Effect of the Green Cross method on patient safety culture in a postanaesthesia care unit: a longitudinal quasi-experimental study

Background

Globally, more than 10% of hospitalised patients experience adverse events.1 Some of the most common types of adverse events are related to surgery.1 Adverse events are unintended injuries caused by medical management rather than the underlying disease that prolong hospitalisation and cause disability or even death.1 This is an immense burden on individuals and consumes resources in health systems and societies that could be used productively elsewhere.2 About half of the adverse events can be prevented through a strategic and coordinated approach.1 3 One approach is to monitor incidents, including harmful events and near-misses, with the emphasis on making future care safer.3 4 It is imperative for healthcare professionals to get an overview of incidents to be able to prevent future harm. However, not all complications can be prevented; patients get older and frailer and react differently to medical treatment. By monitoring incidents, healthcare professionals can anticipate complications and respond more effectively when they occur, thereby contributing to resilience.3 5 6

To get a comprehensive review of the types of events that occur, complex adaptive systems should use multiple monitoring methods.3 7 The most widespread methods are incident reporting systems where healthcare professionals record incidents.4 8 However, incident reporting systems are not effective for double loop-learning, that is, cultural change.8 9 Under-reporting is common and linked to a lack of feedback and learning.10 Other barriers are non-consensus on what to report, complicated systems and fear of shame and blame.11 To make incident reporting systems more effective, it is advocated to decentralise their management from centralised hospital departments to clinical teams, make reporting easier, give timely feedback and focus more on learning.4 8 12–14 To promote learning it is imperative to develop a culture of respect, openness and transparency.3

The Green Cross (GC) method is a simple visual method for healthcare professionals to recognise incidents in real time.15 Contrary to traditional incident reporting systems, the GC method is based on teamwork where incidents are discussed in daily safety briefings and weekly quality improvement meetings, thus decentralising its management and providing daily feedback. The non-anonymous reporting requires psychological safety to dare to speak up about errors, thus facilitating openness and transparency.3 16 Moreover, it requires that everyone involved avoids blaming and shaming and supports a restorative and just culture.16 17 Templates and the use of incident definition facilitate clarity and promote learning.16 The GC method was invented in Sweden in 2011 and has since spread internationally.18 It consists of seven steps: (steps 1–3) daily interprofessional safety briefings in which incidents are collected, assessed and visualised, and (steps 4–7) the recording of adverse events in the hospital incident reporting systems, involvement of patient and relatives, and working on improvements.15

A culture of openness and learning is closely linked to the safety culture. The term was first used in 1986 to describe the cause of the nuclear power plant disaster in Chernobyl, which was attributed to a breakdown in the safety culture of the organisation.19 The aspects of safety culture that relate to patient safety are termed patient safety culture (PSC).20 PSC is the cornerstone of the safety movement21 22 and is perceived as an indirect measure of quality of care.23 24 A PSC can be defined as ‘an integrated pattern of individual and organisational behaviour, based on shared beliefs and values that continuously seeks to minimise patient harm, which may result from the processes of care delivery’ (EUNetPaS, p4).25 This definition implies active involvement in reducing patient harm, which is the crux of the GC method.

Positive PSC is statistically associated with reduced adverse events.26 It plays an essential role in the effective recognition and response to surgical complications and may be the main driver of the variation in failure to rescue.27–29 PSC as a part of safety culture can be measured and improved.30 Since PSC is a group-level property that emerges and lives in work units,31 32 initiatives to improve PSC at the unit level are necessary.27 Thus, the GC method was implemented in a Norwegian postanaesthesia care unit (PACU) in 2019, which is the context of this study.33 Questionnaires, such as the Safety Attitudes Questionnaire (SAQ),34 can effectively capture tangible themes of PSC, such as teamwork, error notification and learning, and staff well-being.35–37 Since 2018, Norwegian hospitals have used an annual hospital staff survey (staff survey) to assess the safety culture.38 This study explores the Staff Survey factors ‘work engagement’, ‘teamwork climate’ and ‘safety climate’. The factors were chosen because they play an important role in providing safe patient care.26

Related reporting methods like safety briefings have significantly improved PSC.39 The GC method has also significantly improved PSC in nursing units in a Swedish hospital.15 However, the longitudinal effects of these methods are not studied. Longitudinal studies are useful in evaluating the sustainability of interventions.40 This study fills the gap of longitudinal, controlled studies on the effect of the GC method and safety briefings on PSC,41 specifically in relation to teamwork, job satisfaction and work engagement.39 42 This may be useful to present and future users of the GC method and similar methods.

This study aimed to explore whether the implementation of the GC method in a PACU changed nurses’ perceptions of different factors associated with PSC over 4 years. The research question was How does the implementation of the GC method in a PACU change the nurses’ perceptions of ‘work engagement’, ‘teamwork climate’ and ‘safety climate’ over 4 years.

