The best way to enhance patient safety is to build a culture of safety at the hospital. The Johns Hopkins Hospital Comprehensive Unit-based Safety Program (CUSP)

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FROM BLAME TO FAIR AND JUST CULTURE:
A Hospital in the Middle East
Shifts Its Paradigm
By Krishnan Sankaranarayanan MS, MBA, CPHQ; Steven A. Matarelli PhD, RN;
Hasrat Parkar, MBBS, MRCGP; and Mamoon Abu Haltem MS, RN
Tawam Hospital, United Arab Emirates

2. JULY/AUGUST 2013 WWW.PSQH.COM 31
T
he concept of a “culture of safety” emerged from
high reliability organizations (HROs) such as in the
aviation and nuclear power industries. The objective
of HROs is to consistently minimize adverse events despite
carrying out inherently intricate and hazardous work. These
organizations maintain a commitment to safety at all levels,
from frontline providers to managers and executives. Improv-
ing the culture of safety within healthcare is long overdue and
is now becoming essential to preventing and reducing errors,
thereby improving overall healthcare quality (AHRQ, n.d.).
The Institute of Medicine’s (IOM) groundbreaking report,
To Err Is Human (2000), found that as many as 98,000 people
die each year from medical errors in hospitals in the United
States alone, making medical errors a more common cause of
death than motor vehicle accidents, breast cancer, or AIDS.
The report estimated that these errors cost the United States
nearly $38 billion each year (IOM, 2000).
Now, more than 10 years after the IOM report, medical
errors are still a widespread problem in the United States. It
has been estimated that more than 1.5 million people have
been sickened, injured, or killed by medication errors each
year since the report was issued and an estimated 1.7 million
persons have battled illnesses due to hospital acquired infec-
tions, with tens of thousands dying (Clark, 2009).
The concept of patient safety is an emerging philosophy
for healthcare organizations in the Middle East. Coupled
with this emerging philosophy is a lack of a cohesive research
agenda focused on capturing patient harm due to medical
errors. In affiliation with Johns Hopkins Medicine, Tawam
Hospital—one of the largest hospitals in the United Arab
Emirates—has taken a proactive stance for patient safety and
has helped to spearhead the patient safety movement in the
region.
Tawam Hospital faced many of the same barriers to patient
safety present in hospitals elsewhere such as communication
hierarchies among providers and lack of a supportive environ-
ment in which to report errors without fear of repercussions
(Stein, 1967). A culture unaccustomed to acknowledging
medical errors and a tendency for poor communication and
teamwork often lead to adverse events (IOM, 2000). Tawam
Hospital also has a unique set of challenges in that it employs
staff from more than 60 nations, making cross-cultural com-
munication a strong variable in patient safety efforts.
Many of these caregivers have traditionally felt an added
reluctance to admit mistakes because doing so might jeopar-
dize their jobs. The gap between timid nurses who were un-
able to speak up and assertive and authoritative physicians
has been a major communication barrier.
Tawam Hospital’s executive leadership realized that the
best way to enhance patient safety is to build a culture of
safety at the hospital, so in January 2008 they launched the
Johns Hopkins Hospital Comprehensive Unit-based Safety
Program (CUSP). Early in the safety movement at Tawam, the
leadership created a patient safety department specifically to
roll out staff education and program standards. The depart-
ment consists of four patient safety officers and a medication
safety officer. The affiliation of Tawam Hospital with Johns
Hopkins Medicine, which began in 2006, provided access to
experts for training in the science of patient safety and hu-
man factors engineering.
In 2008, the intensive care unit (ICU), neonatal intensive
care unit (NNU), and pediatric oncology unit were selected
to be CUSP pilot units to assess the acceptance of the new
safety culture philosophy. The units were selected in part due
to their high-risk, high-volume nature and their use of closed
medical staffs. Senior executive leaders of the hospital were
assigned to each of the pilot units, where they formed multi-
disciplinary teams in accordance with CUSP’s true meaning as
a partnership-driven program (Pronovost, et al., 2004).
CULTURE ASSESSMENT SURVEY
Safety culture is generally measured by surveys of providers
at all levels. Available validated surveys include the Hospital
Survey on Patient Safety Culture (HSOPS) from the Agency
for Healthcare Research & Quality and the Safety Attitudes
Questionnaire (SAQ) from Pascal Metrics. These surveys ask
providers to rate the safety culture in their units and in the
organization as a whole, specifically with regard to these key
features:
-
tion’s activities and the determination to achieve consis-
tently safe operations.
report errors or near misses without fear of reprimand or
punishment.
