Facilitators and Barriers to
10 National Quality Forum Safe Practices
Sarah C. Blake, MA
Susan Kohler, RN, MPH
Kimberly Rask, MD, PhD
Anne Davis, BSN, MPA
Dorothy Vi Naylor, RN, MN
The objective of this study was to identify facilita-
tors and barriers to the implementation of 10
National Quality Forum (NQF) medication processes
and the culture of safety practices in Georgia hospi-
tals. In-depth interviews with hospital administra-
tors were conducted to identify facilitators and
barriers to the implementation of programs that sup-
port the NQF safe practices. Hospitals identified sig-
nificant as well as other key factors that resulted in
the adoption and/or nonadoption of medication and
culture of safety practices. Informants also identified
strategies used to overcome barriers that were expe-
rienced. Facilitators to both practices include admin-
istrative leadership support and education and
training. The resistance to change was the most sig-
nificant barrier identified in both the safe medica-
tion process interviews and the culture of safety
interviews. Implementing safety practices can be a
difficult process, replete with organizational, finan-
cial, and professional barriers. Strategies identified
by our informants to overcome these barriers may
assist other hospitals currently facing this challenge.
(Am J Med Qual 2006;21:323-334)
Keywords: safety management; quality of health care;
quality assurance; organizational culture; medical errors
AUTHORS NOTE: This project was supported by contract
290-00-0011 from the Agency for Healthcare Research and Quality.
Ms Blake, Ms Kohler, and Dr Rask are at the Emory Center on
Health Outcomes and Quality, Rollins School of Public Health,
Atlanta, Georgia. Ms Davis and Ms Naylor are at the Georgia
Hospital Association, Marietta. The authors have no affiliation with
or financial interest in any product mentioned in this article. The
authors research was not supported by any commercial or corpo-
rate entity. Corresponding author: Sarah C. Blake, Rollins School of
Public Health, Emory University, 1518 Clifton Road NE #672,
Atlanta, GA 30322 (e-mail: scblake@sph.emory.edu).
American Journal of Medical Quality, Vol. 21, No. 5, Sep/Oct 2006
DOI: 10.1177/1062860606291781
Copyright 2006 by the American College of Medical Quality
323
Downloaded from ajm.sagepub.com at UNIV OF VIRGINIA on September 6, 2015
In November 1999, the Institute of Medicine
released its landmark report titled To Err Is Human:
Building a Safer Health System.1 The report claimed
that more than 1 million people in the United States
suffer from preventable medical injuries each year
and as many as 98 000 people die annually in hospi-
tals because of medical errors. Although evidence-
based methods are available to prevent adverse
events, there is concern that the current lack of stan-
dardization among hospitals implementing such safe
practices has the potential to both diffuse and dilute
efforts to improve patient safety.
To address this issue, the National Quality
Forum (NQF) published an evidence-based consen-
sus report listing 30 safe practices for better health
care that should be universally adopted. However,
while there is public pressure for hospitals to fully
comply, there is no evidence-based method of priori-
tizing these practices. Many of the practices are
defined very broadly, for example, create a health-
care culture of safety. Questions also remain as to
the utility and ease of implementing some practices
and identifying the best strategies for implementa-
tion. As the NQF consensus report notes,
For any given healthcare provider, the choice of prac-
tices that will have top priority will depend on the
individual providers circumstances, including which
practices already have been implemented, availabil-
ity of resources, environmental constraints, and other
individual factors.2
The purpose of this study was to identify facilita-
tors and barriers to the implementation of programs
that support 10 NQF patient safety practices. Nine
practices focus directly on medication processes, while
1 practice focuses on hospital safety culture. In-depth
interviews were conducted with top performance
324 Blake et al
improvement managers from a statewide sample of
hospitals in Georgia that have and have not imple-
mented clinical programs supporting the safe prac-
tices. In this article, we present key findings from this
qualitative study.
METHODS
Design
We conducted semistructured interviews of 2
hospital groups: adopters and nonadopters of safe
medication practices.
Participants
The Georgia Hospital Association (GHA) recruited
hospital participants from their Partnership for
Health and Accountability (PHA) membership. PHA
is a voluntary patient safety initiative designed to
promote the health and welfare of Georgians by
improving care, reducing risk, preventing medical
errors, and identifying strategies needed to create a
culture of safety (COS). All 147 acute care hospitals
in the state of Georgia participate in the program.
PHA includes a broad cross section of hospital types,
with 55% having fewer than 100 beds, 25% having
100 to 299 beds, and 20% having 300 or more beds.
Hospitals are evenly divided between urban (54%)
and rural (46%) locations.
Hospital Selection
Hospitals in PHA participate in statewide sur-
veys on safe medication use practices and strategies
for safe culture leadership. Responses to these sur-
vey questions were used to rank all Georgia hospi-
tals from high to low adopters. The hospital ranking
was specifically designed to capture a range of both
top and low adopters. Hospitals were ranked after
sorting blinded hospital IDs in descending order by
total number of fully implemented safety practices
and in ascending order by total number of nonim-
plemented practices. Hospitals with the highest
ranking were those with the greatest number of
fully implemented safety practice interventions and
the least number of nonimplemented safety prac-
tices. From this list, 25 high and 25 low adopters of
medication-related NQF safe practices were identi-
fied. A similar strategy was used to rank and ran-
domly select 25 high and 25 low adopters of safety
Downloaded from ajm.sagepub.com at UNIV OF VIRGINIA on September 6, 2015
AMERICAN JOURNAL OF MEDICAL QUALITY
culture programs. When the 2 lists were compared,
13 hospitals were identified as top performers for
medication process but bottom performers for COS
or the converse and so were eliminated from consid-
eration. Six hospitals were ineligible for reasons
such as being a nonacute care facility. The final
sample resulted in 81 unique hospitals.
