ACHE, Along With IHI, AHRQ Announce National Action Plan to Advance Patient Safety

The American College of Healthcare Executives today joins with members of the National Steering Committee for Patient Safety to announce the release of a National Action Plan to provide health systems with renewed momentum and clearer direction for eliminating preventable medical harm. Continue Reading




Safety 101 Syllabus: Establish Organizational Behavior Expectations

The COVID-19 pandemic has led hospitals across the globe to rethink safety and implement new processes and protocols to protect the health of patients, visitors, staff and anyone else who might enter a healthcare organization. Such measures include creating COVID and non-COVID patient care units, building negative pressure rooms, expanding the use of PPE and encouraging more telehealth visits. These solutions have all helped meet the particular challenges of operating during a global pandemic but maintaining a culture of safety only happens when leaders set and model behavioral expectations for the organization as a whole.




Safety 101 Syllabus: Select, Develop and Engage Your Board

When it comes to achieving zero harm in healthcare, there is no silver bullet solution. Leading a Culture of Safety: A Blueprint for Success does, however, outline six leadership domains that can help ensure safety remains a focus from the top down in hospitals and other healthcare settings.




Safety 101 Syllabus: Prioritize Safety in Selection and Development of Leaders

Welcome back, class. Since posting our last lesson, the COVID-19 pandemic has spread across the globe and presented the healthcare field with new, never before seen obstacles. Between the high contagiousness and rapid spread of the virus, patient surges, shortages of personal protective equipment and ventilators, and limited testing supplies, keeping staff and patients safe has become particularly challenging and especially important.

Continue Reading.




Redefining Criticism

(Members Only) Healthcare organizations are quick to laud, with good reason, employees who fix problems on the fly and make things work, all too often in the face of seemingly impossible situations and systemic barriers. Organizational leaders are sometimes less exuberant about employees who point out defects or potential sources of failure in our systems. Employees who repeatedly identify opportunities for failure are often viewed as chronic complainers. Managers may dismiss them as disgruntled persons who are not team players; colleagues may regard them as disruptors to a comfortable status quo. Worse, they may be labeled “whistleblowers.”




Five to Zero: How High Reliability Happens

(Members Only) In the mid-1980s, following a scathing attack on anesthesia safety by ABC television’s 20/20 program, Ellison “Jeep” Pierce Jr., MD, then president of the American Society of Anesthesiologists, conceived the idea of the Anesthesia Patient Safety Foundation, and the ubiquitous term “patient safety” was born out of this effort. Pierce’s vision was a simple one: “that no patient shall be harmed by anesthesia.”




Engaging the Board in Patient Safety Goals

Over the past few decades, many hospitals and health systems have invested significant time and resources in building and reinforcing quality improvement and patient safety programs. This has led to declines in some medical error rates. For instance, central line-associated blood stream infections dropped by 50 percent between 2008 and 2016, and have continued to fall. 




The Promise and Practice of a Just Culture

Leaders whose organizations have made big safety gains will tell you that a high-reliability safety culture is one of shared learning characterized by an atmosphere of trust. Members of the workforce feel safe speaking up when they make an error or encounter circumstances that could lead to harm. And, since these high-performing organizations recognize that most errors are due to flawed systems, not individual negligence, they’re listened to and supported.




Walk the Walk

What does it take to truly establish a culture of safety in your hospital? According to Mark P. Jarrett, MD, senior vice president and chief quality officer at Northwell Health in New York, the secret to success is none other than leadership. And, he claims, good leadership is ensuring that the culture will sustain itself beyond your tenure. “Simply budgeting dollars will not fix the issue,” he says; “a thoughtful patient safety strategy requires leaders to engage on a personal level.” Jarrett points out that, in commercial aviation and nuclear—two industries widely hailed as highly reliable—analysis following accidents nearly always reveals the problem to stem from failure of leadership to promote a safety culture.  

In an article written for the Journal of Healthcare Management, Dr Jarrett encourages leaders to “walk the walk” in their efforts to establish a lasting culture of safety. By “walk the walk,” Jarrett is talking both figuratively and literally: he encourages healthcare executives to do weekly patient safety rounds in which they engage with and listen to staff and drive home the importance of and commitment to safety. Jarrett also recommends a brief, daily telephone discussion to “engage all leaders in a rapid situational safety review of the organization.”

