Evidence-based practices support the Heart of Safety Declaration of Principles
01.19.2022
by Liz Boehm
Executive Strategist, Human-Centered Research
In 2021, the CEO Coalition, a group of health system leaders across the U.S., engaged the Institute for Healthcare Improvement (IHI) to research evidence- and experience-based practices that support team member safety and wellbeing principles outlined in its Heart of Safety: Declaration of Principles.
The Declaration expands the traditional definition of safety to include protecting psychological and emotional wellbeing of team members, promoting health justice by declaring equity and anti-racism core components of safety, and ensuring physical safety, which includes a zero-harm program to eliminate workplace violence, both physical and verbal. “We want to recognize that psychological/emotional safety and health justice are just as important as physical safety to a team members’ sense of security and well-being,” explained M. Bridget Duffy, MD, one of the founding partners of the CEO Coalition.
The work uncovered a set of more than 30 practices that aligned to the Declaration’s six principles. IHI’s research team then used a mix of feedback from leaders and frontline team members, review of the evidence, and understanding of how widely adopted the practices already are to narrow the list to eight evidence-based practices and two emerging practices which, if broadly adopted, are likely to have a meaningful impact on team member safety and wellbeing. Here is what IHI found (practice and description), plus my added commentary on how the practice links to safety and wellbeing:
| Practice | Description | Link to Safety and Wellbeing |
| Workplace violence prevention bundle | Adoption of the five key elements of the OSHA workplace violence prevention program (management commitment, employee participation, worksite risk analysis, hazard control and prevention, safety and health training for employees and recordkeeping and program evaluation). | Workers are at risk physically when workplace violence occurs, and at risk psychologically when they know the risk of violence is high and/or there’s little recourse when it occurs. |
| Advanced team-based care model | Novel designs of care teams. For example, increased staffing ratios of medical assistants per physician to accomplish real-time in-room documentation and order entry support; standard work elements; routine escalation and problem-mitigation methods. | Advanced team-based care models ensure that team members can work at the top of their license, increasing joy in work and decreasing cognitive burden and frustration. |
| Values-based hiring | Health systems can hire employees while assessing for values—specifically equity and anti-racism and an absence of biased or discriminatory behaviors. | Hiring for values ensures that core values of equity are not undermined when new team members join. |
| Implicit bias training | A health system makes available and/or requires implicit bias training for all employees, including leadership and the Board, to build awareness of racial bias and how it can manifest in healthcare. | Team members who experience bias and discrimination – whether conscious or unconscious – experience both emotional trauma and physical distress. |
| Uninterrupted medication rounds | To reduce interruptions during medication administration and cognitive burden, nurses use “do not interrupt” signals such as visible colorful symbols (e.g., a red vest) and signs, and leaders educate staff on the importance of not interrupting. | Safeguarding critical processes from interruptions reduces cognitive burden and reduces the likelihood of an error that would lead to emotional distress. |
| HIPAA/ADA compliant suicide risk assessment | Administered by a health system is typically an anonymous, web-based screening tool that allows participants to understand their risk level, and then suggests appropriate next steps, including connecting to local support resources (e.g., a dedicated case manager employed by the health system). | Suicide risk assessment and concomitant access to mental health resources normalizes help-seeking behaviors and destigmatizes the idea that team members are likely to need support for the challenges of caring work. |
| Cognitive rehearsal | A technique that can be incorporated into workplace violence training. The cognitive rehearsal technique allows staff how to respond to the 10 most common workplace bullying behaviors and practice an effective response. Some research suggests that participants build skills to confront bullying behaviors more effectively. | Cognitive rehearsal allows team members to draw on learned skills when emotionally challenging interactions arise. Already widely used in patient safety processes, cognitive rehearsal reduces the stress of conflict by helping team members respond from strength. |
| Teamwork Communication Tools | Tools including unit-based daily goals checklists, team morning briefings or huddles, and interprofessional shadowing (e.g., nurses shadow PAs or physicians shadow nurses, or managers shadowing staff) can help increase team-level understanding and lay a foundation for open communication. | Healthcare teams can be transient, making both process and communication clarity and consistency more challenging. Teamwork communication tools add structure, improving team cohesion and safety. |
| EHR Rationalization of Best Practice Alerts* | Assessing all EHR best practice alerts against set criteria with a dedicated team of a clinician leader and project managers (e.g., does this add clinical value, is it duplicative). Process to re-review alerts on an annual basis. (Related Caring Greatly podcast episode) | Time spent in EHRs on low-value tasks, such as dismissing irrelevant BPAs or documenting non-care-related information adds to team members’ cognitive load, increases frustration and reduces joy in practice. |
| Toolkit for Responding to Incidents of Patient Bias* | Creating guidance for clinical staff at all levels (e.g., residents, nurses, physicians, administrative staff) on how to respond when a patient behaves in a way that is discriminatory or biased; includes topics such as when patients should be re-assigned, establishing behavioral contracts, and when to escalate to higher levels of management. | Clear guidance on how to respond to incidents of bias reduces the stress of uncertainty when these incidents arise, reassures team members that the organization is living its values, and that leadership will support actions taken to mitigate bias and racism. |
*Innovative practices – not widely studied, but early indications suggest efficacy.
In a IHI blog post, the research team outlined actions that health systems can take now to support team member safety and wellbeing, including by gathering and examining data on team member safety incidents (physical injury, emotional harm, bias, or discrimination), listening to frontline team members to learn safety needs and solutions, making a culture of safety a priority and stratifying workforce safety data by race, ethnicity, gender, age, and specialty to build a baseline from which to improve.
One of the key learnings from the research was that quite a few practices with a solid evidence-base had relatively low adoption. This speaks to the need to integrate staff safety approaches into systemic, culturally-based change approaches such as high reliability or human-centered Lean management. It also strengthens the imperative to work closely with frontline team members to refine implementation approaches and ensure there are enough resources and staff to prioritize staff safety and wellbeing protocols.
As part of the ongoing work to redefine safety, protect healthcare workers and preserve these essential professions, the Coalition will be undertaking the next level of research over the coming months to uncover the ways that system leaders and team members are addressing workforce safety and managing through both another wave of COVID-19 and staffing disruptions with team member well-being intact. Our aim is to identify the top practices that leaders and team members are embracing now to mitigate the traumatic impact of pandemic and build a future of systemic safety and well-being.
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