Data Collection
Between April and May 2005, letters seeking
hospital participation in a telephone interview were
distributed to the 81 eligible hospitals. A second mail-
ing to nonresponders was sent in early July 2005.
Because researchers were blinded to the hospitals
identification, recruitment efforts were conducted by
the GHA. Hospitals that wished to participate were
instructed to contact Emory University researchers
directly. Contact information was provided in the
introductory letter. A total of 19 hospitals agreed to
participate, and 18 interviews were completed. Each
interview was conducted by telephone and lasted
between 30 and 45 minutes. The completed inter-
views represented a participation rate of 22.2%
(18/81).
Survey Instrument
Two survey instruments were developed for this
project: a safe medication use questionnaire and a
COS questionnaire. The questionnaires were used
to solicit feedback on key facilitators and barriers
to implementing safe practices.
Medication Process Questionnaire
Nine of the NQF patient safety practice initia-
tives specifically targeted medication practices
(Table 1). Informants initially were asked to quan-
tify the extent to which their hospital adopted each
of the safety practices. Next, informants were
asked to select both their most successful and most
challenging initiative for an in-depth discussion
about factors that resulted in the adoption and/or
nonadoption of these practices. Informants were
asked to identify the most significant facilitators
and barriers as well as strategies used to overcome
barriers. Finally, informants were asked how they
prioritized the adoption of these safety practices
and their experience piggybacking initiatives
onto other patient safety practices.
AMERICAN JOURNAL OF MEDICAL QUALITY
Table 1
List of National Quality Forum (NQF) Medication Process Practices
NQF Number Variable Name
1 Culture of safety
5 Consultant pharmacists
6 Verbal orders
7 Abbreviations
9 Information transfer
12 CPOE adoption
27 Clean work spaces
28 Labeling and storage
29 High-alert medications
30 Unit dosing
CPOE = computerized prescriber order entry.
COS Questionnaire
One NQF COS program initiative was targeted for
this study. Eleven COS dimensions were identified
within this initiative (Table 2). These dimensions
were identified in a safety culture assessment tool
developed by Westat for the Agency for Healthcare
Research and Quality.3
The interviews began with assessing the interview-
ees job responsibilities, knowledge of and interaction
within the hospital unit, and understanding of the
term culture of safety. Interviewees also were asked
to report on what resources they used to understand
or interpret COS. Informants were then asked to
report which of the 11 COS dimensions were adopted
and/or implemented by their hospital. Next, inform-
ants were asked to describe 2 of these initiatives that
were of greatest importance to their hospital.
Informants were then asked to discuss facilitators
and barriers to the adoption of each implemented
COS initiative, as well as to identify the most signif-
icant facilitator to adoption and strategies used to
overcome barriers. Finally, informants were asked
additional questions about each of the 2 COS initia-
tives they discussed. These additional questions were
adapted from the Westat Hospital Survey on Patient
Safety. This survey is an employee survey that meas-
ures aspects of organizational culture that affect
patient safety, such as overall perceptions of safety,
Downloaded from ajm.sagepub.com at UNIV OF VIRGINIA on September 6, 2015
10 National Quality Forum Safe Practices 325
Description of Safe Practice
Create a health care culture of safety
Pharmacists should actively participate in the
medication use process including, at a minimum, being available
for consultation with prescribers and reviewing medication orders
Verbal orders should be recorded whenever
possible and immediately read back to the prescriber
Use of standardized abbreviations and dosage designations
Ensure that care information, especially changes in orders and new
diagnostic information, is transmitted to all providers
Implement a CPOE
Keep work spaces where medications are prepared clean, orderly,
well lit, and free of clutter, distraction, and noise
Standardize the methods for labeling,
packaging, and storing medications
Identify all high-alert drugs
Dispense medications in unit dose or, when
appropriate, unit-of-use form whenever possible
norms about and frequency of error reporting, non-
punitive response to error, and teamwork (T. L. Scott,
L. Schuessler, E. Friedman, V. Naylor, S. Walzcak,
unpublished data, 2006).
Analysis
Interviews were audiotaped and transcribed.
Interviewers also kept notes from each interview
that were used in combination with the transcrip-
tions to produce an interview summary that cap-
tured participants key points about their hospitals
patient safety initiatives. Content from both the
medication process interviews and the COS inter-
views was analyzed according to the interview ques-
tions and organized into frameworks of categories
and subcategories determined by the responses. Key
themes were then placed into summary matrixes to
facilitate analysis. Both interviewers reviewed all
summaries and matrices and found consensus with
the key themes that were identified, therefore
ensuring 100% interrater reliability.