According to Jarrett, there are
several factors that are essential to a safety culture—and these can only be
fostered by effective leadership. These are:

  • Commitment
  • Nonpunitive response to errors and “near
    misses”
  • Shared belief in the importance of safety
  • Teamwork
  • Widespread trust

Measurement

How do leaders achieve these foundational elements? To begin with, says Jarrett, measure. The only way to gauge success in performance improvement efforts is through measurement. At Northwell—a metropolitan system with 21 acute-care and 450 ambulatory locations—Jarrett’s team employs the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture, administered every 18 months.

Human
Error

The results of the survey must be analyzed
with a keen understanding of human psychology, cautions Jarrett. He reminds
healthcare leaders to question the outcomes and never assume the causes behind
the data. Rather than celebrate results indicating 100% compliance, first
determine if the numbers stem from complacency in reporting rather than
conformity.

“Improvement will only occur if leadership establishes a safety culture as a foundation to build on—and only then will we know that every patient, including our own family members, can receive the best possible care.”

Teamwork

A “team approach is necessary to drive lasting cultural change throughout the organization,” Jarrett maintains. At Northwell, they have adopted TeamSTEPPS, developed by the Department of Defense to heighten patient outcomes through multidisciplinary team training and common terminology to improve communication.

Just
Culture

Finally, a successful safety culture must be founded on a “model of shared accountability” that is based in nonpunitive reporting of errors, staff accountability and willingness by care providers to speak up.

Jarrett concludes, “Improvement will
only occur if leadership establishes a safety culture as a foundation to build
on—and only then will we know that every patient, including our own family
members, can receive the best possible care.”


Be sure to read “Patient Safety and Leadership: Do You Walk the Walk?” to see Jarrett’s checklist of elements required for the promotion of patient safety. ACHE Members: Visit ache.org/Journals and select Journal of Healthcare Management to log-in and access for free.




The Story as Catalyst for Change

As healthcare leaders we gather data and use the numbers to guide
our decisions and make strategic plans for our organization’s future.
Sometimes, however, we come across a patient story so revealing and so humbling
that it compels us to act now. The
all-to-real human experience as relayed to us by a distraught mother, by the
trustee-turned-patient, or by a trusted staff member becomes so palpable that
it is clear what change is urgently needed. The story becomes the catalyst for
change.

That is the premise behind “Inspired to Change: Improving Patient Care One Story at a Time,” a compilation edited by Linda Larin. Her book contains perspectives written by patients, family members and healthcare providers that illustrate patient care at its shining best and shameful worst. Larin’s hope in preparing this volume is that the stories will influence healthcare leaders and providers to discover better methods for delivering care that is more patient- and family-centered, safer and more efficient. 

“It’s time to consider healthcare with a new lens and ask ourselves: What are we doing today that will be obsolete tomorrow? What will compel us to challenge the status quo?”

Her book challenges us to envision a future far from today’s status quo. In one chapter, Larin reminds us that hospitals only adopted smoking bans beginning in the 1980s. Prior to that time, the right of staff and patients to smoke was practically unquestioned. “It’s time to consider healthcare with a new lens and ask ourselves: What are we doing today that will be obsolete tomorrow? What will compel us to challenge the status quo?” she asks.

In chapters with titles such as “Going Above and Beyond Expectations,” “Looking Back with Regret,” “A Little Caring Goes a Long Way,” “The Stress of Illness,” and “A Day in the Life of a Hospital,” Larin’s collection of stories challenges the reader to see opportunities for improvement. Each chapter concludes with lessons learned, resources for more information, and recommended readings.

“Some [stories]…are a tribute to humankind, but others are dramatically sad and insensitive and show us that we could and should have performed better. From these, we attempt to gain a better understanding and improve for the future.”

The editor and healthcare executive
encourages her colleagues to listen to their patients, draw out their stories
and learn from the lessons hidden within. Patients with chronic illnesses, she
says, often have so much experience of the healthcare system that they know our
organizations’ strengths and weaknesses better than we do. “We need only ask
for their input,” she suggests.

“The reality of healthcare, as any
experienced leader or clinician knows, is that it is full of stories about
patient–staff interactions. Some are incredibly poignant and are a tribute to
humankind, but others are dramatically sad and insensitive and show us that we
could and should have performed better. From these, we attempt to gain a better
understanding and improve for the future,” she writes.

This
book will live up to its title: it will inspire you to make lasting changes at
your hospital or health system to provide the kind of quality care that you would
want for yourself and for your loved ones.