-
plines to seek solutions to patient safety problems.
safety concerns (AHRQ, n.d.).
Tawam Hospital—
one of the largest
hospitals in the United
Arab Emirates—has
taken a proactive
stance for patient
safety and has helped
to spearhead the
patient safety movement
in the region.

3. 32 WWW.PSQH.COM JULY/AUGUST 2013
FAIR AND JUST CULTURE
In the Middle East, studies on safety culture assessment
have been conducted in Qatar and in the Kingdom of Saudi
Arabia. Al-Ishaq (2008) assessed nurses’ perceptions of safety
culture in one Qatar health system, and Al-Ahmadi (2010)
has reported safety assessments from healthcare systems in
the Kingdom of Saudi Arabia. Both studies reported using
the HSOPS instrument. Neither study discussed the use of a
structured approach, such as CUSP, to establish an organiza-
tional culture of safety prior to or following the staff assess-
ment.
Tawam Hospital adopted a scientific approach to CUSP im-
plementation and conducted pre-test measurement of staff
perception of safety culture using the SAQ instrument prior
to CUSP implementation.
The SAQ is a survey instrument used in more than 500
hospitals in the United States, United Kingdom, and New
Zealand, and has been validated for use in critical care, op-
erating rooms, pharmacy, ambulatory clinics, labor and de-
livery, and general inpatient settings (Sexton et al., 2006).
The SAQ instrument measures culture of safety along seven
dimensions: teamwork climate, safety climate, job satisfac-
tion, stress recognition, working conditions, perceptions of
hospital management, and perceptions of unit management
(Sexton et al., 2006).
Tawam Hospital partnered with Pascal Metrics to imple-
ment the SAQ. The paper-based SAQ was administered to all
Tawam Hospital staff in three phases: 2008 (pre-implemen-
tation), 2010, and 2011. The SAQ was administered under
standardized conditions to ensure staff representation and
uniformity across the organization. The results of staff par-
ticipation during the three phases are illustrated in Table 1.
Eighty-two percent of staff in patient care areas participated
in the SAQ survey, with an overall response rate of 81% in the
three phases combined.
SAQ RESULTS
The survey response is a Likert-like scale with categorical
responses: Strongly Disagree, Disagree, Neutral, Agree, and
Strongly Agree. The responses were coded by number and
percent for measurement, ranging from 1(0%) for Strongly
Disagree, through 5 (100%) for Strongly Agree. The survey re-
sults have been graded against percentage positive responses.
This is the percent of people who, on an average across items,
marked a 4 (Agree) and above, positive responses. That is, it
is the percent of people who have a scale score of 4.0 (or 75%
on the 0 to 100 scale). Therefore, a unit’s response that is less
than a 60% mark—not positive—was graded in the danger
zone, and anything above the 80% mark—positive—was
graded in the goal zone.
Within the SAQ, the domains of Teamwork and Safety Cli-
mate are considered to be the two primary dependent vari-
ables with the most significance relationships in preventing
patient harm. Secondary dependent variables are defined as
morale, stress recognition, working conditions, perceptions
of hospital management, and perceptions of unit manage-
ment (Timmel et al., 2010).
Comparison of Pilot CUSP Units 2008 and 2010
A comparison of the SAQs pre- and post-CUSP implementa-
tion shows that the ICU had sustained its scores on the job
satisfaction domain and has shown an increase in the other
domains—a trend towards improved unit culture. Six out of
the seven domains, however, are still below the 60% percen-
tile mark, indicating a danger zone.
The scores of the Pediatric Oncology Unit significantly
dropped in six domains except for the stress recognition do-
main. All scores remained below the 60% percentile mark, in-
dicating danger zone and potentially a declining unit culture.
Location Year Targeted staff Surveys
Administered
Survey
Returned
Survey
response rate
Phase 1 CUSP Pilot Units 2008 199 199 199
Phase 2 In-patient areas 2010 1600 1476 1450
Phase 3 Out-patient &
satellite locations
2011 805 497 483
Total 2604 2172 2132
Table 1. Implementation of Culture Assessment Survey
The ICU sustained
its scores on job
satisfaction and has
shown an increase in
the other domains—a
trend towards improved
unit culture.