RESULTS
Hospital Characteristics
A total of 8 medication process interviews and 10
COS interviews were conducted with representatives
326 Blake et al AMERICAN JOURNAL OF MEDICAL QUALITY

Table 2
List of National Quality Forum (NQF) Culture of Safety (COS) Dimensions
COS Dimension Description of COS Dimension

Nonpunitive response to error
or blame-free environment
Frequency of reporting
Staffing
Supervisor/manager
expectations and actions
promoting safety
Organizational learning,
continuous improvement
Teamwork within hospital units
Communication openness
Feedback and communication
about error
Hospital management support
for patient safety
Teamwork across hospital
units
Hospital handoffs and
transitions (hospital-wide)
The hospital implements a nonpunitive policy to address patient adverse events involving medical staff
and hospital employees
A user-friendly and confidential error-reporting system is available for all error levels
The hospital maintains safe staffing through cross-training, adequate staffing ratios, appropriate skill mix,
and limited work hours
Hospital supervisors/managers say a good word when they see a job done according to established
patient safety procedures; supervisors/managers seriously consider staff suggestions for improving
patient safety; whenever pressure builds up, a supervisor/manager wants staff to work faster, even if
it means taking shortcuts
The hospital is actively doing something to promote patient safety; mistakes have led to positive
changes within the hospital; hospital evaluates the effectiveness of new changes made to improve
patient safety
People support one another within and among hospital units; people trust each other and treat one
another with respect; there is teamwork when a lot of work needs to be done
Staff freely speak up if they see something that may negatively affect patient care; staff feel free to
question the decisions or actions of those with more authority; staff are afraid to ask questions when
something does not seem right
Managers and staff talk openly about patient safety problems that exist
Hospital management provides a work climate that promotes patient safety; the actions of hospital
management show that patient safety is a top priority; hospital management seems interested in
patient safety only after an adverse event happens
There is good cooperation among hospital units that need to work together; hospital units work well
together to provide the best care for patients; hospital units do not coordinate well with each other;
it is often unpleasant to work with staff from other hospital units
Transferring patients between and among hospital units goes very smoothly

of the 18 participating hospitals. Eight hospitals
(44.4%) were top performers, and 12 (66.7%) were
located in urban areas (Table 3). In contrast, among
all Georgia hospitals, 50 (34.0%), are top performers,
and 80 (54.4%) are located in urban areas. With
respect to bed size, 6 (33.3%) participating hospitals
had fewer than 100 beds, 5 (27.8%) had 100 to 300
beds, and 7 (38.9%) had more than 300 beds. When
compared to all Georgia hospitals, the study sample
had a smaller proportion of hospitals with fewer than
100 beds (33.3% vs 55.1%) and a larger proportion of
hospitals with more than 300 beds (38.9% vs 19.7%).
Of the 8 top-performing hospitals that participated in
this research, 4 were in urban areas of the state and
2 had more than 300 beds. Of the 10 bottom-
performing hospitals, 8 were in urban areas of the
state and 5 had more than 300 beds.
Adoption of 9 NQF Safe Medication Practices
Among the 8 medication practice participants, 4
were performance improvement coordinators, 2 were
directors of quality, 1 was a quality improvement
manager, and 1 was director of patient safety. Given
their job positions, the interviewed persons gener-
ally had good knowledge of their hospitals imple-
mentation efforts. The number of participating
hospitals that reported having fully implemented
the targeted safe practices is shown in Table 4. Full
implementation was defined as adoption in greater
than 90% of the organization. Five of the safe prac-
tices were reported as being fully implemented by at
least three fourths of the hospitals including identi-
fication of high-alert medication (7/8), use of unit
doses when appropriate (6/8), minimizing verbal
orders (6/8), ensuring information transfer (6/8), and
standardizing labeling and storage (6/8). Providing
clean workspaces and minimizing abbreviations
were reported as being fully implemented by 5 of the
8 hospitals, while availability of consultant pharma-
cists was described as being fully implemented by
4 of the study hospitals. None of the participating
hospitals had fully adopted computerized prescriber
order entry.

Downloaded from ajm.sagepub.com at UNIV OF VIRGINIA on September 6, 2015

AMERICAN JOURNAL OF MEDICAL QUALITY 10 National Quality Forum Safe Practices 327

Table 3 Table 4
Hospital Characteristics Number of Hospitals Fully Implementing 9
National Quality Forum (NQF) Medication Safety
Georgia
Sample Hospitals Practices, Sorted by Percentage Adoption
(n = 18) (n = 147) NQF Number Title Full Implementation
Characteristic n % n % 29 Identification of 7/8 (87.5%)
Location* high-alert medication
Urban 12 66.7 80 54.4 6 Minimize verbal orders 6/8 (75.0%)
Rural 6 33.3 67 45.6 30 Use of unit dosing 6/8 (75.0%)
Bed size group* 28 Standardize labeling
<100 6 33.3 81 55.1 and storage 6/8 (75.0%)
100-300 5 27.8 37 25.2 9 Ensure information transfer 6/8 (75.0%)
>300 7 38.9 29 19.7 7 Minimize abbreviations 5/8 (62.5%)
Performance level 27 Provide clean workspaces 5/8 (62.5%)
Top performer 8 44.4 50 34.0 5 Availability of consultant 4/8 (50.0%)
Mid performer 0 0.0 53 36.1 pharmacists
Bottom performer 10 55.6 44 29.9 12 Computerized prescriber 0 (0.0%)
order entry adoption
*Not significant at P = .05.

