Volume 35, No. 2 • June 2020   Issue PDF

Effective Leadership and Patient Safety Culture

Brooke Albright-Trainer, MD; Rakhi Dayal, MD; Aalok Agarwala, MD, MBA; Erin Pukenas, MD

Effective leadership is necessary in medicine to foster an organizational culture that promotes patient safety. By fostering an environment of psychological safety that encourages others to feel safe communicating issues and speaking up with concerns, leaders are able to act decisively and timely to protect patients and employees. Ultimately, leaders who promote a positive organizational climate contribute to higher job satisfaction among employees, decreased burnout, fewer medical errors, and an overall improved culture of safety.

Effective leadership is necessary in medicine to foster an organizational climate that promotes patient safety. Leadership is the cornerstone of success to any project or business. Effective leaders lead by example, value a strong work ethic, and demonstrate a commitment to the mission of an institution or department beyond that of self-preservation.1 Capable leaders use a clear vision to instill a larger sense of purpose, setting the tone for the direction of an organization. Leaders who promote a positive and cohesive work environment engender trust among providers and staff and establish psychological safety for employees. Leadership determines organizational priorities and can funnel resources toward important safety initiatives. Fostering an environment that encourages others to speak up with concerns allows leaders to act decisively and in a timely manner to protect patients and employees. Ultimately, leaders who promote a positive organizational climate contribute to higher job satisfaction among employees, decreased burnout, fewer medical errors, and an overall improved culture of safety.2

Safety Culture

Improving safety culture within health care systems is an essential component of preventing and reducing errors. The Joint Commission defines safety culture as the collection of “beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety”.3 A core measure of a strong safety culture is the willingness of employees, whether clinical or in support roles, whether newly hired or experienced, to feel comfortable speaking up when they see something amiss. It is imperative that leaders support and foster an environment in which speaking up is encouraged so that care teams can learn from adverse events, close calls, and unsafe conditions. This can be accomplished by encouraging a transparent and nonpunitive approach to reporting. Moving to a “just culture” where individual blame is minimized or removed, and a focus is placed on system faults that contribute to adverse events, can improve a safety culture.

Leaders must also adopt and champion efforts to eradicate intimidating behaviors. When unprofessional behavior is tolerated within an organization, it undermines patient safety. Failing to address unprofessional behavior in a fair and transparent manner allows such behavior to persist and signals to new employees that such behavior may be tolerated, potentially promoting more of it. Addressing unprofessional behavior in disruptive employees can yield improved staff satisfaction and retention, enhanced reputation, improved patient safety and risk-management experience, and better work environments.4

Team members who identify unsafe conditions or who have good suggestions for safety improvements should be recognized and rewarded. Leaders can use a number of techniques to improve safety culture, including use of surveys to identify culture gaps, encouraging teamwork training, performing executive walk-rounds, and establishing unit-based quality and safety teams.5 By proactively assessing system strengths and vulnerabilities, health care teams can track progress and prioritize areas to improve safety culture.

Psychological Safety

Psychological safety is defined as the belief one will not be punished for making an error or speaking up. It is a core component of a safe culture, and intertwines with both patient safety and burnout. Psychological safety allows for creativity, speaking one’s mind, and lack of fear for having new, different, or dissonant ideas.6 A psychologically safe environment also permits providers to discuss issues related to their own work-life balance. In creating psychological safety, leaders must foster an environment where providers feel safe communicating issues with patient care. Effective leaders maintain open lines of communication and remain open to feedback. Though this may subject one to increased vulnerability, the ability to accept feedback and react constructively allows leaders to recognize problems earlier and deal with them proactively.1 Otherwise, team members may not speak up about a problem for fear of retaliation or humiliation.

Organizational Culture and Employee Burnout

Figure 1: Work-life imbalance can contribute to employee burnout.

Figure 1: Work-life imbalance can contribute to employee burnout.

An organization’s culture can enhance patient safety and drive quality. It can also contribute to burnout (Figure 1). Burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.7 Traditionally, organizational culture in health care has not allowed room for a discussion of work-life balance. Providers have feared voicing concerns regarding their personal needs that may not align with departmental or institutional goals. Some institutions may only start to pay attention to burnout when it begins to contribute to loss of productivity, patient access, lower patient safety scores, and increased costs. Frequent management changeover or uncertainty, lack of a strategic plan, or goal incongruence can lead to physicians feeling devalued or ineffective. High rates of turnover can be a sign that ineffective leadership is contributing to high burnout rates in departments or institutions. Turnover leads to increased costs, recruitment expenses, agency/locum bridging, higher rates of paid time off, and need for additional support services, to name a few.

Today, as data continue to mount relating burnout among health care workers to increases in incidence of medical errors and malpractice, it is in every institution’s best interest to address employee stress and work to successfully manage it. Following the Institute of Medicine (IOM) landmark report asserting that deaths from medical errors had become the third leading cause of death in the US behind cancer and heart disease, quality improvement initiatives to reduce patient harm have spawned nationwide.8 Recent studies have suggested a two-fold increase in medical errors when associated with clinician burnout as compared to those not associated with burnout, with an overwhelming 55% of respondents reporting burnout symptoms.9 If these issues go unaddressed, the health care professional’s well-being, or potentially even the his or her safety, can become compromised. To prevent burnout and increase wellness amongst providers, leaders should reflect on an organization’s climate and implement change when needed. By implementing monitoring tools, including workplace wellness initiatives and workplace response teams, leaders can foster an organizational culture that prevents burnout.

