Although the culture of safety is a serious business, it does not have to be implemented with a grim face. Joy and spirit of care giving are also linked to patient safety. Joy comes from witnessing successful patient outcomes and seeing a patient and family experience their healing journey.The use of emoticons to convey information saturates our wired world. One of the more popular emoticons is the smile. The smile is ubiquitous throughout computer generated communication such as emails, texts and social networking applications. Could we parlay its popularity in our patient safety efforts? We surmised that a healthcare provider, who is trained in the SMILE culture of safety model, would more easily recognize our culture of safety framework when this emoticon was used as a part of their daily communicating life.

1. SAFETY CULTURE
Krishnan Sankaranarayanan and Dr Steven A Matarelli, Tawam Hospital
SUPPORTING CARER'S ROLE
IN PATIENT SAFETY
Putting a smile on the culture of safety framework
In a multicultural and multilingual hospital, language
can be a barrier to effective staff training. Krishnan
Sankaranarayanan and Dr Steven Matarelli utilise
the strength of recognition memory to overcome
learning obstacles through the use of a familiar
emoticon, the smile.
Most frameworks involving a culture of safety place patients
at the centre of the care delivery model1. When considering
health policies, Ostrom stated that frameworks are designed
to organise inquiry through identification of elements and
potential relationships, but are not intended to specifically
test, explain, or predict the behavioural outcomes or strengths
of association that a theory would test2.
In the healthcare setting patients occupy the centre
prominence of our safety efforts, but we suggest that care
providers play an equally important role in optimising patient
safety. Furthermore, extrinsic factors such as government
agencies are, at times, excluded from these discussions.
Some frameworks are structurally complex, making it difficult
for end users to retain, remember, and apply concepts
consistently in practise.
Although the culture of safety is a serious business3, it does
not have to be implemented with a grim face. Joy and spirit
of care giving are also linked to patient safety. Joy comes from
witnessing successful patient outcomes and seeing a patient
and family experience their healing journey4. Leape offers
that joy and meaning will be created when the care providers
feel valued, safe from harm and are part of the solution
for change5.
“although the culture of safety
is a serious business3, it does
not have to be implemented with
a grim face”
How, then, do we approach a complex system framework,
such as patient safety, with a programme that is meaningful,
sustainable, and consistently recognisable - if not marketable to the bedside care givers? We have found that the correlation
of thoughts plays a significant role in the retention and
recognition of information for our multicultural staff. Gigerenzer
posited that the strength of recognition surpasses that of
simple recall in humans – when recall is impaired, recognition
often remains6.
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One way to strengthen recognition and information recall is
through the use of mnemonics7. Mnemonics encode complex
information, in which unfamiliar material to be learned is linked
with known information, pictures or symbols7. Visual cues and
auditory reminders enhance meaningfulness of new
information and promote overall strength of association
between novel learning and known or familiar patterns8.
Healthcare settings are ideal training grounds for the use of
mnemonic learning strategies, particularly when faced with
novel information or step dependent procedures. Mnemonics
such as SBAR, SHARQ, I PASS THE BATON and the 5 Rs
have become ubiquitous in patient safety programmes and
staff education throughout healthcare, as one type of aid to
break communication barriers between various patient care
team members9.
“in our multilingual Middle Eastern
setting, we needed something
with the power of recognition over
recall to help drive the message
of our patient safety programme”
In our multicultural and multilingual Middle Eastern setting,
we needed something less complex and more in line with
the power of recognition over recall to help drive the message
of our patient safety programme. The SMILE culture of safety
framework was created with this purpose in mind.
The use of emoticons to convey information saturates our
wired world. One of the more popular emoticons is the smile.
The smile is ubiquitous throughout computer generated
communication such as emails, texts and social networking
applications. Could we parlay its popularity in our patient
safety efforts? We surmised that a healthcare provider, who
is trained in the SMILE culture of safety model, would more
easily recognise our culture of safety framework when this
emoticon was used as a part of their daily communicating
life. Here, we hope, is where the correlation of thought comes
to fruition with information retention and recognition in our
multicultural staff.
Through our programme implementation and staff evaluations
using instruments that assess cultures of safety, such as the
Pascal Metrics’ Safety Attitude Questionnaire (SAQ), the
Agency for Healthcare Research and Quality’s Hospital Survey
on Patient Safety Culture (HSOPS), and through deep, unit
based conversations over the past five years, we have derived
certain domains that we feel are inextricably linked to our
programme’s understanding and implementation success.