Significant at P = .05.

Facilitators to Adoption: Most Successful Practice
Participants were asked to identify a highly suc-
cessful safety initiative for an in-depth discussion
of implementation facilitators and barriers. Most
of the interviewees (6/8) chose to discuss their hos-
pitals safety program for minimizing abbrevia-
tions. Frequently named facilitators, barriers, and
strategies employed to overcome these barriers are
described below beginning with those facilitators
identified as most significant.
Most Significant Facilitators to Adoption
Administrative leadership: The commitment of
hospital executives, physician leaders, and
department heads was among the most fre-
quently mentioned facilitator contributing to
the adoption of the unapproved abbreviation
list. Four of the 6 interviewees believed leader-
ships ability to communicate and commit to
this initiative was an essential first step toward
establishing and promoting a COS. As one
interviewee stated, We have a leadership team
that embraces the National Patient Safety
goals and their importance . . . it is an expecta-
tion at our hospital . . . an important part of our
culture.
Audit and feedback: The importance of regular
monitoring to reinforce compliance was a recurring
theme in almost all interviews. Random chart
audit with feedback to staff and/or physicians
helped reinforce the patient safety message.
Feedback consisted of individual profiles of past
practice compared to peers coupled with face-to-
face meetings and/or letters from administra-
tion. Most hospitals shared results from the
chart audits with their performance improve-
ment committee and/or department chiefs.
According to one interviewee, The use of any
dangerous abbreviation is considered a rule vio-
lation which is against hospital policy. Another
informant noted, Anytime youre monitoring
something, compliance is better . . . everyone is
willing to change . . . its just a habit and habits
are hard to break.
Education: Most hospitals initially relied on for-
mal or informal education efforts to raise aware-
ness, confront resistance, and discuss goals
and/or expectations. However, according to one
respondent, education has its limits: From my
experience, simply talking to medical staff
about their rates of abuse is only effective for
about 2 weeks . . . after the meetings youll start
to see the old habits beginning to creep back in.
Another participant noted, Its not just the edu-
cation getting them past the bad habits, you
have to keep going back and back and repeating
and then they get into a rhythm . . . they need
constant reinforcement.

Downloaded from ajm.sagepub.com at UNIV OF VIRGINIA on September 6, 2015

328 Blake et al
Champions: Several hospitals designated a
champion leader to drive the initiative. One
hospitals champion was a pharmacist who
conducted ongoing discussions with clinical
staff on all units to raise awareness about the
banned abbreviations and to emphasize the
importance of preventing medical errors and
improving patient safety.
Other Key Facilitators to Adoption
Physician and staff buy in: Most of the interview-
ees considered the involvement of physicians
and staff in the development of the dangerous
abbreviation list to be critical for success.
Several hospitals established multidisciplinary
work groups to ensure that a broad spectrum of
physicians and staff members were involved in
the process of creating and approving the list.
Surveys were conducted to solicit staff feedback
and suggestions for changes.
External pressure: Most interviewees reported
that the compliance with Joint Commission on
Acreditation of Healthcare Organizations
(JCAHO) recommendations was a source of
motivation in adopting their unapproved abbre-
viation list. Several interviewees mentioned the
fear of being out of compliance, while another
noted that the tips and guidelines available from
the JCAHO were beneficial in convincing physi-
cians of the importance of this initiative. Giving
examples of sentinel events from the Joint
Commissions website was very helpful . . . exam-
ples of bad outcomes and deaths . . . [physicians]
paid attention to those.
Reminders: Many hospitals reinforced their
education campaign by placing posters in clini-
cal areas, break rooms, dining rooms, and on
bulletin boards. One hospital placed laminated
copies of the unapproved list on every chart,
while another reported removing unapproved
abbreviations from all standard forms.
Facilitators named by no more than 1 interviewee
included using a multipronged approach, having
a sustained initiative, keeping communication
open and free flowing, and establishing the impor-
tance of patient safety.
Barriers to Adoption and Strategies
to Overcome Barriers
Resistance to change: The challenge of chang-
ing physician and staff behavior was the most
Downloaded from ajm.sagepub.com at UNIV OF VIRGINIA on September 6, 2015
AMERICAN JOURNAL OF MEDICAL QUALITY
predominant theme in our interviews. As one
interviewee stated, Abbreviations was a tough
sell . . . we have physicians who had practiced
here for 25 to 30 years . . . who have used
abbreviations so much and now they have
to change. Another interviewee lamented,
Changing habits is very difficult . . . this one
was not a bad habit that was picked up, it was
actually taught. You spend years learning the
abbreviations and then all of the sudden some-
one comes by and tells you not to use them
anymore.
Strategies used to change behavior: Motivating
change through education, reinforcement, pos-
itive incentives, and full leadership support
were strategies employed by most of the par-
ticipating hospitals. For example, a highly suc-
cessful initiative implemented by 1 hospital
included a multipronged program of education,
positive incentives, and feedback. As described
by the interviewee,
Our hospital had a drive called the Write it Right
campaign where we made stickers, posters . . . and
placed reminders on charts. We also had some
rather inventive T-shirts . . . we gave big loser
T-shirts to our worst offenders and gift certificates
to staff who improved the most. . . . When the cam-
paign was over we went back through orders and
counted up to see how everybody was doing . . . and
we met with the doctors face-to-face [the ones that
needed the most improvement] and talked to
them. . . . It turned out that our Medical Director
[who supported the initiative] was our biggest
offender . . . but he was also the one who improved
the most so he received a nice prize. . . . Now Id say
were probably 99% compliant.
