Workforce Safety Panel: Obstacles to Becoming a High Reliability Workforce

Added on Nov 1, 2018

By Andrea Fitzgerald, Staff Writer

teamwork (1)Research shows that an organizational commitment to workforce safety leads to better patient and caregiver experiences, better outcomes and better bottom lines.[1] Without such a commitment, initiatives will be limited and improvements unsustainable. That is why organizations dedicated to transformational change make consistently protecting their patients and caregivers from errors, injuries, accidents and hospital-acquired infections a top priority.

However, this increased awareness hasn’t necessarily translated into significant improvement. According to the National Institute for Occupational Safety and Health, rates of nonfatal occupational injury and illness in health care settings are among the highest of any industry sector. Data from the Occupational Safety and Health Administration show that health care workers are more than four times as likely to experience incidents of serious workplace violence that result in injuries requiring time off than any other private sector employees in the United States. Worse, studies indicate that many injuries and assaults go unreported.

Health care faces unique challenges in overcoming the underreporting and high rates of workplace injury and violence. The health care environment poses potential risks of infectious diseases, musculoskeletal injuries and violent or combative behavior of patients.[2] Furthermore, the ethical duty to “do no harm” to patients often compels caregivers to put themselves at greater risk for stress, injury or violence.[3]

Recently, a group of safety and patient experience experts from Press Ganey convened to discuss the progress that health care organizations have made and the next steps required to become as safe as High Reliability Organizations (HROs) in aviation, nuclear power and other industries.

Among the panelists were Donna Cheek, safety consultant with more than four decades of health care experience in multiple executive and nurse executive roles; Rob Douglass, safety consultant and former commanding officer with 30 years of experience in the nuclear naval and commercial energy industries; Don Goble, safety consultant with more than 35 years of experience in naval and commercial nuclear power; and Julie Samuelson, RN, patient experience consultant with more than 40 years of experience in health care across a range of settings. Christy Dempsey, chief nursing officer and president of Clinical Excellence Solutions, moderated the discussion, and Craig Clapper, Press Ganey Strategic Consulting partner, contributed.

The panel weighed in on many aspects of a High Reliability journey, including systems for safety event reporting, data strategies and the role that the C-suite and other members of the workforce can play. The following questions were addressed.

1. What are some of the top obstacles that keep the health care workforce from achieving the same levels of safety as an HRO workforce, and why?

2. What is preventing health care organizations from motivating their workforces to consistently speak up about deviations from safety protocols and standards of behavior?

3. What three questions would you pose to health care executives, including the CEO, CNO and CMO, about their organization’s efforts to keep their workforce safe?

4. What is the role of the health care CEO in achieving Zero Harm?

5. How can health care organizations use Total Case Incidence Rate (TCIR); Days Away, Restricted or Transferred (DART); and other data to prevent and reduce the significance of injuries?

6. How can occupational nursing staff efforts be supported by other roles?

7. Reflecting on your own experiences along the journey to becoming an HRO, what advice would you give to those in health care considering the commitment to a highly reliable workforce?

The panel’s discussions will be presented in a series of seven blog posts. In this first post, the panel provides insights into some of the obstacles that health care organizations must overcome to continue on their journey to becoming an HRO.

Q: What are some of the top obstacles that keep the health care workforce from achieving the same levels of safety as an HRO workforce, and why?

Christy Dempsey: This is a critically important consideration. Ours is an industry designed to help people, yet we are not doing a good job keeping our own people safe. When Press Ganey acquired the National Database of Nursing Quality Indicators® from the American Nurses Association in 2015, one of the first things we did was develop a nursing-sensitive quality indicator for Assaults on Nursing Personnel, which went into effect in 2017. A total of 1,666 units submitted data in the third quarter of that year, and the results showed that over 1,000 assaults on nurses were reported.

Rob Douglass: I think there can be a mindset, even high up in leadership, that stress, injury and even workplace violence is “the cost of doing business.” That mindset has ripple effects. If leadership does believe these issues are the cost of doing business, and safety hasn’t been a focus previously, it’s difficult to advocate for investments in workforce safety. The challenge there is to demonstrate the impact of workforce safety, or lack thereof, meaning both the personal cost of injury, assault and burnout on team members and the financial impact of workforce compensation and turnover on the overall organization.

Donna Cheek: Because health care hasn’t always had the rigorous safety event review process that other industries have had, there’s a lack of understanding of how injuries resulting from errors are experienced by the individual. Similarly, there’s a lack of knowledge about the work environment and workflow at the sharp end, which leads to less engagement in improvement efforts—whether changing processes or changing equipment—on the front line. Also, because workforce safety hasn’t always been a focus in the past, certain unsafe practices and behaviors have become a normalized deviance. Those patterns can be hard to break, especially for those of us who have been in health care a long time.

Don Goble: Leadership in health care has a number of competing priorities, including workforce engagement, quality and finance, and there is a danger of seeing safety as another topic rather than recognizing it as a core value. HROs continuously develop safety as a core value—a fundamental consideration that defines their efforts and who they are. It’s their culture. In health care, there can be less transparency regarding safety, and limited visibility about employee safety or injuries. We still have a lot of opportunities to help health care leaders recognize the need to continuously emphasize safety and increase awareness through training and observations as HRO leaders do.

Julie Samuelson: I don’t think we’re using data, quantitative or qualitative, to inform our workforces about the scope of the problem. And if leaders and staff members don’t understand the ramifications, then they are less likely to be accountable for creating systems, providing equipment, scheduling, and changing their behavior to avoid putting themselves or others at risk for workplace injury or violence. There’s also a tendency to focus exclusively on patient safety, and while that is a crucial tenet of high-quality care, it does not mean that workforce safety can be an afterthought. Similarly, I think we are too often reactive in our responses to serious safety events. The next frontier is proactively thinking about how to create and implement processes to protect caregivers from all settings, from doctors in the ED to home health and hospice nurses.

This is Part I in a seven-part series on making the health care workplace a safe and highly reliable environment for patients and caregivers. Part II will provide insights into the possible detractions from reporting or speaking up about unsafe practices resulting in errors and harm.


[2] Risk and Responsibility in Providing Nursing Care. Published by: American Nurses Association.

[3] Worker Safety in Your Hospital: Know the Facts. Published by: U.S. Department of Labor, Occupational Safety and Health Administration.