Building a Safety-Centric Culture That Fosters Psychological Safety from Onboarding Onwards

Abstract

The healthcare system’s evolution mirrors the Industrial Revolution, advancing from Healthcare 1.0’s new economics and epidemics to Healthcare 2.0’s mass production. With Healthcare 3.0, micro-controllers and computers revolutionized diagnostics and education, ushering in evidence-based medicine. Now, the healthcare sector is preparing to embrace Health 4.0, integrating digital technology, cyber-physical systems, and Artificial Intelligence (AI) for personalized, proactive care, marking a shift toward a more unified, efficient, patient-centric model. Yet, Health 4.0 introduces risks like cybersecurity and ethical dilemmas, necessitating a culture of safety and human connection as a cornerstone within healthcare organizations. This chapter outlines how healthcare entities can become high-reliability organizations (HROs) and adept at navigating complex, risky environments to maintain high safety and performance standards by preempting threats. It delves into Safety 2.0, which focuses on learning from successes to enhance HRO practices. Emphasizing humble leadership and trust, the chapter highlights psychological safety’s role in fostering open communication, teamwork, and innovation. It offers guidance for integrating new staff and establishing safety norms in Health 4.0. Aimed at healthcare leaders, managers, and staff, this chapter provides insights into improving service safety, quality, and mental well-being in the sector.

1. Introduction

Healthcare has undergone significant changes in recent years, particularly after the changes created during the SARS-CoV-2 pandemic, which have sped up the digital transformation of the industry with the emergence of Health 4.0 and the use of artificial intelligence (AI) in patient care [1, 2]. Creating a culture that supports open communication, psychological safety, and continuous learning is vital for organizations to prioritize the safety and well-being of their employees in this context. In this chapter, we will explore the critical components of a culture focused on safety and provide helpful advice for building and maintaining such a culture in the workplace.

2. Method

This chapter is based on a literature review of the current trends and challenges in healthcare safety, focusing on high reliability, adapting to new technology, and continuing learning. We followed a systematic search strategy to identify relevant sources from academic databases, government publications, and industry-related websites. The search terms included single and paired combinations of the following keywords: Healthcare, Safety, Leadership, Psychological Safety, High-Reliability Organizations, Safety huddles, Communication, Trust, Technology, AI, Quality, Patient Experience, and Virtual Work. We used PubMed, MEDLINE, and Google™ Scholar as the main search engines. We applied filters for language (English), publication date (2010–2024), and document type (peer-reviewed articles, reports, guidelines, white papers, and books). We also scanned the reference lists of the selected sources to find additional relevant literature. We excluded articles that were not relevant to healthcare and were not in English. The themes extracted from the literature review were discussed among the authors and with professional colleagues with leadership and patient safety expertise. They served as the foundation for the main topics covered in this chapter.

2.1 The new normal in healthcare: the ‘patient’s perspective

2.1.1 Family involvement in patient care

Families face extreme uncertainty when their loved ones are admitted to the hospital, particularly to an Intensive Care Unit (ICU) setting [3]. There is a sense of loss of control, which is enhanced by physical transformation noted in their family members, and it is particularly stressful when there are complications and extended stays [4]. The angst the families encounter is heightened when infection control measures are required to protect family and health staff members [5].

Involving family members in health care relies on active participation in the care and decision-making process and support of the patient’s family. In healthcare settings, involving family members can significantly benefit the patient and the healthcare team [6, 7]. Family members can provide emotional support to the patient, improving their overall well-being and aiding their recovery. Additionally, family members often play a crucial role in advocating for the patient’s needs and preferences. They also serve as a bridge between the patient and the healthcare team, helping to ensure that essential and valuable information is effectively communicated and understood by the healthcare providers. They can also help clarify medical information and provide context about the patient’s health history. In outpatient settings, family members can aid in coordinating care, ensure that the patient receives necessary medications, has adequate appointments, and understands treatment plans. When the patient is unable to make their own medical decision, family members can serve as surrogate decision-makers, advocating for the patient’s best interest and ensuring that their wishes are respected [8].

Healthcare providers must recognize and respect the valuable emotional support that family members can provide in caring for their loved ones and actively involve them in the appropriate processes. Effective communication, collaboration, and partnership between healthcare professionals and family members can contribute to better outcomes and overall satisfaction with the care received [9].

2.1.2 Visitation limitations

Patient Experience: Patient visitation from family in the healthcare setting refers to the practice of allowing family members or loved ones to visit and spend time with the patient who is receiving medical care in a hospital or healthcare facility where visitation policies can vary depending on the specific healthcare institution, the patient’s condition, and any infection control measures that may be in place [10].

There are several vital purposes to allow for visitation: family members provide emotional comfort and support to the patient, which can positively impact their well-being and recovery. They also advocate for the patient, sharing that their needs and concerns are addressed and communicating their preferences to the healthcare team. They also can serve as facilitators between the patient and the healthcare team, providing valuable information on medical history, needs, and patient preferences.

Visitation policies may have specific guidelines regarding the number of visitors allowed, visiting hours, and any restrictions based on the patient’s condition or the particular unit within the healthcare facility. In some cases, such as during a pandemic, visitation policies may be more restrictive to ensure the safety of the patient, staff, and visitors [11].

Overall, patient visitation from family members is recognized as an essential aspect of patient-centered care, and healthcare institutions strive to balance the benefits of visitation with the need to maintain a safe and healing environment. It is vital for healthcare providers to communicate visitation policies clearly to patients and their families and to accommodate visitation whenever possible to support the patient’s well-being [12].

2.1.3 Patient experience

Patient experience refers to all patient exchanges with the healthcare system, including their perceptions, interactions, and overall satisfaction with the care they receive. It encompasses every aspect of the patient’s journey, from scheduling appointments and registration to delivering care, discharge process, and follow-up care [13, 14].