Less frequently mentioned barriers included
time constraints, use of contract staff, physi-
cians not directly employed by the hospital, and
the ongoing need to educate new residents and
nursing graduates. As one interviewee stated,
Since medical and nursing schools are not teach-
ing the prohibitive abbreviations . . . it makes our
job harder.
Barriers to Adoption: Most Challenging Practice
Interviewees were also asked to identify their most
challenging program for a detailed discussion about
barriers to adoption. Challenging was defined as a
program with numerous setbacks, obstacles, and/or
difficulties resulting in unanticipated delays or fail-
ure to meet program goals. The most frequently cited
AMERICAN JOURNAL OF MEDICAL QUALITY
practice (3/8) was ensuring transfer of relevant
patient information. None of the remaining initia-
tives was considered challenging by more than 1 hos-
pital participant; therefore, only information transfer
is included in this discussion.
Information transfer includes implementation of
a process for obtaining and documenting a complete
list of the patients medications upon admission, dis-
charge, and transfer to another setting, provider, or
level of care within or outside the organization.4 Of
the 3 hospitals that chose to discuss this initiative,
1 had a fully operational program, while the remain-
ing hospitals were in the early stages of design and
implementation. Barriers to adoption and strategies
to overcome these barriers are described below.
Barriers to Adoption and Strategies
to Overcome Barriers
Physician and staff resistance: Convincing clin-
ical staff to adopt this initiative has been a
major impediment for the 3 hospitals. One
interviewee underscored this barrier when she
noted,
Its the expectation . . . that we have to reconcile
medication across settings or with a previous
provider [whatever retail pharmacy the patient
uses] . . . and you know how chaotic it is in the
ER . . . they dont have time to do sit down and call
the pharmacy and reconcile patient medica-
tions . . . but thats the expectation . . . so just get-
ting employees past the mindset . . . they just flat
cannot do it, cannot fit it into their workday, no
way, shape, form, or fashion, thats a hurdle in
itself . . . you know, how logistically do you do it?
Strategies to overcome barriers: Education,
training, and coaching were commonly used
techniques to confront resistance. In addition,
1 hospital is in the midst of developing better
communication tools such as summary reports,
rounding tools, and patient safety tools to facili-
tate the medication reconciliation process.
The same hospital recently implemented an
electronic medical record system that made
this change a lot easier . . . the IS department
and the pharmacists developed an admissions
report that would capture the patients current
list of medications . . . so all the physician had to
do is place a check in the box to indicate if the
medication was to be continued.
Complexity of the problem: Medication recon-
ciliation can be a difficult process to implement
because it affects numerous transition points
Downloaded from ajm.sagepub.com at UNIV OF VIRGINIA on September 6, 2015
10 National Quality Forum Safe Practices 329
along the continuum of care. As one respondent
stated, It just seems like there are so many
facets to information transfer . . . its a very
complex problem. Another hospital interviewee
noted, The biggest problem we find as we inves-
tigate [medication-related] events is theres a
communication deficit somewhere.
Strategies to overcome barriers: Education and
training were commonly used strategies to
increase awareness of this problem, to empha-
size the need for improved communication, and
to stress the importance of medication recon-
ciliation to ensure patient safety.
Prioritization and Piggybacking of Initiatives
Hospitals participants reported prioritizing initia-
tives based on several factors, including (1) JCAHO
mandates, (2) internal gaps in performance, (3) scale
of the initiative, (4) financial constraints, (5) number
of resources involved, and (6) risk to patient safety.
With respect to piggybacking initiatives, 3 of the 8
hospitals reported having initiatives running con-
currently, but results were mixed. One interviewee
was neutral as to the benefits of this approach,
1 considered it burdensome, and the third believed
it was beneficial because common resources were
used in both initiatives. Some of these initiatives
just dovetail together . . . once youre monitoring one
you might as well monitor others.
Adoption of a COS
A total of 11 hospitals responded to our initial
request for an interview. One interviewee, however,
was not able to find the time to participate; thus,
10 hospital interviews were conducted. One of the
10 interviews was conducted with 2 participants,
a director of quality and a performance improve-
ment coordinator. Among the remaining partici-
pants, 2 were directors of quality, 2 were directors
of quality management, 2 were directors of clinical
quality/performance improvement, 1 was a direc-
tor of nursing, 1 was a director of patient safety,
and 1 was a director of performance improvement.
With an average of 5 years in their positions at the
hospitals, the interviewees had in-depth knowl-
edge of their hospitals COS activities.
Interaction/Knowledge of the Hospital Unit
The informants reported low-to-moderate interac-
tion and/or knowledge of the individual hospital
330 Blake et al
units. Some of the interviewees spend time with
nurses and clinical staff on the unit level when
implementing or overseeing a new patient safety ini-
tiative, and troubleshooting on the hospital unit also
occasionally takes place. However, regular and ongo-
ing unit-level interaction does not generally occur.
