out that creating a culture of patient safety involves more than saying “let’s create a culture of patient safety.” It involves cooperation of all parties, a shift in the organization’s belief systems and, above all, leadership to oversee the efforts.

Any organizational change – especially as it moves toward a safety concept – requires leadership that understands how to set goals and knows how to encourage staff to reach those goals. The literature is filled with success stories about how leadership helped transform an organization – and how lack of leadership doomed that transformation effort to failure.


Carillo, R. A. (2010). Positive Safety Culture. Retrieved 2010, June 22 from

Fosina, M. J. (2004).The role of leadership in instilling a culture of safety: lessons from the literature. Retrieved 2010, June 22 from

Ginsburg, L. R., Chuang, Y., Berta, W. B., Norton, P. G., Ng P., Tregunno, D., & Richardson, J. (2010). The relationship between organizational leadership for safety and learning from patient safety events. Retrieved 2010 June 22 from;col1

Leadership and Organisational Safety Culture (n.d.). Safety matters!: A guide to health & safety at work. Retrieved 2010, June 22 from

Leadership Guide to Patient Safety (2006). Institute for Healthcare Improvement. Retrieved 2010, June 22 from

McSween, T. (n.d.). Developing effective safety leadership. Retrieved 2010 June 22 from

Patient Safety First: The 'how to guide' for leadership for safety [Data file]. Retrieved 2010, June 22 from

Schein, E. (2004). Organizational culture and leadership. Jossey-Bass: San Francisco.

University of Michigan Health System Patient Safety Toolkit. Safety culture (n.d.). Retrieved 2010, June 21 from

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