A patient safety model that truly works for patients can only exist in a culture of safety. Yet 15 years after the groundbreaking report To Err is Human, which concluded that U.S. hospitals kill up to 98,000 patients each year, we still have a long way to go to integrate a culture of safety. This, according to the Institute for Healthcare Improvement (IHI), a leading organization that has collaborated with hospitals to develop, disseminate, and educate about quality and safety programs nationwide.
It’s been said that one of the biggest impediments to patient safety is cultural, and includes the usual suspects of organizational commitment, desire to change, and willingness to invest in what may be expensive equipment and facility improvements.
Here are some of the larger cultural imperatives I believe hospitals must address.
1. Leadership Buy-in
Everyone knows the importance of this. And any healthcare leader will tell you that patient safety is their organization’s number one concern. But let’s be honest, when faced with tight budgets and competing priorities, not all of these healthcare leaders will make decisions that truly put patient safety first.
To truly create a model of safe patient care, leaders must pay more than just lip service to safety. Launching high-reliability organization strategies and patient safety initiatives is a good first step. But leaders must relentlessly support their value, importance, and funding for long -term success.
A colleague once told me about her work with Ascension Health and its vision of Healthcare That is Safe. Healthcare That Works. Healthcare That Leaves No One Behind. Year after year, she witnessed the system’s C-suite and individual hospital leaders authentically integrating this vision into the health system’s culture and decision making. It’s this kind of long-term commitment that’s needed to turn the tide on safety. In large healthcare systems, success takes years not months.
2. Blame-Free Environment
6 out of every 7 hospital-based errors, accidents, and other adverse events go unreported. Not surprisingly, one of the top reasons is fear of retribution; physicians and other providers aren’t comfortable reporting errors because they fear disciplinary action, reputational damage, or job loss.
What is your organization doing to fight this fear so that everyone is comfortable reporting errors and near misses? Have you implemented non-punitive response protocols from the top down so that physicians and staff worry less about “their mistakes” being in their file and held against them? How are you building trust with providers that your organization is focused on the problem not the people?
3. Everyone On Board
This is a no brainer but it’s easier said than done. Everyone from the CEO to housekeeping staff must be committed to creating and upholding a model for patient safety. This can be difficult in large organizations where employees come and go, but it has to start at the point of new employee orientation, be persistent throughout every department, and remain an integral part of each employee’s responsibility. If not, the result will be like a bad orchestra in which the violins play the Mozart Requiem, the trombones play Sousa’s Stars and Stripes Forever, and the percussion section reads from a Justin Timberlake score: nothing harmonious can occur.
4. Adequate Staffing
For several decades now, our healthcare system has been focused on seeing a higher volume of patients with greater efficiency to collect declining reimbursement. We have had to figure out how to do more with less. It’s a paradigm familiar to other industries as well. But unlike a soda company that can increase the volume of bottles produced by purchasing a faster, higher tech machine, hospitals take care of people - each of which is a unique, “custom job.” There are no economies of scale with complex, polypharmacy patient. She is your grandmother. Or he is your three year-old.
When providers care are required to treat or care for higher patient loads, attention is distributed, shifts get longer or more frequent, fatigue sets in, and more errors happen. When staffing ratios are kept at unsafe levels to save money, the pharmacy technicians who catch multiple medication near-misses during the day time shift are not available to catch an adverse drug event for the 81 year old COPD patient at 1:00AM because the floor nurse was managing 7 patients and had to spend additional time with a non-ambulatory, obese patient.
I recognize what a Herculean effort it can be to juggle the need for capital investments, budget cuts, and staffing costs. But hospital leaders intent on creating a culture of safety must find ways to ensure safe staffing levels because they recognize the impact.
5. The Right Attitude About Failure
Most hospitals conduct after action reviews when medical errors and ADEs occur. But research by Harvard Business School professor Amy Edmondson indicates that lessons learned in such assessments don’t go deep enough and aren’t always used in a way that reduces future failures. Edmondson maintains that blame and a belief that failure is bad get in the way of real learning.
In addition to leaders changing their attitudes and messaging about failure, Edmondson says that effectively learning from failure requires organizations to go narrow and deep to understand why something went wrong - without focusing on “who did it.” Consistently report and analyze failures, no matter how small, and identify those that represent an opportunity to try new methods. As an example, at Intermountain Healthcare, physicians’ deviations from medical protocols are routinely analyzed for opportunities to improve the protocols.[1]
Read Edmondson’s article on this topic, in the Harvard Business Review.
[1] Strategies for Learning from Failure, Edmondson, Amy C., Harvard Business Review, April 2011, https://hbr.org/2011/04/strategies-for-learning-from-failure
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