We all agree that leaders can excel when they unite their teams around a common cause and promote lateral, open communication complete with employee empowerment and ownership of the cause. We can agree that no safety culture is built entirely on behavior-based safety or regulatory compliance alone. Ultimately, we can all agree that safe behaviors must exist within safe conditions in the workplace.
Many of these safe conditions are regulated by OSHA or are addressed in voluntary consensus standards. However, while safety professionals work diligently to engage both leaders and employees, there is often the troublesome situation in which leaders wish their employees would just “be careful” without doing diligence to hazard identification, assessment and control. Workers claim leaders are only concerned with productivity and budgets.
The government has definitive expectations that are reasonable, but become more difficult to comply with when expected in an organization spanning tens of thousands of employees, possibly across multiple cities, states or even countries. It can become easy to point fingers in an ongoing standoff. OSHA may get called.
Even when the popular saying is that “everyone owns safety,” the reality is that, should an incident occur, someone is going to answer for it. However, if we trace the proverbial cord back to the wall, we can see how everyone owns their own piece of the safety culture and how each has their own responsibilities.
Mixed Management or Mixed-Up Management?
Top-down, hierarchal leadership has its place within a situational or contingency leadership environment; after all, a transformational environment during a contingency response could lead to stagnation or even an increased disaster. Instead, a transactional environment may be necessary when lives, property and/or the environment are at stake.
However, during planning, preparedness, training exercises and other facets of a high-reliability organization, the transformational environment allows for lateral communication, a trusting and just culture, and the empowerment and ownership necessary to continually improve processes through persistent hazard identification, assessment, and control. Open communication has been shown to decrease turnover (Smith & Macko, 2014) while servant leadership and its dedication to improving followers’ professional development and opportunities has been shown to increase operational capabilities (Liden, Wayne, Liao et. al, 2014). However, whether in a contingency environment or an organic, transformational environment, it is
critical that leaders in each functional area know what their responsibilities are and where their authority and accountability begins and ends.
In many health systems, hospital or organizational leadership exists in a vertical structure. Each hospital has its CEO, COO, CNO, CFO and other leadership positions. These macro-leaders push directives down to campus leaders and department directors. Directors then push directives down to managers who push them down to supervisors. This continues down to the frontline staff.
In the case of safety, however, a troubling delineation exists in which there are rarely, professional safety managers at the hospital level. There may be safety officers of the Joint Commission variety, but the era of professional safety leadership accounting for all programs, regulations, conditions and behaviors, as well as ensuring integration of the safety culture throughout all areas of the workforce has not yet dawned. In some systems, safety management exists at the system level, usually one or a few centralized professionals doing their best to develop a culture by developing a network to decentralize safety processes throughout a large volume of employees in a horizontal structure. In this same structure, many other functional areas
have horizontal leadership at the system level. Facilities engineering, human resources, education, and other areas have centralized leadership who have decentralized leaders at the hospital level. It is this structure that can cause confusion and stagnation when it comes to safety.
Figure 1: Chart of vertical and horizontal integrated leadership. This figure shows how vertical hospital leadership integrates with horizontal functional area leadership; because each hospital in the system has its own internal chain of command directing its hospital-specific functional area leadership, the system-level functional area leadership must be able to balance system initiatives with hospital priorities while both maintain the value of safety. If neither applies a focus on safety, it can easily be lost in the day-to-day gridlock of hospital operations.
If hospital leadership either declines to or does not know how to develop a safety culture through continual hazard identification, assessment and control, and the processes and programs that integrate this culture throughout their vertical organizations, the horizontal leadership at the system level does not have the authority to redirect efforts. With functional area leadership at the hospital level existing in the vertical structure and accountable to the local leadership, horizontal macro-leaders do not have the ability to adjust metrics and indicators to ensure that safety is given its due diligence.
Furthermore, if the hospital leadership applies itself to a safety culture in the vertical construct, but the horizontal leadership’s focus is maintained elsewhere, the vertical, local leadership must still pay diligence to these initiatives as they may affect the hospital’s system metrics, funding, allocations and more. With this, it is easy for both vertical and horizontal leadership to bypass the hard, arduous process of developing a safety culture. They may think the other functional area leadership is working on it. They may have competing priorities, a dangerous proposition when safety should not be a priority, but a value. When one or even a few centralized safety professionals are attempting to maintain a focus on the value of safety against the powerful tide of everyday operations, system initiatives and compliance standards that may or may not direct resources toward safety, it is easy for safety to be pushed to a back burner.
Ultimately, while this mixed management structure creates efficiency and effectiveness in operational capacities, it can easily steamroll a safety culture. However, if both horizontal and vertical structures maintain safety as a value and existing in valuable key performance indicators, the possibilities are endless for continual improvement. With this, these few safety professionals can fine tune processes and stoke the fires that create safe conditions and influence safe behaviors. When this occurs, everyone benefits.
Liden, R.C., Wayne, S.J., Liao, C., et al. (2014). Servant leadership and serving culture: influence on individual and unit performance. Academy of Management Journal, 57(5), 1434-1452.
Smith, J. & Macko, N. (2014). Exploring the relationship between employee engagement and employee turnover. Annamalai International Journal of Business Studies & Research, 6(1), 56-69.
Cory Worden, M.S., CSP, CSHM, CHSP, ARM, REM, CESCO, is manager of system safety for the Memorial Hermann Health System in Texas and is pursuing his Ph.D. in Safety Leadership. He was the 2014 Institute for Safety and Health Management Safety Professional of the Year, a 2015 National Safety Council Rising Star of Safety and the 2016 ASSE Healthcare Practice Specialty Safety Professional of the Year. Worden has presented his work for ASSE, AOHP, the Global Healthcare Conference and the College of the Mainland.