This case study first appeared in the report Committed to Safety: Ten Case Studies on Reducing Harm to Patients by Douglas McCarthy and David Blumenthal, M.D.

Organization. Sentara Norfolk General Hospital (SNGH) is a 569-bed, level-one trauma center located in Norfolk, Va. It is one of six hospitals in a regional integrated health care delivery network operated by not-for-profit

Many companies and some medical centers have instituted behavior-based workplace safety programs comparable to the program at SNGH. Thomas Krause, Ph.D., CEO of Behavioral Science Technology, Inc., in Ojai, Calif., describes behavior-based safety as a comprehensive program for continuously improving the safety environment by identifying workplace behaviors that are critical to safety, removing barriers to their practice, and reinforcing desired behaviors through observational feedback (Krause 2002). His study of behavior-based workplace safety programs in 73 companies found that they resulted in significant reductions in reported occupational injuries (Krause et al. 1999).

Implications. SNGH's experience models the idea that culture change is enhanced by embedding specific tactical safety improvement projects and activities in a larger organizational strategy. "Organizational culture drives behaviors and behaviors drive outcomes," said Johnson. The process also works in reverse, in a self-reinforcing circular fashion. Hence, an organization can use behavioral observation, coaching, and feedback as a form of social engineering to promote the practical learning of new safety-enhancing skills and behaviors that, over time, can become the internalized norms of a safety culture.

Some labor unions have criticized behavior-based workplace safety programs, which they perceive can lead managers to blame workers for unsafe acts, avoid responsibility for correcting hazardous conditions, and reward the suppression of injury reporting (Lessin 2002). Thomas Krause, Ph.D., one of the fathers of behavior-based workplace safety, acknowledges that some poorly implemented approaches focus on rewards rather than genuine employee involvement or fail to adequately consider behavior in the context of systems. In a well-designed program, hazards should be addressed as close to their source as possible, he says. For example, hearing protection should not be promoted as a safe behavior if the source of noise can be eliminated in the first place.

Given these considerations, three elements of SNGH's approach should be noted:

• Strategies originating in other industries were evaluated and internalized to the health care setting through the participation of frontline staff in implementation.
• Behavior-based expectations were implemented in concert with enhanced organizational capability to conduct rigorous systems analysis.
• Behavioral observation occurred within a framework that eschews blame for honest mistakes while encouraging the reporting of errors for organizational learning.

Through a multifaceted approach, SNGH appears to have achieved a reasonable balance for meeting safety goals incorporating individual behaviors, systems design, and organizational factors.

back to top>

This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.