The PA-PSRS Patient Safety Advisory has invited healthcare leaders in Pennsylvania to contribute their perspectives on patient safety. We are pleased to lead this series with comments from Charles H. Chodroff, MD, MBA. Please look for more contributions from other healthcare leaders in future issues.
There are few aspects of a health system’s performance that leaders can influence more than an effective safety program. While leaders might attribute less than stellar financial performance to inadequate government reimbursement or an adverse competitive environment, the success of an organization’s safety program is directly related to the focus and diligence its leaders provide to fostering a culture and program of safe care delivery. For unlike economic performance, an effective safety program only requires will, commitment, and the thoughtful and persistent implementation of behaviors, methods, and technologies that have proven effective in other healthcare settings and other industries.
The leadership of a health system encompasses a diverse group of mutually dependent stakeholders that includes governance, administration, and leaders of the medical staff, each of whom has a vested interest and contribution to the overall safety of the organization. An overriding imperative for all of these groups is the ethical responsibility to assure that the system does everything reasonably possible to minimize the chance of harm to patients and staff. For governance, the promise of the safe provision of care is the bedrock of a service promise to the community and those that the organization serves. For administration, a safe environment helps assure the most favorable economic position of the organization by avoiding needless liability risk and the economic waste of preventable adverse outcomes. For providers, a safe environment provides the platform for all else that is offered the patient, helping fulfill the aphorism of “primum non nocere” or “first, do no harm.”
For certain, all leaders of healthcare organizations would express the expectation that the care provided by their colleagues would always be safe. Yet, our industry’s record of achievement seems to indicate our intentions do not match our results. What then, could leaders do differently to assure that caregivers who practice with hope and humility might avoid acts with good intentions that have unwanted consequences?
First, the governance, administration, and medical leadership of any healthcare organization must accept the shared responsibility for this challenge. No single constituency can achieve safe care without the active involvement of all other groups. Together, creating a shared vision that strives for the full and unwavering implementation of safe attitudes, practices, and techniques, these leaders can achieve what the leaders of other high-risk industries have accomplished in assuring the safe delivery of services. Foremost among these shared responsibilities is the recognition of the inherent high risk of healthcare delivery and acknowledgement that our present practices and culture can and does impair the safety of patients. Understanding and accepting this fact is an essential first step towards helping the organization adapt its behavior and make the necessary changes needed to minimize the risk of harm to patients. A corollary is the need to foster a culture of learning the best techniques for promoting a safe environment such as team-based communication, overcoming the hierarchal authority gradient, learning from errors, and analyzing current practices to anticipate and mitigate possible adverse outcomes.
Leaders play an essential role in the defining how an organization reacts when a serious error in care results in harm to a patient. Support for the principles of “Just Culture” helps assure employees and medical staff that human error is inevitable but that the rate of these errors can be influenced by the behavior and attitudes that each of us chooses and exhibits during the course of our daily work. A risky or reckless behavior does have potentially detrimental consequences for the continued participation of the individual in the organization. But, we know that most errors in care are the result of inadequate system safeguards that place all of us at risk of an unintended action.
Finally, the leadership of an organization must plot the course for continuous improvement in the safe delivery of care for the entire organization. The effective planning and implementation of safe practices cannot and should not be expected to occur over the course of months or even a year or two. It is a long journey that requires the commitment of resources, attention, communication, and unwavering stamina when other priorities or short-term issues may seem to undermine the organization’s diligence.