A Rock-Solid Safety Lesson

Added on Jul 2, 2019

WikimediaHealth care safety leaders from across the country were not sure what to make of the “gift” that was waiting for them on the first day of the Press Ganey 2019 Safety & High Reliability Executive Summit last month in Denver: a beribboned mesh pouch containing a single black rock placed on every seat.

In the spirit of leaving no stone unturned, literally, these safety experts (who are accustomed to adopting a questioning attitude when something doesn’t seem quite right) shared a number of hypotheses with those around them, ranging from the topically relevant—a lump of coal to signify limited and inconsistent progress in the reduction of preventable patient harm in the United States—to the unlikely—a black diamond in the rough to represent the indestructible spirit of safety champions.

Though neither coal nuggets nor black diamonds, the stones did have a meaningful connection to health care safety and they were chosen because of their special powers, according to Carole Stockmeier, a partner with Press Ganey Strategic Consulting. The stones, she explained in her opening comments, were pieces of magnetite, a naturally occurring mineral with magnetic properties that were used as early as the 8th century to magnetize the first compass needles. “Mariners would magnetize a thin piece of iron by repeatedly stroking it in one direction with a lump of magnetite,” she said. The magnetized needle, when stuck through a piece of cork and set to float on a water surface, would seek out north.

“For ancient mariners who looked for landmarks and to the stars for guidance, the compass was a breakthrough. It enabled them to safely leave land-hugging routes and navigate even in overcast or foggy conditions,” Stockmeier said. To maintain the needle’s north-seeking properties, however, it was necessary to touch it to the magnetite frequently. “So seafarers carried a lump of magnetite with them so that they could re-magnetize the needle from time to time to keep the directional force strong. As a result, magnetite came to be known as a lodestone, which in Middle English means course stone or leading stone.”

In the same way, leaders in High Reliability Organizations (HROs) have to continuously direct and set the course to a safety culture. “The leader is responsible for providing a compass with a needle magnetized for safety,” Stockmeier said. And while what the board, CEO, and senior leaders say about safety is important, what they do about it positions safety as the top priority for the organization. This includes clarifying safety as a core value that will not be compromised, building knowledge of safety and reliability science, and establishing expectations for behaviors to reduce error and optimize human performance.

And just as a needle in an early compass would lose magnetization, the clarity of safety values and behavior expectations can weaken if not constantly reinforced. “In High Reliability Organizations, leaders monitor for drift in culture. Signs of drift indicate that it’s time to take out that lodestone to re-magnetize the needle,” Stockmeier said. “Leaders must provide a constant drumbeat for safety that maintains a sense of direction in the midst of other priorities.”

Distributing pieces of magnetite to the health system leaders who gathered to discuss strategies and practices for advancing safety culture transformations was meant to remind them that they are the keepers of the lodestones for their organizations, Stockmeier said, adding, “We have an obligation to those we lead and to those we serve to direct and set the course for safety and to maintain and correct the course when we detect drift.”