Definition of COS
Definitions of COS ranged from very broad con-
cepts of hospital safety to more specific ideas of
having a blame-free environment that promotes
patient safety and satisfaction. COS was reported
as a way of functioning, an awareness of staff,
an essence, or a sense that safety comes first.
Two of the informants indicated that having a just
culture is important for their hospital. Several
interviewees explained that COS means letting
their hospital staff know that safety is a number
one priority. It also means keeping staff account-
able for their errors even though the system sets
up people for failure. The informants reported
that they relied heavily on written materials to
form the basis of their understanding of COS.
These materials include journal articles and publi-
cations from organizations such as the JCAHO, the
Institute for Healthcare Improvement, GHA, and
the Georgia Department of Human Resources.
Most Important COS Dimension Adopted
Participants were asked to identify which of the
11 COS dimensions were adopted by their hospital
and to discuss which 2 were the most important or
significant to the hospital. The most important COS
dimension adopted by the hospitals was nonpuni-
tive response to error, or a blame-free environment.
Six of the 10 participants listed this dimension as
most important or significant to their hospitals
COS. Informants suggested that the most effective
way to ensure a blame-free environment is to edu-
cate staff about the need for reporting and to assure
staff that it can be done without retribution.
The next most important COS dimension was
teamwork within hospital units, with 4 informants
reporting this to be one of the most important COS
dimensions adopted by their hospitals. Leadership
support and education about the need for this ini-
tiative are key to this dimensions success. One of
the 4 hospitals that discussed teamwork within
hospital units at great length has not yet adopted
this COS dimension but believes it is one of the
Downloaded from ajm.sagepub.com at UNIV OF VIRGINIA on September 6, 2015
AMERICAN JOURNAL OF MEDICAL QUALITY
most important initiatives for the hospitals future.
Frequency of reporting, communication openness,
hospital management support for patient safety,
and hospital handoffs and transitions each were
discussed by 2 of the participants as the most sig-
nificant COS dimension adopted by their hospitals.
Facilitators to Adoption
After identifying the 2 most important COS
dimensions adopted by their hospitals, the partici-
pants were asked to identify the factors that con-
tributed to the adoption of each COS dimension.
They were then asked to identify the most signifi-
cant facilitator that resulted in adoption of the COS
dimension. These facilitators are described below.
Senior leadership: The support of senior hospi-
tal leaders was the most significant facilitator to
the adoption of a COS. Informants reported that
having senior leadership and corporate support
enabled the hospital to adopt a blame-free envi-
ronment and to establish an environment in
which communication is open and staff mem-
bers feel comfortable expressing their feelings
and concerns. As one interviewee stated, If
theyre [senior leadership] willing to be open,
then the rest of us can be, but if youve got lead-
ership that wants errors swept under the carpet
because they are afraid its going to make them
look bad, youll never get it. The leadership and
support of the hospital CEO was mentioned by
6 interviewees as being an especially important
facilitator for patient safety.
Open and clear communication: Having an envi-
ronment within the hospital that promotes open
and clear communication across hospital staff
was reported as an important facilitator for the
adoption of a COS. An open and transparent
channel of communication allows staff to feel
comfortable about reporting errors, it provides
education and training to staff about patient
safety initiatives, and it promotes teamwork
within and among hospital units. One respon-
dent stated that openness has particularly
helped allay some staff fears about reporting
errors: By being open, weve shown staff that
theres no hidden agenda . . . being open is the
first thing they need to see. One hospital
reported being able to successfully implement a
COS because of its new administrations commu-
nication system. We have a new administration
AMERICAN JOURNAL OF MEDICAL QUALITY
that promotes a very openness in communica-
tion, and is very quick to recognize systems prob-
lems and not people problems, so to speak.
Education and training: Participants explained
that the education and training of staff and man-
agement has been critically important for the
adoption of a COS within their hospitals. Most
education and training initiatives have focused
on reporting errors and assuring staff that there
is a blame-free environment. As one informant
stated, We really educated the staff on why we
needed to know when the errors occurred. Not
that we wanted to get the person, but to look at
problems that could be contributing to the
errors, and that way it would help us to help
them to make things better. Participants also
reported that the education and training must
come from and be promoted by senior adminis-
tration. One hospitals senior management regu-
larly shares error reports with all its staff
members in an effort to educate them about the
problems occurring at the hospital. The inform-
ant feels that this is an important educational
experience for the staff and that it actually pro-
motes error reporting within the hospital.
JCAHO and external pressure: Accreditation by
the JCAHO and pressure by external sources
serve as important facilitators for the adoption
of a COS. External sources usually included
hospitals corporations, which tend to hold
hospitals accountable for patient safety. One
informant stated that because the JCAHO
stresses patient safety in its accreditation
standards, the JCAHO served as a driving force
behind the hospitals COS activities. The
informant further explained, If you have no
accreditation [JCAHO] then you dont get reim-
bursed and you dont stay open. A second par-
ticipant who stated that adopting a COS was
important for the hospital because it is the
right thing to do, listed the need for accredita-
tion as a close second. A third interviewee
believes that the hospital is able to achieve a
COS because JCAHO provides patient safety
goals and sets clear deadlines for achieving
these goals. It has especially helped the hospi-
tals efforts to improve teamwork with the units.