Essential aspects of patient experience include the effectiveness of communication between healthcare providers, staff, and patients, including the clarity of information provided, active listening, and respectful dialog. It is also influenced by the ease of scheduling appointments, waiting times, access to different specialists, and the availability of resources and services. The quality of care provided for the patient includes the technical quality of the medical treatment, the success of interventions, the attention to safety and infection control, and the overall care outcome. The physical environment also plays a significant role in significantly impacting the ‘patient’s experience, including cleanliness, comfort, privacy, and amenities [15]. A crucial factor related to the patient’s experience is the ability of healthcare providers to demonstrate empathy, compassion, understanding, and emotional support for the patient’s needs and concerns. The ‘patient’s perception of empathy and compassion in their medical care is the foundation of trust in the medical system. Creating trust allows patients to actively become involved in their care, including sharing- decision-making, involvement in care planning, and believing they receive accurate and educated information about their condition and treatment options [16, 17].

Healthcare systems prioritize patient experience because it has been shown to directly impact health outcomes, patient safety, and overall patient satisfaction. Patient experience is increasingly recognized as an essential component of high-quality care delivery, and it’s often measured through patient satisfaction surveys, feedback mechanisms, and other tools to capture the patient’s perspective [18]. Improving patient experience requires a focus on patient-centered care, active engagement, and continuous efforts to enhance the overall quality of care delivery. Extensive reviews of the literature have described interventions that improve the patient experience, including developing support groups including social workers, psychological professionals, and nursing groups, clinician training, journal writing by the families and patients, face-to-face meetings for medical updates, family participation during medical rounds, open visiting hours, information to families through nursing staff, pamphlets, use of technology (DVDs, phones, SMS (Short Message Service), developing family care plans, and improving the physical environment [6].

2.2 The new normal in healthcare: the healthcare ‘provider’s perspective

2.2.1 Staff shortages

During the COVID-19 pandemic and afterward, staff shortages have significantly impacted medical care [19]. The increased demand for healthcare services due to the pandemic exacerbated staffing issues and created additional challenges for the healthcare industry. Beyond the COVID-19 pandemic, the healthcare industry continues to be challenged, needing experienced healthcare providers. A decrease in the quality of care with staff shortages reduces the patient-healthcare provider interface and decreases time dedicated to each patient. During limited nurse staffing, there is an increased risk of adverse events, poor patient experience, and reduced treatment effectiveness [20]. Staff shortages can also affect the timing of test results and the procedures required, potentially delaying patient diagnosis and treatment and theoretically increasing patient safety events [21]. The effects of staff shortages continue as healthcare systems work to rebuild their workforce after the SARS-CoV-2 pandemic and address the long-term impacts on staff mental health and well-being. Solutions to address this issue have been documented since the pandemic’s beginning, addressing mutual support and communication [22].

2.2.2 Workforce demoralization

The shortage of medical staff results in healthcare workers being overworked and experiencing burnout, negatively impacting patient care [23]. Aiken et al. found a strong association between high patient-to-nurse ratios, higher emotional exhaustion, and greater job dissatisfaction. There was also a significant impact on morbidity and mortality among the surgical patients included in the study. Further investigations have associated the shortage of nursing staff with a negative effect on patient safety [24]. Several investigators have noted a correlation between perceived medical errors and burnout [25, 26]. There can be an increased perception of medical errors since the providers cannot deliver the care required under normal circumstances [27]. Tawfik et al. described in a cross-sectional study how burnout, well-being, and work unit safety were strongly and independently associated with perceived medical errors [28]. Further, in a prospective study of self-perceived medical errors among internal medicine residents, burnout predicted subsequent perceived medical errors and could be related in a reciprocal cycle [29].

Job experience – An essential outcome of COVID-19 was the revelation of healthcare systems working under already stressed systems, which led to a job-related crisis. System stresses, overwork, and poor working conditions further exacerbated workforce strain, under-staffing, and high job turnover rates [30]. Burnout is an occupational phenomenon characterized by 1) fatigue or exhaustion, 2) negative feelings towards ‘one’s job, and 3) reduced professional efficacy [31].

Mental and emotional Health - During and in the post-pandemic period, mental well-being became and continues to be a significant priority. It became clear that not addressing mental and emotional health creates a significant societal financial burden with a notable impact on the healthcare community and causes higher rates of mental disorders and psychological distress [32]. In 2019, a consensus from the National Academies of Sciences, Engineering, and Medicine proposed a systems model of clinician burnout that emphasizes not only targeting downstream interventions (meditation as an example) but emphasizing the importance of systematic solutions considered upstream interventions (improving the product of the work environment) [31]. In this report, the authors call for increased investment in research and policy changes supporting novel solutions, emphasizing upstream solutions, including changes in government and insurance policies, EMR redesign, and training professionals in norms and expectations.

High-Performing Teams - Enhanced teamwork and teaming: At the highest peak of the pandemic, healthcare providers started to adapt to new challenges with increased collaboration: nurses and respiratory therapists integrated with laboratory services, and primary care physicians worked with intensivists. During this challenging time, the medical community embraced this challenge by supporting each other, learning to adapt during a medical crisis, breaking down hierarchy levels, and supporting each other [22, 33].

2.3 Creating a service excellence culture

2.3.1 Components of high-reliability organizations

High-reliability organizations (HROs) are identified as industries with a high risk of safety events and personal harm due to the catastrophic consequences that can occur when something goes wrong. HROs include the airline industry, nuclear power plants, and healthcare. These industries include extraordinarily complex processes with interdependent relationships that require strong teamwork. When a process fails, the results are commonly loss of life. Understanding the significance of the loss of life, these organizations must be highly reliable in everything related to safety. Therefore, HROs have become fixated on the risk of failure and how to prevent failure. Through investigations into significant accidents and events, organizations have learned there is always an element of awareness before the accident, so organizations are now focused on learning to identify these risks and then mitigating those risks to prevent the incident [34].

The Joint Commission identifies three pillars of high-reliability organizations as

1. Leadership committed to zero harm

2. Safety Culture

3. Robust Process Improvement® (RPI) [35].

HROs must begin with the first pillar of these three pillars, a leadership committed to zero harm. Leadership must be committed to zero harm and possess the characteristics required to build trust with the staff and throughout the organization. Building trust can be challenging and will take time. Trust is simply consistency over time. When staff consistently see leadership engaged, listening, and responding, they will begin to believe that leadership is committed to zero harm and supporting the staff.