Key Attributes of Effective Leaders

Acquisition of certain attributes in leadership is so important that a multitude of workshops, courses, and degrees have been established to help hone and refine these skills. The following list, though not comprehensive, reviews a few of the most important attributes that distinguish an effective leader from an ineffective one (Table 1).

Table 1: Key Attributes of Effective Leaders

Key Attributes of Effective Leaders

Effective Communication

Effective communication is necessary to allow an organization’s people to know what is expected, valued, and appreciated. Clearly articulated goals help people remain focused, track progress, and discuss challenges openly. As new ideas are developed, it is critical to clearly define mission objectives and review them at regular intervals along the way with all involved stakeholders, including frontline providers, thought leaders, or senior faculty. This monitoring of progress with regular checks and balances avoids potential miscommunication and assures compliance with intended goals. At all times, leaders must remain open to constructive criticism and feedback. If this is hindered, team members may begin to fear retaliation or humiliation for speaking up.

Collaborative Teamwork

Fostering a culture of teamwork and camaraderie is essential to building a culture of safety. Leaders should take pride in what their providers have already accomplished while nurturing their skills for further development. The positive attitude from the leader is instrumental and contagious at the same time. When leaders work together with their frontline providers, it empowers them to partner with the vision and the growth at the highest level. One example of collaborative teamwork is the sharing of important data metrics. Providers are more likely to comply with the recurrent demands of workplace objectives when given a better understanding of why they need to do it. Effective communication and collaborative teamwork are essential in aligning with a common goal.


While experience alone does not make a great leader, experienced leaders may be more comfortable taking chances and more confident making decisions. When leaders hesitate or become indecisive, as inexperienced leaders sometimes do, it can lead to confusion and exhaustion among employees. However, every future leader needs a place to start. Professional development and leadership training for high-potential individuals can be of great benefit to organizations. While some may have the skills to be successful as leaders more innately than others, not everyone is a natural born leader. Even those with significant experience or professional leadership training may fail. A study by the Center for Creative Leadership showed that roughly 38% to more than half of new leaders fail within their first 18 months.7 Leaders can avoid becoming part of this staggering statistic by incorporating good leadership strategies that motivate their team members to accomplish their goals. Openness to feedback, checking in regularly with one’s own goals, and recognizing signs of failure are all keys to success and continuous improvement.


It is imperative that leaders work with frontline providers to develop and implement creative work strategies to maximize efficiency while limiting workplace stressors and reducing burnout. Increasing pressure continues to mount from organizational and third-party stakeholders to meet metrics. Some institutions are seeing only a slight increase in volume, yet the work hours are longer, translating to an increased risk to the employee’s health with diminishing returns in productivity. Longer employee work hours are associated with increased fatigue, poor mood, poor recovery from work, and a nearly 40% increase in risk for coronary artery disease.10-12 Men and women working long hours showed higher prevalence of depression and anxiety disorders.13 For decades, the National Institute for Occupational Safety and Health (NIOSH) has recognized shift work and work-related sleep loss to be a hazard in the workplace and has carried out an active research program to address this hazard. A goal of NIOSH’s National Occupational Research Agenda (NORA) for Healthcare and Social Assistance is that health care organizations adopt best practices for scheduling and staffing that minimize excessive workload and other factors associated with fatigue.14 As the cost of health care continues to increase, so do the demands on productivity. With continual improvements in information technology, electronic medical records, and machine learning, there is a growing list of tools available to help improve processes and streamline care so that increased productivity demands do not always translate into increased workload.


Effective leadership in medicine is necessary to promote patient safety. Leaders must continually strive to be role models, stewards of resources, and improve processes. Effective leaders support safety initiatives and create systems that address concerns brought forth by frontline providers and patients. Constraints of any kind in an organization can lead to increased frustration, communication breakdown, and potential errors. In order to remain efficient and effective, leaders must overcome these obstacles and maintain forward thinking, regularly checking in with their employees, ensuring their state of wellbeing, and taking corrective action when elements become out of balance. By creatively adapting and effectively communicating, leaders can help their organizations accomplish goals, even in difficult times. Employees with higher job satisfaction at work have lower rates of burnout, allowing for increased focus, productivity, and fewer overall medical errors.


Dr. Trainer is assistant professor of Anesthesiology at Virginia Commonwealth University and Central Virginia VA Health Care System in Richmond, VA. She is also completing a fellowship in Critical Care Medicine with the Department of Anesthesiology and Critical Care at the University of Virginia, Charlottesville, VA.

Dr. Dayal is program director of Pain Medicine in the Department of Anesthesiology and Perioperative Care, University of California Irvine, CA, and is an associate clinical professor in the Department of Anesthesia and Perioperative Care, University of California Irvine Medical Center, CA.

Dr. Agarwala is chief medical officer at Massachusetts Eye and Ear, faculty anesthesiologist at Massachusetts Eye and Ear and Massachusetts General Hospital, and assistant professor at Harvard Medical School, Boston, MA.

Dr. Pukenas is vice chair and vice chief of Administrative Affairs in the Department of Anesthesiology at Cooper University Health Care and assistant dean for Student Affairs and associate professor of Anesthesiology at Cooper Medical School of Rowan University in Camden, NJ.

The authors have no conflicts of interest.


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