Other facilitators: Participants listed several
other facilitators for the adoption of a COS.
These facilitators include having a collaborative
team that supports patient safety goals, recogni-
tion by all staff that there is a need to improve
Downloaded from ajm.sagepub.com at UNIV OF VIRGINIA on September 6, 2015
10 National Quality Forum Safe Practices 331
communication and specifically patient safety,
having the data to support the need for patient
safety improvement and the value of new ini-
tiatives, having an awards-based system that
encourages the reporting of errors, and having
staff and/or peer pressure that encourages a COS.
Barriers to Adoption and
Strategies to Overcome Barriers
Participants were asked to identify the barriers
they or their hospital had to overcome during the
course of adopting a COS. Then, they were asked to
report what strategies were implemented to over-
come these barriers and which, if any, barriers they
were unable to overcome. These barriers are
described below.
Barriers to Adoption
Resistance to change: Informants explained that
staff resistance to change is the most significant
barrier to the adoption of a COS. Staff members,
particularly older staff, are more likely to resist
change because they have learned how to do
things the old way. One participant described
this barrier as the idea that Im ok, but every-
body else needs to change. Informants reported
that the resistance to change causes conflicts
among staff members, thus affecting teamwork
within and even among hospital units. Inform-
ants find that resistance to change is an espe-
cially challenging barrier for the hospitals
efforts to create a blame-free environment. The
informants, who are often in charge of oversee-
ing their hospitals error-reporting policies, have
found this barrier to be very frustrating because
many clinicians, particularly nurses, often state,
Well, this is the way weve always done it, or
they are concerned and ask, Whats going to
happen to me? Another informant is more posi-
tive about overcoming this barrier: I think it
just takes time to get employees and probably
physicians more than anybody used to the idea
that we can talk about it [error reporting] with-
out it being a problem.
Fear and mistrust: Related to resistance to
change is fear and mistrust. Informants reported
that there is mistrust among staff, particularly
the more experienced staff members who have
worked for years in hospitals that had a puni-
tive response to patient error reporting. Another
332 Blake et al
participant indicated that fear is a barrier to the
hospitals establishment of an open communica-
tion system. This barrier includes being afraid
of professional embarrassment, being afraid of
being wrong, being afraid of retaliation, being
afraid of being alienated. A third participant
indicated that there is a fear among staff of liti-
gation related to patient errors. I think that is a
part of our culture, when people feel very pro-
tective and somewhat defensive because they
are concerned about sitting on a witness stand,
or being sued, or having some risk. So, I think
our culture over time will shift, as we are more
and more supportive of safety culture. But it is
my guess that thats pretty well ingrained for
people in health care.
Poor communication: Poor communication
among staff has hampered hospitals efforts to
implement a COS. One informant stated that
poor communication exists because of the
nature of hospitals as silos. The informant
further explained that hospitals by nature are
organized into different departments that are
isolated and tend not to communicate with one
another. Another hospital finds poor communi-
cation to be a barrier to error reporting. The
lack of communication exists at the clinical
level and the more administrative/senior level.
Knowledge is power, and we werent really
taking the information to the department
directors and the staff-level people like we
should, or the governing board for that matter.
Medical staff tend to be left out in discussions
about errors as well, which one hospital has
acknowledged and tried to correct. Poor com-
munication has also been a problem for
another hospital that has experienced high
turnover in both management and clinical
staff. These staffing changes affect almost all of
the COS dimensions.
Strategies to Overcome Barriers
Strategies to change behavior: Constant educa-
tion and reassurance of staff that they will not
be penalized for reporting their errors has been
the most popular strategy employed by the par-
ticipant hospitals. One hospital conducts one-
on-one sessions with physicians to personally
explain to them why blame-free reporting is
Downloaded from ajm.sagepub.com at UNIV OF VIRGINIA on September 6, 2015
AMERICAN JOURNAL OF MEDICAL QUALITY
necessary and possible. Another hospital has
started to overcome this barrier with the help of
a nurse who comes to training sessions to share
with staff her particular experience with the
nonpunitive error-reporting system. By having
her explain her experience, staff members are
assured that they will not be penalized for
reporting errors and will learn how important it
is for improving patient safety. A third hospital
encourages its managers to regularly stress the
blame-free environment policies at their
monthly staff meetings. Another informant has
learned that changing behavior is almost impos-
sible to achieve, but the informant finds hope in
the new blood, the newer and younger staff
members whom the hospital can properly train
and educate about its blame-free environment.
Strategies to improve communication: As with
changing behavior, hospitals are educating their
staff to improve communication. Training and
educational efforts focus on teamwork within
and across hospital units, among managers and
other hospital leaders, and on the need for and
value of error reporting. One participant feels
that educating managers is critical to improving
communication. We want to make sure its a
2-way communication, and I think keeping them
[managers] up-to-date and informed, letting
them know where we need the help and what
resources we need is helpful. Another informant
suggested that communication could be
improved if senior leaders, particularly hospital
CEOs, would better promote the need for a COS.
DISCUSSION
Using a qualitative approach, we identified major
facilitators and barriers to the implementation of
programs that support NQF safe practices around
medication processes and a COS. Hospitals that
participated in the interviews identified significant
as well as other key factors that resulted in the
adoption and/or nonadoption of 2 self-selected prac-
tices. Informants also identified strategies used to
overcome barriers that were experienced.
