A Culture of Safety

For Marilou Salao, MSN, RN, PHN, CLSSGB, chief nursing officer at St. Francis Medical Center, Prime Healthcare, the concept of “impact starts at the frontline” is rooted in the Lean Six Sigma concept of “gemba.” As Salao interprets it, “Gemba is going to where the work is done, because you learn the most by seeing the work being done firsthand, watching the process and then asking questions.”

“Impact at the frontline to me is the essence of clinical care,” says Corrin Steinhauer, DNP, RN, NEA-BC, CPPS, chief nursing officer at the Arthur G. James Cancer Hospital and Solove Research Institute at The Ohio State University. “Every time healthcare workers encounter a patient, they have the ability to impact the patient’s clinical outcomes,” she says.

Set the right tone

Fostering a culture of safety within the frontline demands leadership involvement. “It’s about being present,” Salao says. “Decisions can’t be made, suggestions can’t be made, without really understanding the inner workings and then understanding the barriers as well.”

To help set the tone and carry it through to the frontline, Dr. Steinhauer finds storytelling to be a powerful tool: “Finding a story that relates back to a patient’s experience or a safety event helps capture the attention of the people you’re speaking to,” she suggests.

Consider incorporating these storytelling moments into huddles and at the start of meetings. Discuss the tools and strategies that helped prevent an error or acknowledge an individual who took action. Dr. Steinhauer likes to take it a step further, referencing the facility’s quality and safety goals “to demonstrate the way all of those things are connected,” she notes.

Positive feedback

Accountability is multifaceted and a key aspect of empowering the frontline staff. Dr. Steinhauer describes formal channels- performance management and corrective action-but stresses, “What’s most effective, and probably the hardest to drive into a culture, is that peer-to-peer accountability.” At Ohio State, they’ve implemented a tool called Crosscheck, encouraging staff to gently remind each other about best practices.

“It’s simply using language to check in with one another,” Dr. Steinhauer explains. For example, if you notice a colleague going into a patient room without sanitizing their hands, she says, “It’s my job to say, ‘Hey, I noticed you forgot to pump in and pump out before you went into the patient’s room. Don’t forget.’” This approach, she notes, is built on psychological safety, and it’s rooted in caring for colleagues, not punitive oversight.

Building on that idea of psychological safety, Salao highlights the importance of transparency and trust. “Your team will be transparent with you on the challenges that they’re facing if I, as a leader, am being transparent with them,” she says. “Once that trust is built…the staff know they can say what they need and there’s no fear of retaliation.”

Supporting staff and strategies with education

Successful education is education that’s ongoing and accessible. To help achieve that, Salao says St. Francis uses a mix of classes, in-services, digital modules and annual skills fairs with interactive components. “You develop competency through hands-on learning,” Salao notes. “You can’t just put up a PowerPoint and then have people take a test and deem them
competent,” she stresses, adding that it’s important that education covers the “why” behind the practice, as well as the “how” to actually perform the work.

Developing specialty area champions within units can help fill knowledge gaps and maintain consistent care from the frontline. “When we develop those champions, staff engage more because they start to see that person as a resource,” Salao explains. “And then those champions bring back feedback from the frontline teams.”

Dr. Steinhauer shares a creative example from a previous organization: Skin champions developed a series of five- to seven-minute educational videos on topics such as wound measurement, and staging and identifying wounds. On prevalence measurement days, after all the monitoring was complete, the skin champions would take their iPads throughout the
department and share the videos with the frontline staff.

“The feedback we got from staff was, they much preferred this micro learning over sitting in a classroom or at a computer and clicking through modules.”

Recognizing successes

Recognizing the work of both the champions and the frontline staff helps keep energy and momentum strong for prevention. At Ohio State, managers use the Bravo system to award points for exemplary actions. Salao’s team celebrates successes in huddles and on hospital monitors where they announce achievements and recognize teams in photos.

“Everyone enjoys seeing one another on those screens—it’s inspiring and encouraging.”

Both organizations make quality measures visible. Dr. Steinhauer describes digital boards displaying days since the last CLABSI or CAUTI, keeping prevention top of mind for staff. Shared governance councils monitor outcomes and ensure that frontline staff are informed and involved. Salao’s team uses monitors and huddles to celebrate improvements and recognize departments that excel.

Prevention begins at the frontline, but it flourishes when leaders are present, staff are empowered, and everyone is engaged in continuous learning and improvement. By fostering trust, peer accountability and individual and group recognition, and by making education accessible and relevant, healthcare organizations can drive meaningful change.