Resolutions, which are popular this time of year, are firm decisions to do or not do something. However, by themselves, they often fall flat. Resolve on the other hand—the determination and grit to see those decisions through—is the true measure of character.
It's been over 20 years since To Err is Human was published, and some argue that we aren't much safer today than we were then. While there have been some marked improvements, we still have a lot of hard work to do.
The abundant information and best practices out there tell us almost everything we must do to improve patient safety. Just some examples: The Patient Safety Authority’s website alone houses more than 50 patient safety improvement toolkits and 500 articles; the Patient Safety Movement Foundation has dozens of Actionable Patient Safety Solutions bundles on their website; and the Institute for Healthcare Improvement has three decades' worth of knowledge and tools available on theirs.
So why aren't we better than we are? We seem to have a lot of the information needed for real change, but that change has been a bit lackluster, to say the least. I believe we need to consider some critical items to achieve true success.
These resolutions are not for the faint-hearted. They will take an enormous amount of resolve, courage, and maybe even a small leap of faith, but I guarantee none of them will leave you awake at night wondering if you did the right thing (and there's something, actually quite a bit, to be said for that).
1. Look for the lessons—overcome the adversity of 2020
There are three kinds of lies: lies, damned lies, and statistics.
Wait, that might be the wrong quote. I think I meant, “There is no education like adversity." Both come from Benjamin Disraeli, former British politician and two-time prime minister of the United Kingdom.
Honestly, they probably both fit. 2020 taught us that our collective health is critically important to some for the advancement and destruction of political agendas. It also taught us that we have no idea what the COVID-19 numbers really are; we are learning as we go, just as the world-renowned experts are learning as they go; we weren't as prepared for a crisis of this magnitude as we thought we were; and we can't just wish the virus away because we're tired of it.
As a positive, we learned that some people have genuine concern for themselves and those around them, taking precautions seriously and erring on the side of caution for their fellow humans. We learned that some people would show up for the rest of us, whether that's caring for us when we are sick, running the cash register at our grocery store, or fixing our infrastructure when it breaks down.
Altruism is real and we are witnessing it.
Some of you have literally scoured the earth trying to secure personal protective equipment for your staff. Some of you are facilitating COVID-19 safety huddles seven days a week, and more than once a day. Some of you pick up blood pressure cuffs or stretchers and don the mantle of healthcare provider when needed. Some of you sent your children away to protect them from what you might bring home. Most of you haven't had a good night's sleep in almost a year. I commend you and I thank you.
It's so difficult to see beyond the here and now. But as you continue to battle the invisible menace each day, don't forget about all the other lessons learned. Crisis often uncovers the breaks in the system—sometimes those are small cracks and sometimes they are Grand Canyon–sized chasms.
Take stock in what has been uncovered. Debrief. Do it often and have someone write everything down. There will come a time, hopefully in the very near future, when this subsides. Take advantage of the opportunity given and build the foundation for a stronger tomorrow, today.
2. Take the road less traveled—move beyond trying to educate errors away
We've all heard that old saying, “If I had a dollar for every time, I'd be rich." Well, that could not be truer than every time someone has said we are going to educate or reeducate someone after a patient safety event occurs.
If you're not in the habit of reviewing the details of every patient safety event in your facility, I encourage you to make time to peruse a sample. Make sure the information you review includes actions taken to prevent future recurrence. Count how many times education/reeducation is listed, then look at how often that same type of event is occurring. Certainly, education is important and has a time and place, but if it is the only tool in the box that your staff is using then expect disappointment.
There is a reason education is relied upon so frequently; it's EASY.
The real work is in identifying and implementing high-leverage prevention strategies. This is one of the most important jobs of your managers and supervisors, and it is one of the ways you should want them spending their time (more on that in resolution 3). High-leverage strategies are those strategies that are system-based, compared to low-leverage strategies (like education) that are person-based. The Institute for Safe Medication Practices published a feature, “Education is 'Predictably Disappointing' and Should Never be Relied Upon Alone to Improve Safety," that reinforces this notion and provides additional context around high- and low-level strategies. Challenge your staff to identify the highest-level strategies and demand their implementation whenever possible.
3. Commit to meetingless Mondays, and Tuesdays, and Wednesdays, and…
I know, you are thinking I'm out of touch. I assure you, I'm not. I challenge you to reevaluate where and how your clinical leaders are spending their time.