Common among both patient safety interviews
was the value of administrative leadership and
support. Patient safety initiatives were easiest to
adopt because of the strong commitment of senior
hospital leaders such as hospital executives, physician
AMERICAN JOURNAL OF MEDICAL QUALITY
leaders, and department managers. Several partici-
pants reported that the adoption of patient safety
initiatives was most successful with the help of a
champion such as a CEO or pharmacist. These cham-
pions were largely responsible for driving 1 or more
patient safety initiatives.
The participants also revealed that education
and training have helped raise awareness about
patient safety. These educational efforts included
formal and informal approaches to patient safety,
and they have targeted medical staff and adminis-
trators as well. Participants also suggested that for
these educational efforts to really be effective, they
must be constant, always reinforcing the message
of patient safety.
Resistance to change was the most significant bar-
rier identified in the safe medication process inter-
views and the COS interviews. Most of the study
participants explained that physicians as well as
nurses, especially those who have been in practice for
many years, have the most difficult time adapting to
new patient safety policies and procedures. These
clinicians struggle with these policies and proce-
dures, including the adoption of standard abbrevia-
tions and the acceptance of the hospitals blame-free
environment, because they are used to doing things
the old way. The informants reported that educa-
tion and positive reinforcement are strategies their
hospitals have used to change behavior. For the most
part, these strategies have been successful.
Many participants in this study sought advice
and/or suggestions for implementing their hospitals
programs from key organizations such as the
JCAHO, PHA, and the Institute for Safe Medication
Practices. Strategies for achieving safe medication
goals of minimizing abbreviations, minimizing ver-
bal orders, and COS are available on their respective
Web sites. In addition, the JCAHO has made compli-
ance with 4 NQF safe medication processes manda-
tory for accreditation.
There were some limitations to this study. First,
we attempted to include an equal proportion of top-
and lower-performing hospitals in the 2 interview
groups. Although we achieved this goal for hospi-
tals participating in the medication process inter-
views, the COS sample consisted of a relatively
high percentage of bottom-performing hospitals
(60% vs 40% top performers). Because recruitment
efforts were coordinated by PHA, we were unable
to actively solicit additional hospitals that were
Downloaded from ajm.sagepub.com at UNIV OF VIRGINIA on September 6, 2015
10 National Quality Forum Safe Practices 333
doing well in implementing these practices. The
extent to which this biased our conclusions is
unknown. Each hospitals performance ranking
was based on voluntarily provided self-assessment.
Interviewees were asked to quantify the extent to
which their hospitals adopted each of the 10 safety
practices. The hospital-reported ratings have not
been independently verified for accuracy.
An additional limitation to this study was the
self-selection of patient safety practices. Hospital
participants in both the medication process and COS
interviews were allowed to self-select the patient
safety practices with which their hospital had the
most success. In the medication process interviews,
informants also identified the patient safety practice
with which their hospital had the least success.
There are limitations to this approach because there
were no data to support these hospitals best or
worst practices, nor were there any specific guide-
lines to define success. Thus, participants selections
of these patient safety practices might be biased to
reflect areas in which the hospitals have more suc-
cess or are doing better than in actual practice.
Despite these limitations, this research study
has many strengths. First, it is the only known
qualitative study to examine NQF patient safety
initiatives adopted by Georgia hospitals. The
researchers have gathered invaluable information
about the facilitators and barriers to 2 important
NQF patient safety programs: medication process
practices and COS initiatives. Second, the involve-
ment of the hospitals quality assurance and/or
patient safety directors strengthens the validity of
the data because most of these informants oversee
and monitor their hospitals patient safety practices.
In addition, the research findings are timely and
provide current patient safety practices adopted by
Georgia hospitals.
In conclusion, implementing safety practices can
be a difficult process, replete with organizational,
financial, and professional barriers. Strategies
identified by our informants to overcome these bar-
riers may assist other hospitals currently facing
this challenge. These strategies include educating
staff about safety practices and providing positive
reinforcement by hospital administrators. Although
full implementation of patient safety practices is
an ongoing process, hospital participants were gen-
erally pleased with their progress and anxious to
keep moving forward.
334 Blake et al
REFERENCES
1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human:
Building a Safer Health System: A Report From the Committee
on Quality of Healthcare in America. Washington, DC: National
Academy Press; 1999.
2. National Quality Forum. Safe Practices for Better Healthcare: A
Consensus Report (NQF Publication No. NQFCR-05-03).
Washington, DC: National Quality Forum; 2003.
Downloaded from ajm.sagepub.com at UNIV OF VIRGINIA on September 6, 2015
AMERICAN JOURNAL OF MEDICAL QUALITY
3. Nieva VF, Sorra J. Safety Culture Assessment: a tool for
improving patient safety in healthcare organizations. Qual
Saf Health Care. 2003;12(Suppl. 2):ii17-ii23.
4. Joint Commission on Accreditation of Healthcare Organiza-
tions. 2005 hospitals national patient safety goals. Available
at: http://www.jcaho.org/accredited+orgainizations/patient+
safety+/05+npsg/05_npsg_hap.htm.