One method to measure if staff trust leaders is through reporting. This component is part of the second pillar, a safety culture. All HROs must have a reporting system that allows staff to share events and, more importantly, report possible hazards or unsafe conditions. For an organization to become highly reliable, it must move from reactive to proactive. This approach can only be accomplished when leaders listen to the frontline providers [36]. It also means including members who designed all processes and were aware of unsafe conditions and failures. Some refer to this situation as the ‘black swans.” This term denotes the black swans on the west coast of Australia that were unknown to the Europeans before they visited this location. While the Aboriginal people were always aware of the black swans, outsiders did not even know of their existence. This metaphor applies to an HRO; if leaders do not know risks exist, they are not listening to those who are aware of them. So, one could theorize that all events are preventable if leaders only talk to the right people [37].

This preamble leads to the third pillar of robust process improvement. Since the ‘To Err is Human: Building a Safer Health ‘System’ publication in 1999, healthcare has embraced quality improvement methodologies. However, acknowledging the methodologies is not enough. The organization must implement the known best practices of change management, lean methodology, and six sigma. Robust Process Improvement (RPI®) is a blended set of strategies, tools, methods, and training programs incorporating all three best-known practices to improve clinical outcomes and business processes. Of these three, “change management” is defined as a systematic way to implement and sustain good solutions, and it is the one component that can prevent the sustainment of any improvement, particularly if people do not easily accept, or even resist, good solutions regardless of their intentions. Dr. Chassin, President of the Joint Commission, stated, “Process improvement in healthcare ‘isn’t rocket science. It’s much more difficult than that because rocket science involves getting machines to behave as you want them to. With process improvement, you have to change the behavior of people” [35].

Process improvement also includes an effective communication network to ensure sustainable control plans, close the communication loop to all stakeholders [38], and a repository of lessons learned to prevent repeat occurrences. This approach addresses complex problem-solving with a systematic, data-driven approach.

To become proactive, an organization needs leaders who can build trust with staff and encourage them to report all risks. However, the reports must be accompanied by feedback to the staff who reported them. This feedback and loop-closure is the only way to ensure the reporters witness improvement. The reporting system is the life cycle of an HRO: trust, report, improve, as demonstrated in Figure 1 [39]. Without improvement and communication circled back to staff, each unanswered report will erode the trust that someone will respond. Over time, the lack of trust will erode the culture of the organization, and the element of high reliability will be lost.

Figure 1.

The life cycle of high reliability begins with building trust that encourages reporting of events and unsafe conditions. That reporting leads to improvement, reinforcing trust. This life cycle supports the commitment to zero harm by having a safety culture and continuous process improvement.

The healthcare setting has become a complex environment where operations are high-risk and require highly effective solutions and high interdependence of various aspects of organizational performance to prevent failure. HROs are mindful organizations that place significant effort into developing a culture of constant awareness of the possibility of failure. This culture leads to “collective mindfulness,” where all workers look for and report minor problems or unsafe conditions, preventing severe events [39]. Five basic principles characterizing an HRO can be divided into two groups: 1) anticipatory action and 2) containment. These two major groups have been described graphically in Figure 2. Both groups place patient safety as the framework with which to work. The anticipatory action includes a. preoccupation with failure consisting of driving a culture to zero harm and addressing minimal risks or events; b. reluctance to simplify by striving to understand all events and diving into the root causes to find solutions; c. sensitivity to operations by being conscious of strong correlations between people, processes, and systems impacting the outcome. The containment actions include a. commitment to resilience, where past events are used to learn, grow, and improve processes to improve the system; and b.deference to expertise, where insights from staff with pertinent safety knowledge are embraced.

Figure 2.

High-reliability organization (HRO.) principles. The five principles of organizational mindfulness are the core of HROs. These fundamental principles include anticipation (preoccupation with failure, reluctance to simplify, sensitivity to operations) and containment (commitment to resilience and deference to expertise) [40].

2.3.2 Introducing human connection

Virtual health care requires effective and compassionate human connection for quality health care delivery [41]. Several research-based tips for enhancing human connection in the virtual healthcare setting have been described by Cooley et al. [42]. Some recommendations include A. Being present; demonstrating focus, interest, and curiosity; reducing distractions and interruptions during virtual interactions; B. Identifying needs; asking open-ended questions and finding preferences and expectations, goals, and priorities; C. Listening; attending to verbal and nonverbal signals, reflecting, recapping main points, and verifying understanding; D. Responding with empathy; recognizing and affirming emotions, expressing support and compassion, and giving hope and reassurance; E. Sharing information; providing clear, brief, and relevant information, using simple language and visual aids, and encouraging questions and feedback.

These tips can help improve the personal quality of virtual communication by video or phone and can be helpful for patients and colleagues. Furthermore, other sources recommend balancing digital innovation and human connection by incorporating personal interaction in health care, such as developing a human-centered culture that values and rewards personal connection and collaboration [43]. Using technology to enhance, not substitute, human abilities and relationships. Offering training and support for health care providers and patients to use virtual health technologies efficiently and comfortably [41].

2.3.3 From H.R.O. To culture of safety

1. Tangible to front healthcare staff

2. Resonance of practice on a day-to-day label

3. Technology in the new workforce

4. Difference in mindset and understanding in communication in the new generations

5. Tread of technology

Understanding how technology has helped and hindered current healthcare practices is critical for healthcare leaders [44]. With the current workforce growing up with technology, there has been a disruption in the expression of empathy and an alteration in society’s communication patterns [45]. Given that effective, emotionally intelligent conversations are not natural for people, training for the workforce with the behaviors necessary to develop emotional intelligence and digital empathy [46]. The leaders are challenged to support safety while balancing accountability through a fair and just culture. This gap in quality is countered by the emergence of AI to aid in the level of excellence while fostering more effective and efficient delivery of patient care. Conversely, the older, more experienced staff are comfortable with the soft skills of personal interactions and feedback. This leaves leadership with the blend of the younger workforce with the technical skills to support the emergence of AI technology and the older workforce with the soft skills of human interactions to support teamwork.

The other factor of technology now included in healthcare is the ever-growing population of virtual staff [47]. Team building activities with virtual staff are a requirement to ensure safety and job satisfaction [48].

