April 26 marked the 36th anniversary of the cataclysmic event at the Chernobyl Nuclear Power Plant. The Chernobyl disaster occurred for several reasons, including faults in the reactor design, poorly conceived tests and unauthorized changes to the tests, significant training deficiencies, poor management oversight, and a “production over safety” mindset. Ultimately, it was the outcome of poor decisions, a lack of oversight, and no safety culture.
At the time of the Chernobyl disaster, I was a midshipman at the Naval Academy. The nuclear event stuck with me throughout my entire 20-year naval career—including when I was in command of a nuclear submarine and nine years in commercial nuclear power. Today, over three decades later, the event serves as a sobering lesson in how complex systems can experience tragic outcomes when a robust safety culture isn’t in place.
Like healthcare organizations, nuclear power plants are high reliability organizations (HROs)—meaning they operate in “complex, high-hazard domains for extended periods without serious accidents or catastrophic failures.” The pursuit of nuclear safety—much like the pursuit of zero harm in healthcare—takes tremendous, continuous, and relentless investment and effort by all individuals involved. An HRO’s journey never ends with safety being a “dynamic non-event.”
Although you might not draw many parallels between the nuclear power and healthcare industries, the Chernobyl disaster taught us many important things about safety and high reliability organizing. Based on my ongoing work with many amazing healthcare organizations, I submit that there are three key lessons from Chernobyl that are still applicable across our industry today.
1. Safety must be a core value. Healthcare leaders must nurture a culture of safety and adopt a zero-harm goal—and champion this goal as the #1 priority with others. Every year in the United States alone, an estimated 4.8 million hospital patients suffer serious preventable harm. Leaders must establish an environment that promotes psychological safety, where all employees are encouraged to speak up when they see unsafe practices or areas for improvement. Leaders should also engage employees to help find solutions. Every healthcare organization must ask four questions when adopting a safety culture:
- Has your organization declared a zero-harm goal for patient and workforce safety?
- Do leaders at all levels champion zero harm as the only acceptable goal?
- Is safety mentioned in your mission/vision statement?
- Is safety positioned as your core value or listed first among your stated values?
(Read more about the fundamentals of transforming safety culture here.)
2. Employee engagement is a necessity. Some research shows that, in health settings, the most engaged organizations have 41% fewer patient safety incidents (e.g., falls, medical errors, infection rates, and risk-adjusted mortality rates). Leaders must invest in their teams’ skills and proficiency and promote teamwork and employee engagement. Healthcare leaders should teach and model high reliability skills, such as asking questions, having a healthy questioning attitude of the answers they are given, communicating clearly, building engagement and accountability, and sharing lessons from incidents of harm.
3. Productivity must never override safety. In an effort to be efficient and quicker, safety can take a back seat to productivity as we seen in so many root causes of disasters in all industries. In healthcare, this may take the form of shortening appointments and missing subtle symptoms, not using checklists to minimize errors in procedures, or brushing off a sponge count that isn’t adding up correctly.
Today, healthcare organizations can look to Chernobyl and see the necessity of a robust safety culture, so they don’t have to experience the tragedy of preventable patient or coworker harm.
Press Ganey partners with healthcare organizations on their journey toward zero harm. Our High Reliability Platform helps to increase team awareness of safety issues, reduce harm, and sustain improvements over the long term. Press Ganey’s safety consultants work alongside healthcare leaders to improve patient and workforce safety. Reach out to an expert to see how we can help address your organization’s biggest safety challenges.
Join us May 11 for the next webinar in our High Reliability Learning Series: “Engaging the Board as Trustees for Safety.” Save your spot here.