Creating a culture of safety is what’s best for provider and patient

November 01, 2023
A stethoscope sitting on a table surrounded by dozens of plastic cutouts of people, like you would see on a restroom sign
Just Culture got its roots in the airline industry, but according to Dr. Danielle Scheurer, it was tailor-made for health care. iStock

A lawyer, engineer and astronaut walk into a sub shop.

Though it might sound like the beginning of a joke, it’s actually the origin story of a culture of safety in dozens of hospitals and outpatient clinics across the state of South Carolina. The lawyer, engineer and astronaut in this case is David Marx, legal expert, aircraft designer for Boeing and former advisor to NASA. Disenchanted with safety regulations within the workplace, he began to study laws, examine regulations and look at industry practices in the hopes of finding a better way to do things. 

What he came up with was something he termed “Just Culture,” an environment where open reporting of things that are wrong, unsafe or inefficient can be done without fear of major repercussions. That’s where the sub shop comes in. After years of research, Marx wrote a book called “Dave’s Subs,” that illustrated what he felt was a better way to handle safety in the workplace, set within a lighthearted, fictional tale. 

His methods quickly caught on in big industry, most specifically the airline industry. Hospitals weren’t far behind. So in 2015, MUSC Health Chief Quality Officer Danielle Scheurer, M.D., and her team invited Marx to come to Charleston and examine how they did things, in the hopes of enhancing the hospital system’s existing way of handling safety in a clinical setting. The result was a custom-crafted system that MUSC Health prides itself on greatly. 

mugshot of Danielle schemer 
Dr. Danielle Scheurer

“People have to feel safe in talking about mistakes,” Scheurer said. “In order to create a true culture of safety, our employees need to feel safe, to feel heard and that they can speak up when they feel things aren’t right – all without the fear of repercussions.”

The resulting system that Marx and MUSC Health produced was based on three basic tenets: reporting issues should be easy, learning and improving should be encouraged and, finally, using a Just Culture to understand and hold people accountable for their behavioral choices should be the standard.

Over the almost-decade since the system has been in place, MUSC has gotten safer nearly every year. And that’s not just anecdotal; Scheurer and team track safety through specific data points – the very same data points other hospitals use so they can all compare themselves against others in the field of health care – which they use as a tangible measuring stick. 

Today, MUSC’s reported harm rate – examples of harm include medication errors, surgical mistakes, preventable patient falls, etc., – is 2.5%. This means that of all event reports received, only 2.5% of them resulted in actual harm to the patient. The remainder are near misses or unsafe conditions. This indicates a very high reporting culture, which allows MUSC to know about and address issues often before they result in harm. Though any harm rate above zero isn’t ideal, Scheuer said that compared with other hospitals, MUSC Health’s number is very low. 

“That means a lot of our employees are reporting things such that we’re able to prevent bad things from happening,” Scheurer said. “That’s really important.”

tight shot of hands holding a scanner scanning a box of medication 
Scanning medications is just one of the many ways patient safety has been improved at MUSC. iStock

Some of the specific ways MUSC has bolstered its culture of safety include: making reporting easy with a system in place known as SHIELD. Every day, during shift change, all units do a huddle to talk about anything related to safety. Any issues are passed along through a four-level “tiered brief” system, which manages the appropriate level of issues, starting at the front line and escalating up to system senior leadership – the most serious reports go further up the chain, similar to the courts in our country’s legal system.

Today, the hospital system has more than 350 Just Culture certified team members who not only know the system backward and forward but who serve as ambassadors for the program, constantly teaching and educating others along the way. According to Scheuer, any leader in human resources, compliance, legal counsel and quality is certified. 

Some examples where Just Culture has helped to make MUSC a safer place include improving the way medications are administered through barcode scanning and redundancy systems; creating checklists for areas, such as an MRI bay to prevent any harmful items from being present; and offering continuing education on how to use new and existing equipment properly in every department or specialty.

“Nobody else is doing this to this degree,” Scheurer said. “To be this meticulous about it, to invest this much time and effort into a program, really is the only way to get better. You truly can’t have safe patients without a Just Culture program. It just doesn’t work. I am proud that we built this program the right way.”