As a young adult, I spent one summer working for a trucking company. Each time I contemplate many of the problems in healthcare, I go back to one practice that the trucking company had in place that we generally do not—hands-on supervision of the operation. When an incoming dock supervisor started their shift, they walked the dock with the outgoing supervisor. They continued to walk it—again and again—noting what freight was where, who was working on what, what needed priority.
We do not do this in healthcare. We employ supervisors, managers, and directors, but our staff largely work autonomously. So where are our managers spending their time (in non-COVID times)? We know where, and you can change it.
Before scheduling a meeting, ask yourself, is it more important than managing the care of the patients that are here right now? Will it help identify and resolve issues that threaten the safety of our patients? Will it result in actionable items for improvement in care and safety? If the answer to these questions is “no," reevaluate who needs to be at that meeting.
4. Stop “risk managing" patient safety
Patient safety and risk management are very dependent on each other. The safer our facilities become, the less risk management there is to do. The more transparent and robust risk management becomes, the more patient safety improves—which leads to lower risk.
The Patient Safety Authority invites Pennsylvania facilities to join us as we embark on a statewide journey to implement a Communication and Optimal Resolution (CANDOR) process. Through its implementation, hospitals can expect to better engage patients and families when an event occurs; understand its importance; create a “care for the caregiver" program; establish or improve its resolution process for patient safety events; and I might argue, most importantly, improve transparency around event investigation to minimize future risk to patients.
We are excited to have an early adopter of CANDOR to help guide us in this process. Seth Krevat, MD, assistant vice president for Safety at MedStar Health, served as Agency for Healthcare Research and Quality (AHRQ) expert faculty to lead the design and teaching of the CANDOR curriculum and its tools.
Through MedStar Health, Dr. Krevat implemented a comprehensive patient safety program, which included CANDOR, that decreased patient safety events by 65% and the associated cost of care by more than $70 million.1
Recruitment for the first cohort will begin in early 2021. Are you ready to join us?
5. And finally, walk the walk—and I do not mean executive leadership rounding
Honestly, I'm tired of hearing people lauding the fact that their executives are rounding on patients and staff and solving problems in real time. This is not a good thing; in fact, it tells me there are major flaws in your organization.
I know you have been told for the last decade that this is what a good leader does, but I think you have been misled. If it takes you (the CEO) to listen to and solve employee and patient problems, then there are several people in between you and that employee or patient who are not effectively doing their jobs.
There are many reasons for this, and most probably aren't the fault of those people (see resolution 3).
Engaging with employees in their work,
managing patient care and safety,
and resolving issues at the bedside
are the most important responsibilities of managers/supervisors
—not the CEO.
If they are doing these things effectively, then the need for you to round becomes more about visibility (not a bad thing) and less about problem solving.
I encourage you to rethink why you are rounding. Your time may be better spent rounding on your managers to understand why they can't do their most important tasks. Your time might also be better spent rounding with your managers, so they understand the expectations of their roles. And your time might be better spent developing a framework that allows your managers to do so.
Now let's truly walk the walk. This one is harder than rounding, because it elevates patient safety above all else, not just saying it, but meaning it. This is saying to every single employee that if they speak up to keep a patient safe, you have their back.
You must mean it and you must show it, every single time.
One of the most difficult situations I encountered happened in a hospital where there was only one provider of a specific service—a large, revenue-generating service. This provider was textbook disruptive to staff, patients, and everyone around them.
This abuse went on for years, because they were the only provider. (Did I mention they were a large revenue generator?) I say that not to make the hospital out to be in it for the profit. It was the exact opposite; they really needed the revenue to pay the bills.
Finally, the provider crossed a line—they walked out in the middle of a patient procedure. This required medical leadership and the CEO to act, and they did. The story had a positive ending: no harm came to the patient (thankfully), another group stepped in to fill the resulting void, procedures increased in number, outcomes were better, and employee satisfaction improved.
Not every decision is going to come with a simple solution or even a happy ending, but there comes a point that you must mean what you say and act upon it. For some this is easy; for others this may be the biggest challenge they face. But when you do it, it becomes the strongest message you can possibly send about your commitment to your patients and your staff.
2021 is full of renewed hope and promise. Take this opportunity to recommit to what matters most: effective and safe healthcare for all.
1. CANDOR Helped Significantly Reduce Patient Safety Events, Malpractice Claims at MedStar Health. Content last reviewed September 2017. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/news/newsroom/case-studies/201712.html