A culture of safety: A critical atmosphere for performance improvement in trauma

Jan. 09, 2018

Table of a just culture of safety A just culture of safety

A just culture of safety — what is it? Graphic reprinted with permission from The Canadian Medical Protective Association.

Trauma care shares a common principle with the airline industry and nuclear power plants.

In each of these high-reliability service provider sectors, the concept of a culture of safety is crucial, wherein organizations regularly facing high risk constantly strive to achieve minimal to no errors in their performance.

"A culture of safety is kind of a general term that encompasses an entire organization, program or unit within an organization," says John Cumming, M.D., M.B.A., vice president of medical affairs at Hennepin County Medical Center. Dr. Cumming is chair of the American College of Surgeons Minnesota Committee on Trauma, on which several Mayo Clinic Trauma Center surgeons serve. He also collaborated with Mayo Clinic as a guest speaker at a conference it hosted for Minnesota trauma practitioners, Trauma PI Forum Part II: Refining Your Performance Improvement and Patient Safety Program.

"In a culture of safety, you engage all members of the unit, team or organization: They're all engaged to seek issues related to safety, and then they are empowered to either correct those things on the spot or escalate as needed," he says. "It's a whole culture of minimizing adverse events."

In trauma care, the risks are indeed high. Patients seen by a trauma service have by definition already been injured in some way and are presenting to trauma centers, big or small. The risk with trauma patients is that the nature of the injuries often requires immediate action, usually in the form of interventions, which have inherent risks. Additionally, injuries may evolve over time.

"It's pretty self-evident that trauma is a life-and-death specialty, with some patients provided care without which they would die," says Dr. Cumming. "If we look at our real goal — keeping the patient at the center of what we do and minimizing any harm, developing a culture of safety is the answer."

At present, the concept of a culture of safety is not well-developed in medicine, says Dr. Cumming. Rather, health care organizations across the United States are just beginning their journeys into creating this culture, with considerable variation between institutions.

"I would give a shout out to trauma as being further along in that journey than other medical disciplines, as it has had an emphasis on performance improvement (PI) for many years," says Dr. Cumming.

A culture of safety provides the groundwork for the PI process, in which even if patient outcomes are good, clinicians continually strive to improve care.

"PI starts with everybody embracing the culture of safety, which is something The Joint Commission wants us to espouse," says Carol R. Immermann, R.N., Mayo Clinic Trauma Center program manager.

Key elements

Several key elements need to be present in order for a culture of safety to be established at a health care organization. These include:


Employees from the highest levels, including the CEO, must embrace the concept of a culture of safety and feel free to speak up in order for this culture to function properly. Beyond a supportive spirit, a medical center needs to provide resource support.

"There has to be appropriate resource allocation if you want to have an effective process: time in people's workday to review cases, do action plan development and then follow through on the plans," says Dr. Cumming. "There also needs to be transparent discussion about how to improve that."

Just culture

A just culture model recognizes that providers go to work every day with the best of intentions: They go to work with the desire to do the best they possibly can for their patients. Yet, at times, somewhere along the way, either providers are led down a path where they are making incorrect decisions, or there are systems issues that impede the provision of health care services. Problems are viewed as process issues.


Along with a just culture, a culture of safety does not advocate looking for someone to blame when things don't go as planned. As Dr. Cumming states, "If we punish people for making mistakes, then no one will bring their mistakes forward, because they'll fear that they are going to be punished."

Some health care centers really struggle with creating a blameless culture, due to a long-standing culture that's very different from this — a more punitive one, says Dr. Cumming, noting that slowly transforming an organization's culture can be difficult.

"This is not a finger-wagging, tattletale environment,” says Brian D. Kim, M.D., a trauma surgeon and adult trauma medical director at Mayo Clinic in Rochester, Minnesota. "This is a different mindset than most surgeons have — a blame culture type of environment," he says.


In a culture of safety, there are no secret meetings of the elite. This stands in contrast to a long-standing notion in some medical centers that PI and peer review needs to be enshrouded.

"The idea that a bunch of doctors get together to review their care and give an aura that it's special cannot coexist with a culture of safety," says Dr. Cumming. "It's very difficult for some organizations to embrace that idea, but we have to be open with our errors; there should be nothing secret about peer review."


Being able to review events fairly and without bias is crucial to a culture of safety. In order to do so, leadership can de-identify patient cases, keeping specific providers or patients nameless and ageless, so an event review can be as objective as possible and bias against any particular provider can be minimized.

For smaller trauma centers, two options for objective review might include:

  • Changing some aspect of the case under review while keeping the central elements
  • Sending big cases to be discussed at a regional trauma meeting

Flattened hierarchy

While top management of a health care organization needs to embrace a culture of safety, in order for it to be successful, it needs a less hierarchical environment. An atmosphere that goes beyond top-down leadership and hush-hush doctor meetings and moves to a more collegial, egalitarian culture where anyone can have influence or offer feedback is imperative to a culture of safety.

"There are some larger-than-life providers, and people have to be free to speak up even if it's a chair of a division or a world-renowned neurosurgeon," says Dr. Cumming.

Cultural threats

A number of issues may threaten the development of a culture of safety in a health care organization or specifically its trauma unit, such as:

Interdisciplinary or intradisciplinary conflict

When a medical center's divisions don't collaborate well, making remarks such as, "The emergency department doesn't know what it's doing because they are not trauma," or "because they are not surgeons," this erodes a culture of safety, says Dr. Cumming. Within a unit, such as a trauma sector, conflict can lead to blaming, tearing down the culture being developed.

Backward-looking perspective

In order to have a culture of safety, staff needs to spend less time looking at the past and finger-pointing, and more time looking toward the future, discerning what can be learned and improved from events that have transpired.


This behavior is also antithetical to a culture of safety, as it involves looking for and assigning fault to others instead of assuming the best of other staff members.

"This is not about blame," says Immermann. "If there's something we could do better next time, we want to do so."

Steep hierarchy

Over time, this can be broken at a health care organization, though it involves intolerance of blame or retaliation for speaking up, and recognizing those who are bold enough to come forward with issues to be addressed.

"Disciplining the other behavior is also key: If there's a surgeon who is always belittling or demeaning to people who are willing to speak up and really suppressing the culture we're trying to develop, those providers need to get some feedback," says Dr. Cumming. "In my role as the vice president of medical affairs, you can be a family practitioner or you can be a cardiac surgeon — it really doesn't matter to me. I don't care how important you are to the organization. If you are not supportive of our culture of safety, you'll come and have a conversation with me."


The goal of a culture of safety is to improve patient outcomes and reduce harm. A key measure of a well-functioning culture of safety is seeing the number of issues brought forward increase.

"If people see it will be a fair, objective, blame-free and nonpunitive process, they'll bring more issues to the table," says Dr. Cumming. "A culture of safety is forward thinking, not backward thinking: We can learn from the past, but we can't punish the past."

For more information

John Cumming, M.D., M.B.A.