4. JULY/AUGUST 2013 WWW.PSQH.COM 33
The NNU sustained their job satisfaction scores, improved
teamwork scores, and dropped on the safety climate scores.
Four domains had low scores indicating a danger zone and an
overall mixed result in unit culture.
results of 2010 and 2011
In the 2010 and 2011 SAQ surveys, the overall hospital score
on all the domains were in the danger zone—less than 60%—
and 20 clinical locations in 2010 and 7 clinical locations in
2011 had scores of less than 60% in the primary dependent
variables.
Amongst the secondary dependant variables, perception
of hospital management was the lowest scoring domain in all
three phases of the survey. This could be attributed to staff
being more familiar with their unit management addressing
their concerns than the hospital management.
There were two additional items in the SAQs of signifi-
cance for the senior leadership:
1. Safety: In 2010 and 2011, a total of 17 units scored less
than 60% for the question, “I would feel safe being treated
here as a patient.” Post-hoc analysis of this area using
qualitative inquiry found that staff interpreted this ques-
tion to mean their own personal safety rather than an
assessment of “safe” medical care in a particular unit or
service line.
2. Job satisfaction: 20 units scored less than 60% in the
content domain related to job satisfaction indicating a
unit culture where the implementation of a patient safety
program might not achieve intended outcomes unless
more pressing issues are addressed.
The senior leadership was keen to address these themes to
enhance the culture of safety.
results Debriefing and Action Plan
The SAQ results were disseminated to each department in the
presence of a senior hospital executive. Every department was
thenaskedtosetupanactionplanusingtheSAQde-briefertool.
The de-briefer tool contains the least positive and most positive
scores. The unit staff selected one or two items from the least
positive scores, identified specific areas of concern, and devel-
oped action plans for improvement. The hospital administrators,
playing a facilitator role in conjunction with the patient safety
officer, helped the departments to develop actionable plans.
Challenges Faced with the SAQs
Since English is not the first language for most staff at Tawam
Hospital, it was felt that the questions did not translate as ex-
pected due to syntax issues, sentence structure, and language
rules. For example, the question, “I would feel safe being treated
here as a patient,” as previously noted, was misinterpreted by
many staff as their own physical safety in the unit. This was
due to instances of aggressive behaviors in the unit. For other
staff, it was not clear if the phrase meant being treated as a
patient in the unit in which they worked or in the hospital.
Likewise, staff misinterpreted questions such as, “Problem
personnel are dealt with constructively by our management,” as a
statement about personal problems. Additionally, some staff
and unit leadership took results personally if the department
scores were low, and overall they described the unit as “failed”
when scores were recorded in the danger zone.
EXECUTIVE WALKROUNDS™
The CUSP monthly meetings and executive WalkRounds pro-
vided an opportunity for the executive leaders to address issues
raised in the two-question survey and SAQ results. The pur-
pose behind the meetings and WalkRounds is to integrate safe-
ty into the culture of a unit/clinical area (Thomas et al., 2005).
During these leadership rounds, executives focused on
some of the questions that scored low in the SAQs for that
particular unit. For example, executives sought to explore the
prevalence of teamwork in the unit, how physicians and nurs-
es worked together as a well-coordinated team, and whether
nursing input was well-received in the work setting.
Challenges
Tawam Hospital leaders quickly found that not every aspect
of Johns Hopkins CUSP methodology translated word-for-
word at the hospital. Leaders asked frontline staff the two-
unit safety questions and found that staff members often
were uncertain how to respond, no matter how many ways
the questions were phrased. Instead of bringing up dangers,
staff typically talked about the protocols they followed to
prevent harm. Leaders have now modified their walk rounds
questions and ask pointed questions. For instance, Have you
had any problems with pharmacy recently on medications prepared
for the ICU? How is your communication with the physicians? Re-
formatting the questions has shown to improve the tangible
information that is actionable.
Fair and Just Culture
The hospital administrators, playing a facilitator role in
conjunction with the patient safety officer, helped the
departments to develop actionable plans.

