David Mayer, MD, CEO Patient Safety Movement Foundation, Executive Director MedStar Institute for Quality and Safety writes.
As healthcare providers, we are all committed to providing high-quality care to our patients. In doing so, we focus on the quality of the services we provide.
We need to embrace and sustain patient safety by making it a critical component of our culture. Without a culture of safety, we can’t truly face and address issues that lead to preventable patient harm and death.
So, How Do We Do This?
First of all, understand that changing your organization’s culture is not an easy task. It requires a commitment from the top levels of your organization, driven by leadership and staff who must encourage accountability and transparency throughout the organization. Recognize that no one purposefully commits errors and that most errors are shortcomings in complex systems or processes.
Once that commitment is made, you need a plan that ensures hospital leaders are also active in supporting safety and quality for patient care. Leaders must build trust by addressing concerns quickly, communicate openly with staff about improvements and lessons learned, and eliminating any barriers to the reporting of issues. Though the goal is to eliminate preventable incidents, everyone should acknowledge that mistakes are inevitable. When mistakes happen, you need to recognize whether the error was caused by a system or process, or by a human being. A crucial component of this environment of trust is fairness in holding individuals accountable for decisions and for adhering to established safety protocols.
What is needed is an environment of mutual compassion, respect and common goals, where providers, patients and families actively participate in open communication, accountability and support. Compassion and respect are essential for effective communication, collaboration, team building, decision-making, and the implementation of systems and processes that ensure patient safety. This compassion and respect should be extended to patients and patient advocates as well.
You must also support this new cultural paradigm with an infrastructure of systems and processes that makes transparent reporting and communication easy and unintimidating, provides training, oversight committees, and more. Implementing a change management tool can ease the transition to a culture of safety by helping to document and enforce process improvements.
Setting up an electronic reporting application that allows people to report incidents or near-misses also helps to develop a learning culture within the organization and demonstrates that leadership’s focus is on safety issues, not on the people reporting them.
Finally, your safety culture must measure progress and strive to continuously improve the safety culture, as well as improve processes to prevent harm to future patients. You must establish internal communications processes and use them to consistently and openly communicate goals, expectations, outcomes and new protocols to follow to ensure patient safety. Build accountability into job requirements and evaluate staff on their contributions to improving quality and patient care.
Having measurable goals by which to track performance and progress shows your commitment to patient safety and emboldens staff to take further steps in achieving stated goals.
Preventable medical harm is the third leading cause of death in the US - there are still more than 200,000 preventable deaths in US hospitals each year, and as many as one in every three patients are unintentionally harmed. These numbers are simply unacceptable given clinical and technical advancements.
That is why the Patient Safety Movement Foundation has identified Culture of Safety as its first Actionable Patient Safety Solutions (APSS #1). Each APSS is developed by a workgroup made up of healthcare industry professionals and patient advocates. It can help you transform your organization’s culture to one that emphasizes patient safety, trust, transparency and accountability.
Originally published in Issue 3, 2019 of MT Magazine.