A Culture of Patient Safety and Quality Healthcare Requires a Culture of Provider Civility



As medical providers in the United States try to adapt to the many changes required by healthcare reform, an increasing emphasis is placed on the importance of “culture” in improving patient safety and quality healthcare delivery.

The Institute for Healthcare Improvement continues to press forward with its ambitious Triple Aim initiative designed to effect change at all levels of the American healthcare system, hoping to improve statistics such as:

  • The US healthcare system is the most costly in the world, accounting for 17 percent of the gross domestic product. Estimates from the Centers for Medicare and Medicaid Services’ actuarial office indicate this will grow to nearly 20 percent by 2020.
  • A survey by the Centers for Disease Control found that “on any given day, about 1 in 25 hospital patients has at least one healthcare-associated infection” with 722,000 HAIs in U.S acute care hospitals in 2011, resulting in approximately 75,000 deaths.

With billions of dollars in annual direct costs to hospitals, these statistics highlight the fact that a culture of patient safety is integral to transforming the healthcare system in the U.S.

Why is culture so important?

Studies at John Hopkins University School of Medicine show the positive correlation between a high culture of safety with improved clinical outcomes, including:

  • Reduced length of stay
  • Fewer medication errors
  • Lower rates of ventilator-associated pneumonia
  • Lower bloodstream infection rates
  • Fewer decubitus ulcers
  • Higher employee morale
  • Lower staff burnout
  • Less absenteeism

Recently, attendees at a conference sponsored by Qualis, and Idaho’s Centers for Medicare and Medicaid focused on the theme of patient safety and quality healthcare. One of the big takeaways was a single word used by one of the speakers to describe a culture of safety: civility. An environment committed to civility provides a safe, non-threatening atmosphere for truth-telling and transparent communication that leads to effective action.

The conference speakers illustrated the damage caused when a culture of civility is not present in medical settings:

  • 20 percent of healthcare professionals said they would not speak up if they saw an issue.
  • In retrospective wrong site surgery reviews, 60-80 percent of the individuals interviewed said they knew the incision was being made in the wrong place, but they did not speak up.

The Armstrong Institute for Patient Safety and Quality at Johns Hopkins University suggests that medical facilities adopt a Code of Conduct that allows caregivers to speak up when concerned about a patient’s care because “Civility and respect for colleagues—regardless of their role or place in your organization’s hierarchy—is at the core of patient safety.”



Duke University’s Medical Center defines a culture of safety as an environment in which “the focus is on effective systems and teamwork to accomplish the mutual goal of safe, high-quality performance.” In an effort to deviate from the pervasive culture of “shame and blame” that has permeated medicine, “When something goes wrong, the focus is on what, rather than who, is the problem. The intent is to bring process failures and system issues to light, and to solve them in a non-biased non-threatening way.”

Civility training begins in medical school

The ideals of open, transparent, non-threatening communication systems thriving in environments of collaborative respect are not always present in medical schools. Studies in recent years point to a bullying society that is often present in medical schools.

A 2010 whitepaper article on The Health Care Blog, entitled “Unmet Needs: Teaching Physicians to Provide Safe Patient Care” by Maggie Mahar documents widespread abuse and demeaning of medical students, with the majority of the humiliation suffered at the hands of clinical faculty and residents.

Medical students exposed to unprofessional behaviors and values tend to accept and then emulate them. The report offers many powerful observations and conclusions, primary among them that graduates are ill equipped to cope with medical mistakes, further eroding patient safety and quality healthcare. The intimidating medical school culture can make it “psychologically impossible for the doctors who graduate from these programs to … diagnose failed patient care.” A physician with residual emotional scars from the shame and blame environment of her years in training may possess “little insight into ‘what really happened'” and be “unable to empathize and communicate effectively with the injured and frightened patient.” She may also “lack the knowledge and skills necessary to work with other team members to investigate the occurrence.”



Duke University affirms, “Forward-thinking healthcare organizations remember that their primary reason for existence is to take care of patients, and they want to keep them as safe and healthy as possible.” Hopefully, over time, this attitude will infiltrate and permeate the medical school environment more consistently.

Read the Duke University article “What Do We Mean By A Culture of Safety?” – http://patientsafetyed.duhs.duke.edu/module_c/what_do_we_mean.html

Read the Health Care Blog – http://thehealthcareblog.com/blog/2010/03/20/a-culture-of-fear-and-intimidation-reforming-medical-education/