Safety Culture

Few people understand that construction safety and healthcare safety have a great deal in common. In the early 1980’s most American construction companies were perfectly satisfied if their accident rates were at or slightly below OSHA’s national averages. We did very hazardous work and accidents were felt to be unavoidable. I spent the summer of 1977 working as a laborer on the Jim Bridger Power Plant in Rock Springs, Wyoming. In that very brief three-month period, three men fell to their deaths in separate tragic accidents. Each time, the whistle would blow and 5000 workers would get to go home early while the investigators tried to figure out what went wrong. The expected and usual answer was human error: “The guys messed up.” We were sad, but not all that concerned; after all, we were certainly smart enough not to kill ourselves on the job.

It took a construction user from Pennsylvania in the late 80’s (the same state where healthcare safety led the nation) to rock our world with the simple concept that “just because construction accidents occur does not mean that they must occur!” Air Products and Chemicals taught their contractors how to work 2.4 million man-hours without a lost-time accident. They proved that a goal of “Zero Injuries” was not just a dream but was an achievable reality. It took another decade for the rest of construction to catch on. A few smart CEO’s did the math and realized that getting even close to zero would save their companies millions of dollars each year in reduced workmen’s compensation premiums and vastly reduced injury claim costs. Later the followers would jump on board to keep up.

Construction and healthcare are both extremely labor-intensive and, unlike manufacturing, not highly repetitive. Both utilize a great number of tools and rapidly changing technology. Both use technical words that are very Greek to everyday people. Our workforces have a very wide range of education and job-specific training. We struggle with mold; you struggle with bacteria. Sadly, both industries have devastating, often fatal, results when errors happen. Healthcare depends on construction to build their facilities and construction depends on healthcare to heal our injured and take care of our families. We can learn a lot from each other.

In 1993 the researchers jumped in to figure out how these guys from Pennsylvania were so good. They found that the great safety companies tackled the “Guy messed up” problem by doing random drug testing, by doing safety orientations at the beginning of jobs, by forcing the individual to stop and think with a simple process called “Pre-Task Planning,” and by giving awards for safe behavior. Of the four, Pre-Task Planning was the most effective and has the most relevance for healthcare. The idea is simple. At the beginning of the day or before you start a new task, you stop and fill out a simple checklist on a pocket-sized card and describe how you will do the task. Then you get a supervisor or co-worker to review it to see if you are doing anything stupid. Some of you will say, sure, busy nurses are going to stop and fill out a card every time they do a new task?

I witnessed a real-life example of how it could have worked while spending a week in the hospital in 2005. My roommate was an 83-year-old retired minister with a freshly repaired broken hip.  About three days post-op a nurse and a physical therapist walked in and announced that my neighbor was going to walk to the bathroom today. They got on either side and picked him up, took a step, then found that the cubicle curtain was in the way and had to set him back down. The next shaky attempt made it three steps before they found the cart was blocking the route. The third try was successful. Had they stopped to plan the task, two chances of dropping the patient could have been avoided and his wife’s stress level greatly reduced.  Each day there are thousands of tasks that could be planned better with two minutes of thought and a little reminder card.

Even with Pre-Task Planning, we found that some longer operations were so complex that having workers think individually did not address all the hazards. To solve these problems required group thinking, so we created Integrated Work Plans (IWP’s). IWP’s are very detailed how-to manuals jointly written by the project engineer, foreman, superintendent, carpenters, laborers, and safety engineer. They get down to the nitty-gritty detail of bolt sizes, tool model, engineering calculations, where to stand, how to drill, etc. After agreeing on the plan it is placed in the gang boxes and carried by workers on their belts. The group can modify the plan, but it must be in writing and must be distributed. Group planning with IWP’s has produced amazing results in safety, quality, and cost. The biggest adjustment is getting over the very old fear of seeing your production guys spending an hour in the morning planning the work instead of jumping in and immediately doing the work.

Sometimes I am perplexed at how this kind of planning can go into pouring a concrete wall, but a surgeon can saw a guy’s knee out and throw in some stainless with no written plan at all. Healthcare workers are always rushing around, so busy putting out endless fires that they seldom take the time to plan the task or communicate the plan to the rest of the team.

Over the past 15 years construction safety culture has evolved to the point that we no longer are doing it just to keep up with the competition. Much of this is due to extreme commitment by our CEO and VP’s. They do much more than cheerlead; they walk the talk and hold people accountable. It is far easier to get fired for having injuries on your job than it is for losing money. We still have goals and measure everything we can possibly find. When setting goals we gather a group of supervisors together, look at past performance, and then set goals that are significantly better than we have ever done before. The next step is where culture changes. After everyone agrees on a goal, we multiply it by the number of man-hours we expect to work and tell the staff,  “You just agreed it is acceptable to injure eight guys this year.” We then flash a slide of the 400 names of our field employees and ask which eight workers is it acceptable to injure? The room goes dead silent and everyone knows in their heart that zero is the only goal their conscience will allow. Culture can change.  It is not easy, and it is extremely hard to maintain every day. You notice it more in thousands of little everyday worker decisions than on big charts and graphs. The construction industry empowered our workers to call time-outs and stop unsafe work 15 years ago. Today we are growing into the next step, from workers being empowered to workers being obligated to stop any work that they sense might be unsafe. We give new workers red hard hats and a buddy to watch them and help them work safe. It would not be difficult to give new hospital employees an identifying uniform so that the experienced staff could help them work safely.

We are frequently told by subcontractors that we are too extreme on safety; we hurt their production. It is quite a compliment, second only to a worker’s spouse thanking you for sending their loved one home safely each night. I know that healthcare can follow the same path we did.  After all, you were a whole lot smarter in school than we ever were! (But we had nicer trucks.)

Kerry O’Connell  1/25/2010

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About Kerry O'Connell

Kerry O'Connell is a civil construction project manager and a member of the Colorado Health Facility Acquired Infections Advisory Committee. A committed patient safety advocate, he calls for restoring empathy and compassion in health care. He became a Numerator in 2005.
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One Response to Safety Culture

  1. Gary Fasso says:

    Excellent articles, Kerry, especially the one above. I recently contributed to a blog here in Washington regarding the same issue: Construction’s solutions to human error = Safety Hazard Analysis (as we call them). Click or Copy & paste –
    http://www.wapatientsafety.org/surprise-patient-safety-can-learn-from-the-trades-as-well-as-from-aviation
    I see you work for Mortenson, have you heard of the UBC’s training to eliminate Construction related HAI’s? Click or Copy & paste –

    It’s nice to read something in this industry written in my language! Any comments or insight would be appreciated.

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