2.3.4 Humanizing back-2-basics: Reverting to foundational best practices. Machines do not care. People care

1. Onboarding Process and Expectations

   The SARS-CoV-2 pandemic forced organizations to convert to a virtual onboarding process to quickly get staff to a productive status [49]. While this provided timing flexibility and increased efficiency, it also reduced the efficacy of onboarding for a safety culture. In health care, the primary factor is human interaction. In an organization based on human interaction, removing that interaction prevents the organization from setting proper expectations for its safety culture.

   From the first day of employment, the organization is responsible for providing professional behavior expectations, compliance with policies, and establishing a fair and just culture. It is not easy to convey the significance of these expectations without solid communication [36]. These expectations were established as best practices years before the availability of virtual options [47]. Organizations must return to at least some portion of onboarding occurring in a face-to-face setting if leadership desires the ingrained safety culture necessary to prevent harm [50].

2. Safety behaviors

   Safety is the cornerstone of healthcare facilities. A safe environment requires identifying behaviors demonstrating professional ethics and the organization’s culture and environment [36]. These behaviors should be established at each organization according to the mission and values of the organization. Additionally, the behaviors should be universal to clinical and non-clinical staff. Some examples of safe behaviors include paying attention to detail, speaking up, being respectful, and supporting each other. Each of these behaviors applies to all roles within the organization and contributes to preventing safety errors. The ‘leadership’s behavior directly indicates the organization’s safety culture. If the ‘leader’s attitude includes blaming or excessive questioning, the safety culture will diminish, and an environment of fear will grow [36].

   Thus, it is essential to adopt safety behaviors that will be timeless. Staff are most successful when the expectations are set and do not frequently change. This approach applies to behaviors in the work environment. When professionalism is established during the onboarding process, it is easy to sustain that level. It becomes much more challenging to correct unwanted behaviors that have been allowed.

   As discussed later in the chapter, leadership must balance safety with accountability. Senior staff members should clearly show expectations of behavior and accountability to new members starting the first day of employment. It is critical to identify the appropriate response when expectations are not met. This approach is considered accountability, not punishment. Having a candid conversation and providing feedback is more valuable and productive than lighthearted comments [51]. However, if staff are not aware of expectations or the response plan when these expectations are not met, accountability can feel punitive. High levels of psychological safety, as evidenced by transparent conversations, increased safety reporting, and surveys, resulting in a safety culture, will prevent this feeling for staff.

3. Communication

   When discussing communication as a best practice, we must identify the essential components of communication. Those include speaking and listening. Inherently, people will communicate with confidence on topics of familiarity. Some speak well in individual conversations, while others are confident in a group. In either case, it is the responsibility of the speaker and listener to share information. Speakers need to use clear and concise language. Listeners need to have the psychological safety to speak up.

   Challenges for speakers and listeners can range from terminology to culture to learned behaviors. Communication skills can be improved with the appropriate level of emotional intelligence. When a speaker can recognize the listener’s facial expressions and body language, they can adjust the conversation to ensure comprehension. This communication can be accomplished through sincere questions or pausing to allow the listener to speak up. At this moment, the responsibility shifts to the listener to identify whether the information is incomplete or lacks understanding. Active listening is a familiar concept. However, active listening is not sufficient to foster effective communication. The listener needs to go beyond and listen to understand. When all the people in a conversation are listening to understand instead of just absorbing the content, there is an increase in the efficacy of the conversation [51].

   One might think that all organizations are proficient in communication since it is a fundamental skill. Often, safety incidents are caused by communication problems. Improving communication can significantly reduce incidents and enhance safety [52].

4. Handoff

   To achieve HRO status, complex organizations need effective collaboration among their teams. When considering handoffs in that context, a strong team’s primary function is to provide effective handoffs to maintain a level of excellence and continuity [53]. Many of the HROs provide services that operate all day hours, requiring the team to transition from one shift to another consistently. Additionally, complex work requires handoffs between stakeholders for diverse types of work, including projects, proposals, improvements, etc. This essential component of work should not be assumed or overlooked. To have an effective handoff, the teammates must be intentional and mindful and operate with a level of standardization that will provide a firm foundation of operations.

   When handoffs are incomplete or poorly facilitated, the consequences can be catastrophic. Imagine the medication being delivered incorrectly, the inclement weather notice affecting the flight patterns not being shared, or the equipment malfunction that changed the nuclear power level but was not communicated. Any of these events could have been prevented with an effective handoff. Remember that an effective handoff requires articulate communication and techniques to ensure a good handoff. These techniques include the teach-back method, following up with a written form to verbal communication, or utilizing checklists during the handoff. Implementing a standardized method of the handoff process reduces the risk of error [53].

5. Mutual Support

   Mutual support may be considered one of the safe behaviors an organization would like to identify as an expectation. While support may seem obvious, this type of support is not simply being kind to your colleagues but developing a spirit of teamwork that transcends getting the job done. As technology continues to emerge, we know the human component of most organizations will continue to be the greatest resource. As such, humans instinctively need to belong and feel valued by their organizations and teams.

   It is essential to recognize that a component of psychological safety is learning to be vulnerable and take interpersonal risks to speak up. Mutual support is what allows someone to take that risk. Colleagues must feel heard and understood about the topic and their feelings [51]. When someone feels supported, they can learn, test possibilities, and grow in their work environment, leading to job satisfaction and longevity within the organization.

6. Figure 3 summarizes the fundamental best practices described, which detail the onboarding, clearly identified expected behaviors and establishment of a fair and just culture aiming for effective teamwork.

Figure 3.

In-person training creates a human connection among teams and the organization. Setting expectations and articulating the components of the professional environment supports new staff. Establishing a fair and just culture will encourage and promote a teaming environment.

2.3.5 From the beginning: Safety huddles

How safety huddles started in healthcare

Safety huddles are short, daily gatherings where frontline staff and leaders talk about safety concerns and exchange information. They improve communication, collaboration, and problem-solving across units and departments and foster a safe culture and continuous learning [54, 55].

The origin of safety huddles can be traced back to the aviation industry, where crew members gather before each flight to review the flight plan, weather conditions, potential risks, and contingency plans [56, 57, 58]. This practice was adopted by other high-risk industries, such as nuclear power, military, and firefighting, to enhance situational awareness and prevent errors.

Safety huddles in healthcare originated in the intensive care unit (ICU) setting, where they helped to manage care transfers, track patient conditions, and detect safety risks [59]. The advantages of safety huddles include improved teamwork, reduced length of stay, lower mortality rates, and fewer adverse events [60].

