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Voices for Safer Care

Insights from the Armstrong Institute

Coming home

Last week, my family returned from a vacation in Jamaica. The kids had spring break and it was great to get away with them. Upon returning to the U.S. and after clearing passport control, the customs agent said “welcome home.” No doubt they are trained to say this; I hear it every time I travel internationally. Nevertheless, those words always warm my heart and make me smile. They reflect for me a national culture, a set of values and beliefs about how we will behave. Welcome home to the U.S. reminds me that we live under the rule of law, that we are all afforded due process, that we have freedoms to voice our concerns, to practice our religions, to vote.

As we drove home, we rounded the corner and our house came into view. Again warm feelings flooded me. Seeing my home, I reflected on the deeply held beliefs of love, of support and nurturing, of forgiveness, of warmth and comfort—the culture of our home.

Two days later, on Monday, I returned to work, starting as the attending physician in the ICU. As I walked into the ICU, I thought about the culture we have created there, the sets of norms and beliefs that govern behaviors, my largely hidden assumptions about the organization and my colleagues.

Clinicians, when you walk into your clinical or hospital, what kind of culture are you part of? Is this a place where patients are the “North Star,” their needs guiding all of your work? Is it a place where clinicians’ egos are put aside and they focus on what is right rather than who is right, where we commit to practice evidence-based medicine, to work as a team, to continually learn and improve? Is it where staff seek to identify and mitigate patient safety hazards, respect the wisdom of frontline workers and empower them to improve? Is it a place where we see our differences as strengths rather than weaknesses, where we support each other, hold each other’s hands when we are down, laugh and cry together?

If we do, we will improve quality, reduce costs and restore joy in our work. And clinicians can create this type of culture.

We understand these deep aspects of culture though conversations and inquiry into people’s beliefs and assumptions. However we can also measure more superficial aspects of culture through validated staff surveys that seek to understand frontline healthcare workers’ perceptions of safety on their unit. In measuring this culture of safety, we have found that it varies from unit to unit. The ICU has a different culture from the emergency department or the med/surg floor. Indeed, we have found much more variation in culture among units within a hospital than among hospitals. In some units, 100 percent of staff report positive safety culture and in others 20 percent do.

What can you do if your unit’s safety culture is weak? A powerful intervention is to measure safety culture and then feed back results to staff, using the results to start a conversation about how to improve. Envision how you would behave and treat each other if 100 percent of staff reported good safety culture, and discus how to realize that vision.

Every day, every minute, we continuously create culture. The ways in which we choose to act, the ways we respond to conflict and risks, the ways we celebrate successes and mourn failures, the ways we support and understand our colleagues, all contribute to it.

Clinicians can create a culture that is patient-centered, that achieves the best patient outcomes and reduces costs, that continuously learns and improves, that holds us all accountable.

Margaret Mead, the famed American anthropologist, once said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it is the only thing that ever has.” It is your choice. If you want to work in an area that optimizes outcomes, reduces costs and restores joy in your work, you can. Start a CUSP team—a unit-based team intended to improve culture and learn from local mistakes. Recognize that teams make better decisions with diverse and independent input, so seek input from others in decision-making. Listen, smile, encourage, offer a comforting word to relieve the suffering of patients and your colleagues. You can start to change your culture so that when you walk into work, the safety culture will be as strong as our national culture, the norms will be a powerful as when the customs agent says “welcome home.”


Peter Pronovost

One of the world’s leading authorities on patient safety, Peter Pronovost served a the director of the Armstrong Institute, as well as senior vice president for patient safety and quality, at Johns Hopkins Medicine from 2011 until January 2018.

2 thoughts on “Coming home”

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