Recent news coverage about the Boeing 737 Max aircraft and the overall safety of the aviation industry prompted us to start thinking about this topic in healthcare. Do we have the same focus on safety across the healthcare industry?
Unfortunately, the statistics tell a troubling story. Medical (safety) errors resulting in death are estimated to total 250,000+ annually. At these levels, medical errors are the third leading cause of death in the United States, behind only heart disease and cancer. Unlike so many other industries, the healthcare industry has no true regulator that steps in when there are widespread safety/environmental/other issues. There is a large opportunity for health systems to implement processes that improve the quality and care provided by their organizations to win customers, decrease waste, and increase revenue in an era when consumer preferences and value-based care are here to stay.
When addressing safety, the healthcare industry is often prone to assign all human error as a failure of the person—the “bad apple” theory—instead of as a symptom of larger system issues. A blame culture fosters fear, leading to a lack of reporting, ineffective communication, or worse, covering up mistakes. While traditionally clinicians and healthcare workers have worried about errors leading to patient harm and financial loss, they also struggle with fears of more dire consequences such as actions against licensure, loss of reimbursement, or jail
Instead of playing the blame game, health systems should look to build the appropriate tools, procedures, and mindset in order to prevent events from occurring. Research in fields outside of healthcare provide key insights into risk management and making the transformational switch from a blame culture to a learning culture. In a learning culture, human fallibility is acknowledged with communication at the forefront and every error is seen as a teaching opportunity. With improved transparency, communication, and a desire to improve, safety issues are detected early, resolved quickly and decreased in frequency. One example of these recommendations in action is Sentara Healthcare, who in 2011 was featured in a case study titled “Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement,”
that reported their progress in promoting a high-performance healthcare system utilizing daily huddles, safety rounds, and action plans to ensure accountability.
So what does a culture of safety in healthcare look like? The following are procedures, tools and solutions that leading health systems have put in place to improve patient safety and make themselves destinations for consumers.
- Rounding and Checklists. Ensuring best practices and proper policy are followed for every patient, every day is more important than ever in today’s rapidly evolving healthcare world, especially as standardization, mergers and acquisitions, and value-based care are challenging the way organizations and practitioners have operated for decades. Easily capturing data in real-time, rounding supports the reality of making “best practice” standard practice. Rounding and Checklists identify process and patient issues for immediate service recovery, creating a safer environment and happier patients.
- Event Management. Humans make errors. It is important that those errors are reported, investigated, and necessary proactive changes are put in place, so errors occur less frequently in the future. To encourage reporting, healthcare organizations should look to enable easy and real-time reporting of events, near misses, and unsafe conditions. With more data centralized in the organization’s EMR, it’s essential to find ways to leverage this information to learn where events occurred so that the organization can learn and create processes to prevent similar events in the future.
- Peer Review. Ensuring that you have the right people in place doing the right thing, without placing blame, is an under-valued component of the safety process. When an organization embraces a true learning culture vs. the “Bad Apple” view, many more opportunities are uncovered, and events are seen as an opportunity for a physician or nurse’s practice to be reviewed by peers. Coupled with the OPPE (Ongoing Professional Practice Evaluation) and the credentialing process, organizations get a much more comprehensive view to ensure the best people are providing safe, effective care and experience – ultimately maximizing contribution to the organization’s bottom line.
Identifying and appreciating the hurdles that healthcare professionals face is an important first step in reducing medical errors. Organizational culture and system processes deeply impact how errors are responded to by hospital leadership and what action and improvements are enabled to prevent future harm to patients. By learning from other industries and progressive organizations, health systems have the opportunity to create a learning culture that encourages event reporting and communication, proactive identification of risk through rounding, standardization through checklists, and the review of clinical staff to ensure safe effective care.