Safety huddles gradually expanded to other clinical settings and layers of the organization, from hospital units and offices to health centers and health systems [59]. Safety huddles became essential to patient safety programs and quality improvement efforts, such as the Institute for Healthcare Improvement’s 100,000 Lives Campaign and the World Health Organization’s Surgical Safety Checklist [61].

Safety huddles have become a familiar and effective way to improve patient safety and quality of care in healthcare settings. They allow staff to exchange information, voice issues, learn from mistakes, and acknowledge achievements. They also let leaders hear from frontline workers, give feedback, and distribute resources. Safety huddles can help build a positive and supportive work environment where staff feel appreciated, respected, and enabled [59, 62, 63].

a. The use of scripts

Scripts are helpful for safety huddles, as they help maintain consistency and efficiency in meetings. Scripts offer a structured huddle format, which can help participants remain focused and on track [64]. They also help ensure that all critical topics get discussed and everyone has a chance to participate. Scripts can be created locally and adapted to the organization’s specific needs [65]. They usually include a concise introduction, a review of safety concerns, a discussion of any recent incidents or near-misses, and any action items from previous huddles [66]. With the use of scripts, safety huddles can be more successful in finding and resolving safety issues, enhancing teamwork, and fostering a culture of safety.

b. Efficiency and effectiveness

Safety huddles can improve the efficiency and effectiveness of communication, collaboration, and problem-solving among healthcare teams. A recent article states that safety huddles are an effective way for healthcare teams to communicate, evaluate their performance, prevent safety issues before they happen, hold each other accountable, and ensure that safety measures are embedded in the system [59]. Huddles involve and motivate frontline staff in finding problems and create a culture of teamwork and quality, which helps to provide safer care [67]. Huddles have improved patient safety in various areas such as wrong-site surgery, medication errors, poor hand hygiene, unrecognized clinical deterioration, serious safety events, and near misses [66]. Huddles enhance individual and collective responsibility for patient safety, set a regular time during the workday or shift to focus on care coordination, enable quick and direct clarification of issues, reduce distractions during the rest of the workday, and support a culture of empowerment and collaboration in healthcare teams [55].

Data sharing

Data sharing is a crucial part of safety huddles in healthcare. Lamming, Montague, Crosswaite et al. describe how safety huddles can help prevent and resolve safety issues related to electronic health records [68]. The authors describe how safety huddles can be a valuable strategy to identify and mitigate safety concerns and improve teamwork. By sharing data during safety huddles, healthcare teams can identify potential safety hazards, track progress, and develop targeted interventions to improve patient safety and quality of care. This group recommends adjusting safety huddle fidelity criteria to include factors most valuable by frontline staff. describes the main content discussed during safety huddles.

c. Ownership, accountability, and leadership

Safety huddles in healthcare require ownership, accountability, and leadership presence. The Washington State Hospital Association suggests that leaders from different hospital or health system departments gather daily to share what happened in the last 24 hours and decide what actions are needed to address critical safety issues [55]. Safety huddles help ensure leaders are aware of safety concerns and accountable for addressing them (Table 1). Ownership of safety huddles can be shared among frontline staff and leaders, with each member taking responsibility for identifying and addressing safety concerns. One of the key factors that can enhance the effectiveness of safety huddles is leadership presence. However, leadership presence does not mean leaders should dominate or direct the safety huddle. Instead, leaders should act as facilitators, supporters, and role models for staff, encouraging open and honest communication, feedback, and problem-solving.

Data Type	Description
Patient safety incidents	Discuss any patient safety incidents since the last huddle, including near-misses, falls, medication errors, and other adverse events.
Staffing levels	Reviewing staffing levels and identifying potential staffing issues that could impact patient safety.
Equipment and supplies	Discuss equipment or supply issues impacting patient care, such as malfunctioning equipment or low inventory levels.
Infection control	Reviewing infection control practices and identifying any potential issues or concerns.
Patient flow	Discuss patient flow and identify any bottlenecks or delays that could impact patient safety or quality of care.
Quality metrics	Review quality metrics, such as readmission rates, patient satisfaction scores, and compliance with clinical guidelines.
Staff training	Discuss staff training needs and identify gaps in knowledge or skills that could impact patient safety.

Table 1.

Safety huddles in healthcare.

d. Closing the loop

Creating systems to close the loop and communicate with staff about how the issues discussed are addressed is paramount [55]. It is recommended that healthcare organizations use multiple Excellence Canada, it is recommended that healthcare organizations use multiple mechanisms to transfer learning from the analysis between care units through memos, storytelling, huddles, team-based peer review rounds, journal clubs, patient safety workshops using case-based learning methods, and newsletters (Table 2).

Share what was learned internally
Share what was learned from the analysis with internal stakeholders	Identify the key stakeholders who need to be informed of the outcomes, such as patients, families, staff, managers, and external agencies.
	Determine the best mode and timing of communication, such as face-to-face, phone, email, or written reports, and consider the urgency, sensitivity, and confidentiality of the information
	Communicate the analysis findings to internal stakeholders to ensure they are aware and can share their input.
Interface recommended actions	Provide clear and accurate information about what happened, why it happened, what actions were taken, and what changes were implemented or planned to prevent recurrence.
	Communicate recommended actions to all stakeholders,
	Invite questions and feedback from the stakeholders, and listen empathically to their concerns, emotions, and suggestions
Communicate results of recommended actions	Document the communication process and outcomes and report any unresolved issues or new learning to the appropriate authority or committee.
Engage with the patient/family in this process	Sharing stories can foster trust, learning, and change among staff and leaders, and promote a culture of safety and transparency.
	Respect the patient/family’s wishes and preferences about sharing personal or confidential information and get their permission and consent first.
	Discuss the pros and cons of sharing experiences, such as enhancing learning, influencing policy, providing feedback, increasing empathy, or triggering emotions.
	Support and resource the patient/family to share their experiences in several ways, such as storytelling, surveys, interviews, focus groups, committees, or events.
	Thank and appreciate the patient/family for their courage and contribution in sharing their experiences and update them on the outcomes and impacts of their sharing.
Communicate what has been implemented and the results	Review the recommended actions, their status, and their impact. Maintain transparency and trust by being honest if plans have changed and sharing why.
Use multiple mechanisms that transfer learning from the analysis between care units	Follow the organizational policies: use various methods that share the learning from the analysis across care units such as memos, storytelling, huddles, team-based peer review rounds, journal clubs, patient safety workshops using case-based learning methods and newsletters.
Maintain a record of communication	Keep track of communication to make sure all relevant stakeholders are informed.
Recognize that sharing is a dialog	Acknowledge that sharing is a conversation (not a one-sided transfer of information) and is continuous (more than once). Promote respectful, transparent communication about the outcomes of the incident analysis at all levels of the organization.
Share what was learned externally
Use alerts, advisories, and repositories	Explain the situation, causes and reasons, steps followed, and outcomes.
Develop an external communication plan	Communicating to the public the steps taken, their results, pertinent background, and context information, and respecting the patient/family’s preferences for sharing or not sharing their viewpoint
Prepare staff and the patient/family	Consult with the staff and the patient/family beforehand about what, when, and how information will be communicated.