2. SAFETY CULTURE
External constructs
As explained earlier, the key external constructs of the
SMILE culture of safety framework are health policy
decisions, regulators and healthcare leaders, based on
a solid foundation of commitment and engagement.
These external constructs balance and provide supporting
boundaries to the SMILE framework.
Health policy decisions, regulators and
healthcare leaders
These domains were aligned to fit the SMILE conceptual
framework as follows:
S - Systems and support
M - Morale and motivation
I - Information and open communication
L - Leadership and commitment
E - Empowerment and engagement
In examining the role of state legislatures in regulating patient
safety, it was found that legislation serves an important
function in health policy creation, as it is an intermediate step
to bringing the patient’s perspective to the table10. Hospitals
and hospital leaders alone cannot establish a culture of safety;
they are governed by health policy decisions and regulators
as extrinsic factors. As such, health policy decisions and
regulators play an important role in driving the culture of safety
in hospitals.
Devers, Pham, and Liu described three general mechanisms
for stimulating hospital staff to reduce medical errors:
professionalism, regulation and market forces11. Organisational
participation in quasi-regulatory organisations such as the
Joint Commission (formerly the Joint Commission on
Accreditation of Healthcare Organizations) was found to be
the primary driver for hospitals’ patient safety initiatives11. 
29
October 2013

3. SAFETY CULTURE
Government agencies must participate to create atmospheres
and environments that foster the implementation of safety
culture in hospitals – punitive approaches to patient safety have
done little to contribute to a safer environment12. Health policy
decisions must be created in the spirit of patient safety and
regulators must pledge commitment to the cause of a culture
of safety. Healthcare leaders must exhibit their commitment by
engaging themselves in practise and being active participants
where health or organisational policies are created.
Commitment and engagement
When medical errors occur, patients may be harmed and
qualified healthcare providers may seek new positions
or leave the organisation prematurely, rather than face the
consequences often associated with errors13. Leadership
commitment and engagement are critical success factors
that drive a culture of safety. Our experience illustrates that
we can achieve great improvements in clinical and operational
outcomes if our leadership becomes a strong advocate of
patient safety, and if our commitment and engagement is
evident throughout the organisation.
One way healthcare leaders may showcase their commitment
and engagement is by conducting walkarounds in patient
care areas in order to engage, first hand, with frontline staff,
thereby providing a workplace forum to discuss their safety
concerns14. Use of open forums and open door policies
in order to listen to staff concerns are other effective tools.
While these are not unique behaviours to other leadership
engagement models, at the time of implementation they were
unique behaviours for our organisation. Regular walkarounds
have become a trusted forum in which staff can speak up.
Further, we found the importance in leadership commitment
and staff engagement through demonstrated safety awareness
throughout the organisation, in areas such as intimidating and
disruptive behaviours as a complementary path to patient
safety. Commitment and engagement are manifested by
creating a code of conduct and procedures to establish zero
tolerance for disruptive behaviours. We empower staff to
speak up and voice their concerns.
“if leadership fails to challenge
unsafe behaviours, then it means
we have inadvertently reinforced
the notion that such behaviours
are acceptable ”
We found that if leadership fails to challenge unsafe
behaviours, then it means we have inadvertently reinforced the
notion that such behaviours are acceptable in our healthcare
setting. Leadership's decisions and actions must match its
words – congruence of words and actions is one of the
external constructs we used to create a shared vision of the
importance of safety within our organisation.
Internal constructs
As detailed right, the key internal constructs are the patient
and the care providers, respect, information and care for the
patient, and systems, empowerment and support for the care
providers. These internal constructs are a lens best viewed
through the patient’s eyes, thus their strategic placement in
the SMILE image.
October 2013
30
Patient
Edgman-Levitan and Cleary asked patients what was
important to them and what affected them, either positively
or negatively, concerning their hospitalisation. Collectively,
patients indicated that coordination of care, information,
communication, and respect for patients’ values formed
important dimensions of viewing a hospital as ‘safe’15.
“while very new in our culture,
open disclosure is gaining
strength as an effective part of our
patient safety programme”
Respect, information and care are three primary expectations
we found in our patients, operationally defined as:
1. Respect - Patients treated with respect, being treated
equally without any discrimination of nationality or religion,
and care providers being courteous to patients. Respect
is further refined as understanding the feelings and needs
of the patient, and care providers respecting the patient’s
values and beliefs even if different from their own.
2. Information - Care providers communicating with patients
clearly and in an easily understandable manner, using
layman’s language and avoiding excessive use of medical
terms. Information provided in the patient’s native language
is preferred. Information is further refined as telling patients
about their actual conditions and giving them appropriate
hope and support where needed. While very new in our
culture, open disclosure is gaining strength as an effective
part of our patient safety programme.
3. Care - Patients having unrestricted access to care that is
needed to treat their illness.
Care provider
Organisational leaders have long realised that engaged
employees are linked to providing good patient care services16.
There is growing evidence that supports connections between
employee engagement and patient loyalty. Concepts such as
loved ones taking care of loved ones, and caring for those
who care for the patients are emerging trends in the healthcare
industry and should be incorporated into patient safety
programme planning.17
“organisational leaders have long
realised that engaged employees
are linked to providing good
patient care services”
Patient safety is accurately defined as a systems' issue in
which the care provider is one aspect of a highly complex
structure. As such, interventions to improve patient safety
should be made at the system level and through a systems'
lens, in addition to individual care giver education and
commitment. Individuals in an organisation must feel
empowered to report errors.
Organisations’ leaders must implement ways to discover errors
and learn from defects, by employing process improvements
that passively and actively create opportunities for 

