Kelly Vana's Nursing Leadership and Management

Action plansare established based on this prioritization. Action plans identify timelines, financial resources, and individuals responsible for the implementation. A realistic timeline allows an organization to evaluate each goal and objective and the degree to which each can be implemented in the specified time frame and with the available resources. Setting a timeline for completing a strategic plan is similar to the prioritization process in that the strategic importance, resources, and effort required are major considerations. Realistic timelines and individual responsibilities must be developed, specified, clarified, and communicated to all stakeholders. This will help to avoid misunderstandings and unmet expectations.

A plan for communicating the strategic plan, often called a marketing plan, is required for all strategic plans. This holds true whether the strategic planning involves new programming for external audiences or only internal redesign or restructuring. All constituents need to understand the strategic plan, goals, and objectives. This communication is essential when building a culture of high reliability. Designing, implementing, and evaluating new safety strategies will require substantive changes in work flow and in the way that nurses and other staff members carry out their day‐to‐day work processes. Clearly communicating education requirements will help to ensure proper preparation for nurses, physicians, and other staff members. Without adequate thought to communication across the organization about the project, there is less chance of success and a greater risk of poor cooperation. A marketing plan ensures that all stakeholders have the needed information.

Implementationand evaluationof the strategic plan are the final two steps in the process. The action plans must be put into place, and outcomes associated with the plan need to be evaluated. For organizations on the journey toward high reliability, it is expected that safety events will initially rise as nurses and other staff begin to feel more comfortable reporting errors. However, over time, those safety events decrease as the organization begins to practice in new and safer ways.

When implementing a strategic plan with a focus on creating an HRO, nurse leaders must make their commitment to safety clear. This may be achieved by including safety stories at each meeting. A safety story can review a tool for preventing error, provide an example of using the tool, explain why safety is important, summarize a harmful event, or thank a staff member for being committed to patient or employee safety. Many hospitals use safety stories to keep safety at the top of everyone's mind.

Nurse leaders are responsible for creating a fair and just culture to minimize blame and punishment and encourage individuals to report errors so that the system problems can be corrected. In the past, health care took a punitive approach toward errors, viewing those who made errors as “bad apples” (Institute of Medicine, 1999). This approach served as a disincentive to reporting errors and mistakes and resulted in missed opportunities to uncover and correct problems that impacted safety. The approach also over‐simplified safety by overlooking the impact of the system on safety care. More recently, the concept of a just culture has been embraced within health care.

A just culture creates an atmosphere of trust, encouraging and rewarding people for providing essential safety‐related information (Reason, 1997). It views errors as opportunities to improve the understanding of both health care system risk and individual behavioral risk. It changes staff expectations and behaviors so that everyone looks for risks in the environment, reports errors, helps to design safe health care systems, and makes safe choices. A just culture also identifies what constitutes acceptable and unacceptable behavior. The American Nurses Association (2010) has endorsed the just culture model.

Ultimately, the just culture model creates a learning culture that is open and fair; manages behavioral choices; and designs safe health care systems. An HRO cannot exist in the absence of learning. The learning organizationis an organization where people continuously learn and enhance their capabilities to create (Senge, 1990). Nurse leaders in HROs view each failure as an opportunity to learn from mistakes. They readily admit weaknesses and commit to learning from its mistakes. They take a systems approach to safety and improving the culture of safety. Nurse leaders in these organizations create a supportive learning environment by putting processes in place to facilitate learning and encourage creativity among employees. Such a learning environment requires transparency related to safety, so that everyone is aware of opportunities for improvement.

Reporting errors and near miss safety events can assist in understanding a problem rather than hiding that a problem exists. As a result, nurse leaders must put tactics in place to increase error reporting . Speaking up for safety may appear to be easy. Health care providers come into health care to do the right thing, help patients, and cause no harm. However, errors happen. In an HRO, all health care providers are responsible for reporting safety events, including near misses, adverse events, and sentinel events. This type of reporting has its limitations, as it depends on both the recognition of the safety event and the completion of a safety event report. When using voluntary reporting and error tracking, only around 10 to 20 % of all errors are reported in health care organizations (Classen, et al., 2008). A study of Medicare beneficiaries found that only 14 % of patient harm events were captured in hospital incident reporting systems (Health and Human Services, 2012). Nurse leaders must encourage and reward staff who report safety events and decrease the fear inherent in error reporting.

This starts with a robust error‐reporting system which can be easily accessed and completed by direct‐care nurses and other clinicians. Next, nurse leaders need to thank staff for reporting errors, mistakes, events, and near misses. The Good Catch award, implemented in many hospitals across the country, is one way to recognize staff who report near misses or close calls. Edward Hospital in Naperville Illinois implemented the Good Catch award in 2008. Each month, Risk Managers compile a list of safety events that have been identified by staff and have not reached the patient to cause harm. Members of the senior leadership team vote on the most significant event. The person or team is recognized at a Management Team meeting and receives a certificate, a lapel pin, and a Good Catch trophy. The program recognizes those who speak up and fosters a culture of transparency and safety.

Speaking up for safety requires more than reporting actual or potential errors. It also involves clinicians stopping a care process whenever a member of the care team has a safety concern. This may be uncomfortable for clinicians who have historically viewed health care as hierarchical. As a result, nurse leaders must clearly communicate that everyone has the authority to stop for a safety concern at any time. Nurses are expected to voice their concern and “stop the line” if they sense or discover a safety issue. The acronym CUS may be used. The letters represent “I am Concerned;” “I am Uncomfortable;” and “This is a Safety Issue.” Consider this powerful and effective way of speaking up: “I am concerned with Mr. Lopez's sudden hemiparesis and am concerned with your choice of not implementing the stroke protocol. I believe this is a safety issue.”