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Nurse leaders must also assess the organizational culture to determine the shared values and beliefs of individuals in a group or organization. This chapter will consider culture as it relates to safety and high reliability.

Culture is sometimes described as the way people act when no one is looking. For example, consider Beth, a patient care technician caring for a patient in isolation. Beth entered the patient's room without wearing appropriate personal protective equipment. By deviating from policy, she put herself, her family, her patients, other staff, and everyone she encountered at risk for infection. When asked about her behavior, Beth stated that she knew the patient was in isolation and that she should put on a gown and gloves. She further explained that she did not think anyone was watching. This illustrates an employee who has not yet internalized a culture of safety.

On the other hand, consider Bill, a housekeeper who informed his supervisor that he found a sharp metal edge on a door handle on the Adolescent Behavioral Health Unit. Bill and his supervisor were concerned that someone could get hurt and alerted the unit manager. The manager asked Joe from facilities to fix the handle as quickly as possible. Joe noticed that two screws were missing from the metal plate. The manager of the unit was notified, and staff members searched the unit including each patient's room. The missing screws were eventually located in a patient's tooth brush holder. Because Bill and Joe paid attention to detail and spoke up, the patient was kept safe from harming himself. This scenario exemplifies employees who are living a culture of safety.

Many organizations use a culture of safety survey tool to capture the perspectives of health care providers. Two commonly used tools are the Survey on Patient Safety Culture (AHRQ, 2017) and the Safety Attitudes Questionnaire (Sexton et al., 2006). Organizations may also choose to assess their stage of organizational maturity toward becoming an HRO using a model proposed by Chassin and Loeb (2013).

The AHRQ sponsored the development of separate patient safety culture surveys for hospitals, nursing homes, medical offices, community pharmacies, and ambulatory surgery centers. Each survey measures multiple dimensions of safety culture. For example, the hospital survey measures teamwork within units; supervisor/manager expectations and actions promoting patient safety; organizational learning; management support for patient safety; overall perceptions of patient safety; feedback and communication about error; communication openness; frequency of event reporting; teamwork across units; staffing; handoffs and transitions; nonpunitive response to errors; number of events reported; and asks the participant to assign a patient safety grade to the organization. The Patient Safety Culture surveys are available in English and Spanish and are publicly available at no cost on the AHRQ website.

AHRQ also created databases for Patient Safety Culture survey data from organizations that administer the surveys. The databases allow health care organizations to compare their patient safety culture survey results to similar sites in support of patient safety culture improvement. Survey results are used by organizations to raise staff awareness about patient safety; assess and diagnose the current status of the patient safety culture; identify strengths and areas of opportunity for patient safety culture improvement; examine trends in patient safety culture changes over time; evaluate the impact of patient safety initiatives and interventions on the culture; and conduct internal and external evaluations the culture of safety. AHRQ provides an Action Planning Tool to assist an organization in analyzing and improving their patient safety culture.

The Safety Attitudes Questionnaire was developed with funding from the Robert Wood Johnson Foundation and the AHRQ. The 36‐item survey obtain frontline staff perspectives about specific patient care areas. The key factors that are measured include teamwork climate; safety climate; perceptions of management; job satisfaction; working conditions; and stress recognition. The survey is used by health care organizations to compare themselves to other organizations; identify interventions needed to improve safety attitudes; and measure the effectiveness of the interventions.

Chassin and Loeb (2013) developed a grid to allow health care organizations to assess their stage of organizational maturity toward becoming an HRO: beginning, developing, advancing, and approaching. Chassin and Loeb identified performance based on Position (Board, CEO/Management, Physicians); Initiatives (quality strategy, quality measures, and information technology); Safety Culture (trust, accountability, identifying unsafe conditions, strengthening systems, and assessment); and Robust Process Improvement (methods, training, and spread). Their grid may be used by leaders to assess their journey toward becoming an HRO.