Methods

Intervention

A modified version of the seven-step GC method was implemented in February 2019, to better respond to context. Figure 1 shows how it was practised and some empirical experiences with the steps. The modification considered the time of recording the incident. This was done in real time by the nurse before the safety briefings (step 1). Modification also considered the daily safety briefings that were not attended interprofessionally, as this was not feasible. The recorded events were read aloud, and their severity was assessed and visualised using a template that included the days of a month assembled in the shape of a cross (step 3). At the weekly quality improvement meetings, the previous weeks’ events were discussed to develop a common understanding of patient risks and to learn from them (step 4). Although the managers prioritised the quality improvement meetings, it was not always possible to carry them out, especially on busy days.46 The meetings were attended by PACU nurses, certified nursing assistants and nurse managers. They were sometimes attended by one or two anaesthesiologists, pharmacists, surgical nurses and nurse anaesthetists, although their respective units did not use the GC method. More details regarding attendance are described elsewhere.46 Improvement work could be initiated based on these discussions and the monthly summary (step 5). The modification also regarded the patients’ and relatives’ involvement when patient harm occurred. This was not done because of the patients’ short stay in the PACU. Further details of the intervention are described elsewhere.33

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Figure 1

The GC method as it was implemented, including empirical experiences with the steps. Original templates are reproduced with permission.15 GC, Green Cross; IRS, incident reporting system; QI, quality improvement.

Kotter’s eight-step process for leading change helped guide the implementation.47 In the preparation phase (1) the need for change was established, (2) a project group was created and (3) a modification of the GC method and a systems focus on patient harm were agreed on.48 In the action phase (4) the vision was conveyed to the nurses through 2-hour lectures, (5) all material was made available to empower the intervention, (6) small wins were celebrated and (7) the project group, including management, did not stop pressing on. To create a culture (8) daily safety briefings and weekly interprofessional improvement meetings continued. The managers even introduced the GC method to nurses during employment.46

Results

Descriptive results

In the period of 2018–2022, a total of 277 individual survey responses were completed in the intervention unit (mean 55 surveys /year), and 565 individual survey responses were completed in the comparison group (mean 113 surveys /year). The average response rate in the intervention unit ranged from 49% to 77% (mean 71%). The lowest response rate, in 2020, coincided with the beginning of the first wave of the COVID-19 pandemic. The response rate in the comparison group ranged from 67% to 84% (mean 75%).

The descriptive statistics of ≥75 scores of all the included factors in all years are presented in table 2 and figure 2. This score refers to the distribution within the unit and to an extent to the degree of consensus, which has been found to correlate with patient safety.52

Table 2

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Percentage of respondents who answer positively (≥75 scores) on each factor

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Figure 2

Work engagement, teamwork climate and safety climate. Proportion of respondents in the intervention unit (IU) versus comparison group (Comp) that answers positively (≥75) on each factor. Vertical line marks the start of the Green Cross method implementation (February 2019).

Discussion

As related to the SEIPS model, the improved outcomes with time in the intervention group, with a medium-to-large effect size, indicate the effect of the GC method.53 The results suggest that the greatest change in PSC was achieved in the first month after the implementation (2019). In 2020, during the first wave of the COVID-19 pandemic, all factors returned to the baseline level. Due to the low response rate, this result might not have been representative of the culture.54 Nevertheless, the GC method was used to a lesser degree during this period because of the strains of the pandemic and could explain the lower score.46 The decrease, followed by the significant large increases in ‘work engagement’ and ‘safety climate’ in 2021, indicates its effect on PSC. After 4 years, ‘work engagement’ remained significantly increased, suggesting that the effect was only partially sustained and that the intervention perhaps affected the individual level more than the group level.

There was a significant, sustained, medium-to-large increase in ‘work engagement’, which strongly suggests that the GC method increased work engagement. This can be regarded as an improved professional outcome in SEIPS. Healthcare professionals’ well-being is equally as important as performance in SEIPS.55 In this study, ‘work engagement’ includes job satisfaction, having engaging work tasks, being able to develop oneself through work and receiving constructive feedback (table 1). The findings matched the nurses’ commitment to patient safety and to improving the system, which was sustained 3 years after the implementation of the GC method.46 The results also agree with previous studies in which safety briefings were found to increase job satisfaction.42 A possible explanation for the increased engagement may be the novel safety briefings and weekly meetings, which allowed the nurses to participate in decision-making and communicate openly with their managers. While most PACU nurses attended the daily safety briefings on a regular basis, they attended the weekly quality improvement meetings less frequently due to shift work and an unpredictably busy unit.46 This suggests that the safety briefings influenced the nurses more than the improvement meetings. Job satisfaction is strongly linked to psychological safety, which is a prerequisite for being willing to contribute ideas and actions and is thus essential for the GC method.56 Discussing patient safety questions and suggesting improvements might have increased the nurses’ autonomy, contribution and sense of belonging. These are important steps to promote well-being and reduce burnout.57 Involving the team in decision-making and creating a psychologically safe climate is also associated with a positive PSC.35 Healthcare professionals’ well-being affects patient experience.58 Therefore, increasing ‘work engagement’ should be the prime consideration for every manager, and the GC method could help facilitate this.