5. 34 WWW.PSQH.COM JULY/AUGUST 2013
FAIR AND JUST CULTURE
LEARNING FROM DEFECTS
In 2008, within a month after the roll out of CUSP in pedi-
atric oncology, two medication errors were reported. Upon
full investigation, it was determined that a nurse had failed
to perform the final check of Five Rights of medication ad-
ministration and inadvertently administered chemotherapy
to the wrong patient. The second error, minor in nature, re-
sulted from administration of an expired routine vaccina-
tion. Again, a nurse failed to perform the Five Rights safety
checks. Neither case resulted in patient harm. In both the
cases, the errors happened to highly experienced charge
nurses on the unit.
Since CUSP and the philosophy of patient safety were in
progress with the pediatric oncology team, the staff members
were motivated to be open and report incidents. A CUSP-driv-
en investigation of both incidents, examining processes and
not just people, substantiated the organization’s practice of a
“fair and just” culture and instilled confidence in the staff that
this cultural shift was indeed a reality.
The two charge nurses not only shared their personal expe-
riences with the pediatric oncology staff members, but have
gone on as advocates of patient safety by sharing their experi-
ences with nurses in the other CUSP units and throughout
the organization. This incident served as a perfect example
to all staff in the three CUSP units: there is no substitute for
constant learning from defects, and culture change is both
evolutionary and revolutionary.
Lessons learned from the pediatric oncology errors pushed
leadership to establish Safety Analysis Teams in the CUSP
units. The primary aim was to encourage and improve staff
awareness of incident reporting and learning from defects,
There is no substitute
for constant learning
from defects, and
culture change is
both evolutionary and
revolutionary.

6. JULY/AUGUST 2013 WWW.PSQH.COM 35
proactively identify and implement risk reduction strategies,
and finally to enhance the culture of safety.
These team members meet on a monthly basis prior to
CUSP meetings to review incident reports submitted to Pa-
tient Safety Net (PSN®), the event reporting system for the
University HealthSystem Consortium. Information from fo-
cused incident analyses has helped the team identify one or
two defects for learning, planning and implementing systems
changes wherever required to reduce the probability of the in-
cident recurring (Pronovost et al., 2006).
CONCLUSION
Efforts are now underway in the UAE, Qatar, and the King-
dom of Saudi Arabia to collect data on medical errors in a sys-
tematic process. The integration of such information across
the region will benefit all organizations as well as health policy
at the government level.
What began as a pilot project in 2008 at Tawam has now
expanded to include seven additional units. Tawam Hospital
now has 10 actively functioning CUSP units representing crit-
ical care, pediatrics, and general medical surgical services, and
recently, ob/gyn services. Today, the pilot units have complet-
ed 5 years of CUSP implementation and six out of the seven
new CUSP units have completed 1 year of implementation.
The culture of safety is a never-ending journey.
Building trust amongst care providers in CUSP units is a
key imperative. Although some of the Tawam units have been
in CUSP for many years, we still continue to face challenges to
keepstaffactivelyinvolvedintheprogram.Toempowerstaffand
inculcate leadership qualities, CUSP meetings are being chaired
by frontline staff members. The CUSP executive remains present
but serves in a supportive role for team mentorship. It is esti-
mated that it may take as long as 5 years to develop a culture of
safety that is felt throughout an organization (Ginsberg, Norton,
Casebeer, & Lewis, 2005). Tawam Hospital’s leadership supports
the journey to build a culture of safety; a journey that is built on
patience, perseverance, commitment, and engagement.
Krishnan Sankaranarayanan
holds a master of science degree in patient safety leadership from the University
of Illinois-Chicago and a master of business administration degree from Annamalai
-
ing member of the Patient Safety Team at Tawam Hospital. Sankaranarayanan may
be contacted at ksankara@tawamhospital.ae.
works for Johns Hopkins Medicine International and serves
degree in medical surgical nursing and nursing administration and a PhD in public
health. Matarelli is a founding Patient Safety Team executive at Tawam Hospital.
Hasrat Parkar has 25 years of experience in family medicine in the UK and UAE
at Tawam Hospital.
-
ing member of the Patient Safety Team. He is a registered nurse and holds a mas-
-
Fair and Just Culture
ACKNOWLEDGMENTS
The authors wish to thank the leadership of Johns
Hopkins Medicine Center for Innovation in Quality Patient
Care, the executive leadership of Tawam Hospital, and the
CUSP team members for their efforts in implementing the
culture of safety program at Tawam Hospital and finally
Pascal Metrics for helping Tawam Hospital to measure
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