Table 2.

Proposed closing-the-loop strategies.

Leaders should also demonstrate their commitment to patient safety by following up on action items, providing resources and support, and recognizing and rewarding good practices. By having leadership presence in safety huddles, healthcare teams can ensure that safety concerns are addressed promptly and effectively and that everyone is accountable for patient safety (Table 3).

Analyze multiple incidents to find out common system problems.

Check if the lessons learned can be transferred to other processes in the organization.

Report any significant risks and/or best practices to senior leadership or other relevant committees.

Integrate findings with those from other systems to help reveal themes/patterns and speed up learning.

Evaluate the incident management process to find out strengths and areas for improvement, considering the analysis time, the quality and efficiency of the suggested actions, organizational guidance and supporting structures, communication, and processes for spreading the learning, and the experience of those who participated in the incident and the analysis.

Supporting Research and Innovation. Encourage and facilitate research and innovation projects that aim to learn from incidents and improve patient safety.

Table 3.

Expanding the role of safety leaders’ involvement in safety huddles.

2.4 Leadership and psychological safety

2.4.1 Leadership characteristics and humility

Leadership and psychological safety are critical components of a healthy and productive work environment. According to a Frontiers in Psychology article [69], unpretentious leadership can positively influence follower attitudes and behaviors, such as job satisfaction, psychological empowerment, and engagement. The study explores the relationship between unpretentious leadership and follower creativity. It describes that psychological safety is critical in linking unpretentious leadership and follower creativity. This finding is consistent with most of the previous work that shows the mediating influence of psychological safety on the relationship between leadership and psychological safety [70].

A study explores the relationship between baseline leader humility and team psychological safety by examining the roles of humility variability and attractor strength. The study found that consistency reinforces, while inconsistency weakens, the effect of leader-expressed humility on team psychological safety. The findings also reveal that self-other agreement relates to the consistency of leader-expressed humility, depending on the level at which the (dis)agreement occurs. The study indicates that the results of unpretentious leadership rely on the leader’s level of humility, how stable his/her humility is, and how powerful the attractor is [71].

2.4.2 Behaviors associated with building trust

As previously stated, trust is a critical component of the life cycle of a high-reliability organization. That trust must start with the leaders and be built through the staff to maintain a safe culture. Leadership styles vary, and while variation can bring richness to the organization, certain behaviors must be embraced to elicit trust. Servant or ethical leadership are terms used to describe these behaviors. Operating with sincerity, integrity, and compassion are all servant and ethical leadership elements. While transformational leadership is visionary in moving the organization forward, elevating the needs of the staff above themselves is a key marker of a servant or ethical leader. Combined with balanced and fair decision-making, it will build trust within the organization. Staff must feel the leaders are concerned about their well-being and genuinely have good intentions to support them [72], and can be demonstrated through transparent communication, investment of resources to help the staff, or personally engaging with the staff without a predetermined agenda. Leadership must be visible and approachable. By feeling connected to leadership, staff are intrinsically motivated to perform and remain engaged.

2.4.3 Components of psychological safety

Psychological safety in the work environment is where all staff feel comfortable expressing themselves by sharing ideas, concerns, and mistakes. This feeling comes from having confidence they will not be humiliated, punished, or blamed when speaking up [73]. Psychological safety creates transparency in communication and operations, which is critical to a high-reliability organization (HRO). The healthcare industry is a prime example of an HRO. In healthcare, the staff must be able to speak up to prevent medical errors. Two major types of errors are errors of omission that occur as a result of actions not taken, and errors that occur because of the wrong action taken [74]. These two examples illustrate the necessity of having a safety culture that embodies psychological safety.

The challenge is in creating and sustaining a culture of safety. HRO senior leadership has long understood the importance of a safety culture and its impact on the work environment, patient outcomes, and quality of care. However, permeating that understanding throughout the ‘organization’s workforce is challenging. With the advancement of technology, our workforce has become more accustomed to electronic communication versus face-to-face interactions. While efficient, this type of communication erodes the humanity of relationships, investing in those relationships and maintaining a skillset to support psychological safety in professional relationships. Yet these components are precisely what is needed to have psychological safety. Conversations are the cornerstone of an organizational culture. One can ascertain the organization’s psychological safety level by listening to conversations among colleagues. Because psychological safety is being able to speak candidly, leaders and staff must have more than just sharing information. Leaders must understand their staff members’ emotions, values, and attitudes that pertain to daily work and respond accordingly [51]. Active listening is no longer adequate for creating psychological safety. Listening requires a level of understanding that makes conversations more complex and, therefore, translates into a more developed skillset of interpersonal communication.

We must understand the natural human behavior tendencies to develop the professional relationships needed for psychological safety. Dr. Amy Edmonson refers to these characteristics as interpersonal risks. It is one’s conscious or subconscious reaction to prevent looking stupid, incompetent, or disruptive [73]. This behavior is typically learned early when others around us begin to respond when we speak up. Think back to your earliest memory in the school of asking a question, and others laughed or criticized your question. Instantly, the feeling of inadequacy or incompetence created fear of taking that interpersonal risk again. This fear of inadequacy or incompetence can follow us into adulthood. In our professional careers, and even more so in health care, we set an expectation of ourselves to have the answer, execute the skill, or perform as if we have a natural ability. This expectation often prevents us from asking questions, seeking feedback, or being innovative for fear of how our colleagues will view us. When fear exists, we will remain silent when we should and need to speak.