‘Teamwork climate’ can be regarded as an improved organisational outcome in SEIPS. The initial significant large increase in the ‘teamwork climate’ score may be explained by this being the first time patient safety questions could be discussed by healthcare professionals across ‘silos’—that is, the operating room and the PACU. The interprofessional team experienced that the different perspectives conveyed in these meetings improved interprofessional communication and increased the shared understanding of the risks and safety in the perioperative pathway.46 The finding also agrees with previous studies in which safety briefings and the GC method had a positive effect on teamwork.15 42 However, in the present study, the large positive significant effect on ‘teamwork climate’ score was not sustained. A plausible explanation is that interprofessional attendance was achieved only to a limited extent.46 This was partly due to organisational factors, such as a lack of time.46 Interestingly, the comparison group had a substantial increase in ‘teamwork climate’ with time. A possible reason may be that a contamination effect occurred and that the scores were interrelated.44 Creating reflective spaces across an organisation is the foundation of resilient capacity in healthcare.59 Interprofessional reflexive space is key for learning, developing a collaborative culture and mutual understanding.59–61 It strengthens relationships and teams, enhances PSC and improves patient care.39 Moreover, good collaboration can positively influence patients and is vital for good recovery and successful surgery.62–64 Therefore, hospitals stand to benefit from facilitating interprofessional reflexive spaces, such as briefings, for the perioperative team.

‘Safety climate’ may be considered an improved organisational outcome in SEIPS, and this score increased significantly in 2019 and 2021, with a large effect size. Safety climate includes reporting and learning from errors (table 1). The nurses reported more near-misses and had increased communication and learning about near-misses after implementing the GC method.33 46 This concurs with previous studies.7 15 A culture of trust and dialogue, in which it is safe to talk about mistakes and there is collective learning, is a construct associated with a positive PSC.35 This is also the hallmark of the GC method.16 Nevertheless, in 2022, there was no significant increase in ‘safety climate’. The nurses were reluctant to report because of limited visible improvements, for example.46 Insufficiencies in reporting and planning improvement work were also found in other Norwegian hospitals that use the GC method.65 Learning is a complex social process that includes actively reflecting on and reorganising shared knowledge, organisational routines and practices.13 66 67 Interestingly, in Sweden and Norway, injuries that occurred in other units were problematic because they could be considered as looking for mistakes in others.16 33 46 This could have made it difficult to work on system improvement. To increase learning, it is important to collect data in real time and discuss this within the interprofessional team in the closest proximity to the point of care.59 68 However, investigations and improvements targeted at the unit level may give a limited perspective on system failures and provide fragmented and limited quality improvements.69 To make viable improvements, clinicians must be trained in human factors and systems engineering.70 A secondary support structure, such as hospital boards, may be beneficial in assisting in the trying out of new quality improvement ideas.71

In Norway, postoperative death following a surgical complication has dropped around 30% the last decade, without a similar fall in surgical complications.29 This suggests that the safety culture in most Norwegian PACUs has improved. Nevertheless, there are significant differences in postoperative deaths between hospitals, although they have similar complication rates.29 72 Differences in PSC may explain this variance.27 29 In this study, the mean percentage of nurses who responded positively to all three factors increased from 77% to 89% over 4 years (table 2). A positive consensus of above 60% on the safety and teamwork climate is considered a mature PSC in Norway,73 based on recommendations from 15 years ago.74 Perhaps it is time to raise the bar and aim as high as 80% to further reduce postoperative mortality.

Conclusion

The results suggest that the GC method had a positive effect on nurses’ perceptions of areas of PSC over a period of 4 years and could thus be used to achieve a positive PSC in a postoperative context. However, the effect was only partially sustained. The decline in ‘teamwork’ and ‘safety climate’ could indicate insufficient utilisation of the GC method regarding interprofessional safety briefings and work on improvement. It could also be caused by other elements in a complex system. The research took place during COVID-19 which undoubtedly affected the study procedures and findings. Therefore, future studies focusing on how to improve interprofessional learning and improvement work in the perioperative pathway are desirable. We also recommend further research to determine the effects of briefings on work engagement.