4. SAFETY CULTURE
sustainable error reduction. Part of the solution is to ensure that
providers have the proper tools to address system issues18.
Systems, empowerment and support are three primary
expectations we found in our organisation, operationally
defined as:
1. Systems - Human beings are fallible and care providers are
at the sharp end of error19. It becomes the binding duty of
the regulators and healthcare leaders to create systems that
make it both easy for care providers to do the right thing,
and which make it difficult for them to do the wrong thing.
This can be accomplished by creating forced functions in
many healthcare delivery processes20.
2. Empowerment - Creating opportunity for providers to speak
up when things go wrong. There must be zero tolerance to
bullying and disruptive behaviours, while making providers
accountable and involving them as process owners for
employee engagement21. We have adopted a fair and just
culture22, where care providers are responsible for their
professional conduct. We embrace the fact that systems’
issues lead good healthcare professionals to make
unwanted errors.
3. Support - Regulators and hospital leaders supporting care
providers when they become a second victim due to an
error23. We offer affected staff a fair and just investigation
as principles of natural justice24, and we do not dismiss
employees due to errors linked to systems’ issues. We do
hold staff accountable for their professional conduct. Finally,
staff must be given tools and training to do their work
effectively and efficiently in a culture of safety.
Conclusion
The culture of safety is a serious business and current
frameworks are structurally complex, making it difficult
for bedside care givers to remember and apply in practise.
The SMILE framework provides an opportunity for users
to understand and replicate the various components that
influence organisational factors for patient safety. By putting
a smile on the face of patient safety we are able to tap
into a contemporary cultural movement strengthened by
remembrance, rather than information recall alone.
While patients are clearly the centre focus in healthcare
delivery, we submit that care providers themselves hold equal
prominence in the patient safety movement. Care providers
play an important role in delivering safer care, but this requires
October 2013
32

5. SAFETY CULTURE
a right and a safe environment in which to practise. Delivering
safer care is linked to external and internal constructs that
influence and drive a new philosophy. Throughout this article
we have portrayed those constructs we found most
meaningful along our journey.
Acknowledgements
The authors wish to thank Mamoon Abu Haltem,
Carole L Hemmelgarn and Theresa A Morris for contributing
their views in designing the framework, and Bachar Mamich
for his computer skills in bringing the SMILE framework to life.
16. Buckingham M, Coffman C, 1999. First, break all the rules.
What the world’s greatest managers do differently. New York,
NY: Simon & Schuster.
17. Foley M, 2004. Caring for those who care: A tribute to nurses
and their safety. Online Journal of Issues in Nursing, 9(3).
18. Johnson J, Horowitz S, Miller S, 2008. Systems-based practice:
Improving the safety and quality of patient care by recognizing and
improving the systems in which we work. Agency for Healthcare
Research and Quality, Retrieved: www.ahrq.gov/professionals/qualitypatient-safety/patient-safety-resources/resources/advances-in-patientsafety-2/vol2/Advances-Johnson_90.pdf
19. Deskin WC, Hoye RE, 2004. Another look at medical error. Journal
of Surgical. Oncology, 88, 122–129. DOI: 10.1002/jso.20122.
20. Institute of Medicine. Committee on Healthcare in America. (2000).
To err is human: Building a safer health system. Kohn LT, Corrigan JM,
Donaldson MS (Eds.), Washington, DC: National Academy Press.
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Krishnan Sankaranarayanan is the senior safety
officer at Tawam Hospital. He holds a Master of
Science degree in patient safety leadership from
the University of Illinois-Chicago, as well as a
master of business administration degree from
Annamalai University. Krishnan is a Certified
Professional in Healthcare Quality (CPHQ) and a founding
member of the patient safety team at Tawam Hospital.
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