As a leader, it is important to understand your behaviors in order to understand your ‘staff’s behavior. When we think of a lack of psychological safety, it is natural to associate this problem with lower-level staff. However, this problem can be experienced at the highest levels of an organization; thus, there is a need to have psychological safety created at the top and then cascaded throughout the organization. But how do you know if psychological safety exists in your organization? The most common method of measuring psychological safety is through a survey. Some regulatory requirements include conducting a patient safety culture survey. Several psychological safety surveys are available, which include questions about speaking up in the work setting, adequate disagreement resolution, a culture of learning from errors, and the ease of discussing these events [75].

2.4.4 Building the framework

Leaders build psychological safety by setting the stage, inviting participation, and responding productively. This framework is summarized as The ‘Leader’s Tool Kit and described by Amy C. Edmonson in her book, “The Fearless Organization” [73]. In her message, she offers practical guidance for organizations, healthcare institutions, and teams to succeed in the present technological environment, developing a culture where interpersonal interactions do not suppress, ridicule, silence, or intimidate any member. Leaders are role models by asking for help, using emotional intelligence, and discouraging behaviors leading to threatening psychological safety (Figures 4 and 5).

Figure 4.

Performance standards related to psychological safety. Comfort zone: Collegial and open, not challenged. A lack of initiative characterizes teamwork. Learning zone: Collaboration and a learning environment, high performance, excitement in getting involved in complex and innovative ideas. Apathy zone: Physical presence at work without deep involvement, self-preservation, or overexertion. Anxiety zone: Reluctance to offer new ideas, attempt new things, or ask for help. Mistrust. (based on [76]).

Figure 5.

‘Leadership’s role in enhancing psychological safety.

There are various ways to enhance psychological safety and enable a learning process in healthcare organizations, such as showing supportive leadership behaviors, building connections among team members, and using supportive organizational practices [77]. A different strategy emphasizes encouraging open dialog, scheduling leader presentations on speaking up, building a culture of trust, and making team members feel valued [78]. The common thread seems to be the importance of leadership involvement and their messaging while building an environment of trust and respect. Trust becomes ‘visible’ when team members willingly speak up and feel safe. However, building trust takes time and commitment from the leader. It is particularly challenging for teams to work remotely or for managers to lead staff in various locations. It can be done in a variety of ways, including scheduling and keeping one-on-one meetings, following through on commitments, promoting leadership transparency, and simply being available and present. If staff feel they have psychological safety, they will feel empowered to try new things, innovate and avoid ‘workarounds’ [73]. This can be seen when coaching quality improvement teams through their quality project work. Generally, project teams may not entertain the idea of becoming involved in quality improvement work without the autonomy to carry the project through to completion. Nor will they be inclined to produce innovative interventions if they believe they will not receive the buy-in or support required to implement. These concerns can be addressed early on by encouraging the selection of a project sponsor who will provide support throughout the project, remove barriers as needed, and help the team gain buy-in for their interventions [79]. Project sponsors are just one way to help reinforce a safe culture of creativity for project teams. Teams can also be encouraged to communicate often about their quality project work and incorporate change management techniques throughout the project lifecycle. Quality improvement efforts should not be considered additional work. Rather, once staff understands how to apply a structured problem-solving approach to improve outcomes, safety, and experience, the approach can be incorporated into daily work.

2.4.5 Balancing safety with accountability

1. How to respond to near misses: Near-miss events describe events where no actual harm comes to the patient. However, they represent an opportunity to improve patient safety and enhance communication with patients and families about disclosing medical errors [80]. An ideal transparent voluntary reporting system should enable structured reporting, collection and analysis of the data, and subsequent learning from these events when they are examined. A reporting system should be simple to access for reporting and have loop closure with the reporting individual to enhance satisfaction with the events that are addressed [81].

2. How to respond to never events: Preventable medical errors leading to a significant injury or death of patients are termed never events [82]. These events have been categorized into seven distinct groups. (Table 4). Because these events seriously affect patient safety and quality of care in hospitals, developing safety mechanisms to abolish their occurrence in the medical system has become a priority. Several adverse events registries have been designed to determine their frequency and include mandatory reporting, followed by methodology recommended by the Institute of Healthcare ‘Improvement’s Global Trigger Tool [83]. A systematic review specifically addressed the occurrence of the most common never events worldwide and by specialty, describing 60% of them as largely preventable [84], and the most common surgical ones include surgery on the wrong body part or patient and the wrong surgical procedure. Operating room checklists have become engrained in surgical practice to avoid these types of events [85].

   One way to decrease the emotional impact of adverse events on healthcare providers is to provide the directly affected individual(s) with timely and adequate support, including peer-to-peer counseling, debriefing sessions, psychological consultations, or employee assistance programs. Healthcare organizations should foster a culture of care and compassion for their staff and a culture of safety and learning. The burnout risk in healthcare providers can be mitigated by acknowledging the human factors contributing to medical errors and promoting resilience and recovery among healthcare workers [26].

   Ultimately, a strategic change in the healthcare system has been recommended to decrease, and ideally avoid, all never events. A systems approach to patient safety includes establishing and maintaining a safety culture, centralizing and coordinating oversite of patient safety, creating a standard set of safety metrics leading to meaningful outcomes, increasing funding for patient safety research and implementation science, addressing safety across a care continuum, supporting health care workforce, partnering with patients and families and ensuring that technology is safe and directed to optimize patient safety [86].

Surgical or procedural	Surgery on the wrong part of the body; Surgery or invasive procedure on the wrong patient; Wrong surgical or invasive procedure on a patient; Unintended retention of foreign object; Intraoperative or immediately postoperative death
Product or device	Patient death or serious injury associated with contaminated devices or biologics; Patient death or serious injury associated with the misuse or malfunction of a device; Patient death or serious injury associated with intravascular air embolism
Patient protection	Discharge or release of a patient/resident of any age unable to make decisions; Patient death or serious disability associated with patient elopement; Patient suicide, attempted suicide while being cared for in a health care facility
Care management	Death or serious injury related to medication errors, unsafe administration of blood products, maternal death with labor or delivery in low-risk pregnancy; Stage 3, 4, or unstageable pressure ulcers; Falls leading to death or serious injury; Failure to follow up or communicate laboratory, pathology, or radiology results
Environmental	Death or serious injury associated with electric shock, oxygen use, burn incurred from any source in the health care setting, use of restraints or bedrails
Radiological	Death or serious injury of a patient or staff related to the introduction of a metallic object into the MRI area
Criminal	Care is ordered by or provided by a physician, nurse, pharmacist, or other licensed healthcare provider impersonator.

