The challenge of making our health care system safer has been a high priority since the Institute of Medicine's 1999 report on preventable errors such as medication mix-ups, infections, wrong diagnoses or unnecessary surgeries. When the report was published 15 years ago, in fact, the institute compared the extent of the problem to a large plane crashing every day.
Despite sincere and far-reaching efforts, however, the industry still has far to go in making health care as safe as it needs to be. Over the past decade, health care leaders have faced a plethora of challenges vying for their attention — competing regulatory priorities, overburdened health care executives, and emerging care and reimbursement models, to name a few. Creating a culture of patient safety can get lost among concerns about financial solvency, consolidation, and a reduction in workforce and resources.
Physicians, too, operate in a high-stress, high-anxiety environment in which they are pushed to see more (and sicker) patients in less time, which can lead to medication errors, incomplete exams, and missed or delayed diagnoses as patients pass from the ambulatory setting to triage nurse to doctor. Add to this the ongoing pressure to meet performance measures, a persistent hierarchical structure and a culture of infallibility in which doctors still believe they can (and are expected to) be perfect. These conditions make it difficult to focus on patient safety improvements.
Hospital leaders know that patient safety and quality are important, but they have trouble knowing where to start or how to proceed beyond hitting benchmarks. Creating a culture of patient safety is a major undertaking. Developing the strategies and infrastructure necessary to effect real and lasting change — in systems, processes and human behaviors — takes hard work and perseverance. Health care leaders can avoid adverse events that lead to claims, liability and medical malpractice by employing the following four key communications strategies.
Establish a Just Environment
At one end of the accountability spectrum is the profession's focus on personal performance — even though most medical mistakes result from faulty systems and poorly designed processes rather than poor practices or incompetent practitioners. On the other end is a view of errors as a failure of systems, so no caregiver can be blamed personally. This approach carries its own safety risks.
Real accountability lies somewhere in the middle, in what is referred to as a "just" culture. Health care organizations with a just culture offer a no-blame, nonpunitive response to adverse events to promote both a safety culture and safe patient care. Just culture organizations realize that competent professionals make mistakes and develop shortcuts or unhealthy norms, but they have zero tolerance for conscious disregard of clear risks to patients. They also discipline clinicians who fail to adhere to a known safety standard.
While nearly all hospitals have a reporting system they use to track and analyze patient harm, hospital staff do not report the majority of adverse events primarily because they don't believe it will lead to improvement. This attitude underscores the need for creating a safe culture, one that is based on confidence in the reporting system.
Trust is critical to developing an effective error-reporting system. Candidly disclosing medical errors and disseminating lessons learned from them can take place only when there is no threat of enforcement from regulatory agencies. Reporting systems should be voluntary and confidential, and the data de-identified so there is no risk of singling out an individual or institution. Patient safety organizations (PSOs) oversee reporting programs that serve as independent patient safety experts. The data they receive are considered privileged and confidential, and may not be used in lawsuits, such as malpractice claims, or in proceedings against a provider.
In addition to reporting adverse events, staff should be encouraged to report near misses — events that could have had adverse consequences but did not, such as administering the wrong drug or improper removal of a catheter. Near misses provide valuable information about broken and risky systems, such as inadequate training or sleep deprivation, which hospitals can aggregate and analyze to improve patient safety practices.
Implement Meaningful Change Based on Accurate Data
It's not enough to expose adverse events. Health care leaders must repair the problem, follow up and close the loop. Data analysis is a powerful tool to create a culture of safety. Data aggregated from reports of adverse events and near misses enable developers, providers, researchers and policymakers to uncover the causes of mistakes. PSOs can help health care professionals to understand and learn from data on patient safety events, provide advice on safety rules and regulations, and offer expertise to prevent adverse events from happening in the future. Armed with data, facility leaders can compare the hospital's performance with others, develop best practice guidelines and improve patient safety.
Following an adverse event, hospital leaders should take the following steps:
- Create a list of actions and outcome measures.
- Describe an action for each failure mode cause that will eliminate or control it.
- Identify outcome measures that will be used to analyze and test the redesigned process.
- Identify one person responsible for completing the recommended action.
Analysis combined with feedback to staff and other stakeholders on how the data are being used to improve systems and prevent mistakes is crucial to designing better systems, promoting patient safety and building trust.
Widen the Circles of Transparency
Transparency requires commitment and attention to building organizational trust at all staff levels. Perhaps the most challenging step is crossing the chasm from internal to external transparency. Many health care leaders are hard-pressed to see the value in sharing information about their organization's mistakes and performance outcomes with the public, yet doing so can ensure ongoing improvements. Transparency further lifts the veil of blame and shame, and sends a message to patients and staff that safety is a top priority.
Hospitals that aspire to be high-reliability organizations begin by setting clear priorities and goals, then developing measures that will be tracked internally; they gradually enlarge the circles in which data are shared. Conferences are a good place to start; but better still is moving this conversation onto the hospital intranet, into the hospital's newsletters and, eventually, out into the community. Publicly releasing performance data helps to focus leaders' attention on safety and stimulates improvement activity at the hospital.
Creating a safe culture doesn't happen overnight. But by adopting these strategies, health care leaders can replace entrenched habits that impede progress with transparent processes. Doing so will help the organization overcome gaps in safety and take the lead in preventing errors.
Mary Gregg, M.D., F.A.C.S., M.H.A.,is the chief medical officer of MAG Mutual Insurance Co. in Atlanta. She most recently served as vice president of quality and patient safety, medical affairs, with Swedish Health Services, Seattle.