Table 4.

Never events categories [82].

2.4.6 Navigating safety: Evolution or revolution?

1. Safety 2.0

   Safety 2.0 is a term that describes a new way of looking at safety management that emphasizes learning from what works well instead of what goes wrong. Safety 2.0 assumes that everyday performance variability enables the adaptations necessary to deal with changing conditions so things go right [87]. Safety 2.0 also acknowledges that humans are a resource essential for system flexibility and resilience rather than a cause of error and risk [88]. Safety 2.0 aims to understand how people and organizations achieve their goals under different situations and how to support and improve their performance [89]. Safety 2.0 differs from Safety 1.0, the traditional approach that focuses on accidents and tries to prevent bad outcomes by eliminating or minimizing hazards, errors, and failures.

2. Health 4.0

   Health 4.0 is a concept that describes the use of Industry 4.0 technologies, such as artificial intelligence, big data, cloud computing, the internet of things, and blockchain, in the health care sector (Table 5) [90]. Health 4.0 has the goal of improving the quality, accessibility, efficiency, and personalization of healthcare services, as well as of empowering patients and healthcare professionals [91].

   The relationship between Health 4.0 and safety is a crucial and complex issue, as it involves both possible advantages and challenges. On the one hand, Health 4.0 can improve the safety of patients and health care workers by facilitating better diagnosis, treatment, monitoring, and prevention of diseases and injuries and by minimizing human errors, waste, and costs [91]. On the other hand, Health 4.0 can also create new risks and threats to safety, such as cyberattacks, data breaches, ethical dilemmas, legal liabilities, and social inequalities [93].

3. Virtual workers

Stage	Description
Health 1.0	This was the traditional healthcare system, which mainly reacted to health problems and provided care in hospitals and clinics. The emphasis was on curing diseases rather than preventing them, and there was little use of technology.
Health 2.0	In this stage, electronic health records and health information exchanges were introduced, and digital data started to be used, but still within the limits of the traditional healthcare model.
Health 3.0	In this stage, technology became more integrated into patient care, with a focus on personalized medicine and patient involvement. Technologies such as telemedicine, mobile health apps, and wearable devices became more common, allowing for more data-driven and patient-focused care.
Health 4.0	Based on the previous stages, Health 4.0 is marked by a fully integrated, digital healthcare system. It uses advanced technologies like AI, big data analytics, and the Internet of Things to provide proactive, predictive, and personalized healthcare services. The aim is to achieve a smooth patient experience and improved health outcomes through the combination of cyber and physical systems.

Table 5.

Steps towards a more interconnected, efficient, and patient-focused healthcare system, from health 1.0 to 4.0. [92].

Virtual work enables employees to do their work from a different location, such as home or a remote center, using technology to connect and cooperate with their co-workers and customers [94]. Virtual work can provide enhanced safety, flexibility, productivity, and innovation advantages (Figure 6) [95].

Figure 6.

Adopting a Proactive Approach to Safety Management in Health 4-0. This figure illustrates the multifaceted strategy for enhancing safety in healthcare by promoting a culture of safety, encouraging inclusive participation, ensuring data security, and addressing community implications through standards, regulations, and education.

Virtual healthcare employees must feel included for their well-being, engagement, and performance. Some ways to achieve these goals are: The use of various communication tools, such as video calls, chat apps, and social media, to create a sense of connection and belonging among remote workers [96]. Have regular check-ins with remote workers, individually and as a team, to give feedback, support, and recognition [96]. Include remote workers in decision-making and goal-setting processes, enabling them to make choices and take initiative [97, 98]. Acknowledge and appreciate each remote ‘worker’s contribution publicly and privately and provide opportunities for learning and growth [97].

Support remote workers in sharing their values, interests, and personal stories and build workplace friendships through virtual social events and activities [97]. Be aware of time zones and cultural differences when scheduling meetings and events and ensure remote workers can access information and resources equally [99]. A graphic representation of the evaluation and implementation of virtual work is described in (Figure 7).

Figure 7.

Re-designing Virtual Work in Health 4.0 - This figure outlines a comprehensive approach to re-evaluating and enhancing virtual work within healthcare settings. It emphasizes the importance of assessing the current state, defining clear vision and goals, designing effective work processes and policies, evaluating virtual work solutions, and fostering continuous improvement and innovation.

3. Conclusion

In conclusion, this chapter has provided an overview of the current trends and challenges in the healthcare sector and how they affect patients’ and providers’ safety and well-being. It has also discussed the components of high-reliability organizations and how they can create a culture of safety and human connection in the face of uncertainty and complexity. Furthermore, it has explored the concept of Safety 2.0, which emphasizes learning from what works well instead of what goes wrong, the relationship between Health 4.0 and safety, and the challenges and opportunities of virtual work. Lastly, it has explained the importance of unpretentious leadership and trust in building psychological safety, which is the feeling of speaking up without fear of negative consequences, and the best practices for onboarding new employees and setting expectations for safety behaviors.

This chapter aims to provide valuable insights and recommendations for healthcare leaders, managers, and workers who want to improve the safety and quality of their services and their own mental and emotional health. However, it is essential to acknowledge that there is no one-size-fits-all solution for achieving these goals and that each organization and individual needs to adapt and thrive in the dynamic and demanding healthcare environment. Therefore, we encourage readers to reflect on the concepts and ideas presented in this chapter, apply them in their contexts and situations, and seek feedback and learn from others.

Notes/Thanks/Other declarations

We want to thank our mentors, colleagues, and learners who inspired us to seek ways to improve our current medical system. Most importantly, we are grateful to our patients, from whom we have learned how to become better healthcare professionals and best serve their needs. Without this collaboration, this chapter would have been incomplete