How will I know when my hospital is safe?” To that question, many hospital CEOs would likely answer, “When I no longer have to call ahead to let staff know a family member is being admitted.”
Patient safety has been a strategic imperative in healthcare since our wake-up call—the Institute of Medicine (2000) report To Err Is Human: Building a Safer Health System, which suggested that as many as 98,000 people die each year as a result of medical errors. Yet medical errors today are still the third leading cause of death in the United States (Makary & Daniel, 2016). As key stakeholders, healthcare leaders have primary responsibility to solve this challenge.
As with any problem, the first step toward a patient safety solution is admitting that there is a problem. Only then can it be defined and appropriate resources be committed to solve it. True success requires more than establishing a safety culture; the culture must also be sustainable beyond current leadership.
Patient safety is a combination of people and processes, and both elements depend on leadership. In the aviation and nuclear industries, which are widely viewed as highly reliable and therefore safe, almost every analysis of accidents reveals a recurrent theme: the failure of leadership to promote a safety culture (Institute of Nuclear Power Operations, 2013).
How can healthcare leaders avoid this pitfall? Simply budgeting dollars will not fix the issue; a thoughtful patient safety strategy requires leaders to engage on a personal level. Weekly patient safety rounds throughout a hospital, for example, not only give staff an opportunity to learn about safety concerns (with feedback to close the loop); they also allow senior leaders to leave the C-suite and be seen on the units. By rounding, leaders demonstrate to staff their commitment to the importance of patient safety. Similarly, daily 15-minute patient safety calls engage all leaders in a rapid situational safety review of the organization.
Several elements contribute to a safety culture, including a commitment to safety, a nonpunitive approach to reporting errors and near misses, a common belief in the importance of a safety culture, teamwork, and a pervasive feeling of trust. Leadership plays a critical role in fostering each component.
THE IMPORTANCE OF MEASUREMENT
In all performance improvement efforts, one must first measure the current status to be able to confirm that an intervention has resulted in improvement. In patient safety, this process often starts with a survey. At Northwell Health, a metropolitan New York health system with 21 acute care hospitals and more than 450 ambulatory sites, we administer the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture every 18 months.
The following aspects of administering a safety culture survey are key:
1. Key stakeholders must participate in the process. A multidisciplinary team must be involved in selecting the survey, rolling it out, reviewing the data, and formulating a strategy based on the results. At Northwell, all care team members are involved, and the marketing team publicizes the survey to increase participation.
2. A validated tool, such as the AHRQ safety culture survey, is required (Jones, Skinner, Xu, Junfeng, & Mueller, 2009).
3. The data must be analyzed all the way down to the individual unit level. Variation, the bane of quality and safety, can occur between departments in the same hospital as well as between hospitals. Analysis of the data on multiple levels is required where multiple cultures are in place.
4. The results need to be shared with staff. At Northwell, managers are given the results for their areas of responsibility and then share them with frontline staff.
5. Most important, a strategy based on the results must be implemented. A repeat survey 18 months later will not show improvement if team members feel leaders have not responded to their concerns.
Although the AHRQ safety culture survey can measure an organization’s current position, more information may be needed to understand what the responses mean. Focused interviews are an additional measurement tool.
In gathering data to drive improvement, organizations usually focus on units or roles that performed poorly on the survey. However, survey responses from top safety performers also deserve analysis to learn why they scored so well. Finally, organizations should scrutinize areas with low response rates, which may be symptomatic of a cultural issue to be addressed.
Many patient safety practices have been advanced by AHRQ and other safety organizations. To implement any practice successfully, leaders must understand human factors psychology.
The bundle, a common safety tool, can be problematic in practice. A bundle is “a small set of evidence-based interventions that are generally accepted by participating clinicians as elements of care that should be delivered as usual practice” (Resar, Griffin, Haraden, & Nolan, 2012).
In 2013, Northwell Health embarked on a path to zero central line–associated bloodstream infections in intensive care units (ICUs) using bundles. Northwell’s CEO galvanized the effort by stating that zero was the only acceptable result. Bundle utilization audits reported 100% compliance, but when our medical directors observed what was actually occurring on the units, they found physicians inserting the central line alone while nurses were at the nursing station checking off boxes on the bundles worksheet. This scenario, we learned, is common: As people become comfortable with bundles, complacency negates their value and leads to the belief that the bundle does not work. Northwell’s effort to achieve adherence to the bundle with real-time audits resulted in a 60% decrease in central line infections over 3 years. By December 2015, the goal of zero ICU central line infections was reached system-wide in Northwell’s 35 ICUs.
The surgical checklist, another frequently used tool, also exemplifies the complacency issue. Even after checklists were shown to be successful in aviation and were widely adopted in healthcare, incidents of wrong-site procedures have not declined. As with bundles, audits often recorded perfect compliance at Northwell. Video monitoring, however, found low levels of engagement by caregivers—they went through the motions but were clearly preoccupied with other activities or just not paying attention during the time-out process. With nonpunitive feedback (part of a just culture, detailed below) from real-time monitoring, true compliance with checklists and the time-out process topped 95%.
These examples underline a key lesson for leaders: Question data from audits that may be affected by human factors. Probe your team leaders and never assume. Inevitably, human error will occur in healthcare, and this reality must be factored into safety initiatives. Although tactics can help reduce the occurrence of human error, the most effective safety strategy is to build systems to protect the patient that acknowledge both near misses and actual adverse events due to human error.
Teamwork is a bedrock principle of a patient safety culture. Like wingmen in aviation, everyone must prevent each other from making errors. This cooperation requires a free flow of communication to be effective. Northwell has joined many other healthcare organizations in adopting TeamSTEPPS, a set of tools developed by the Department of Defense aimed at optimizing patient outcomes by improving communication and teamwork. TeamSTEPPS can produce “highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients” (AHRQ, n.d.). The key elements of TeamSTEPPS are multidisciplinary training and a common terminology.
This is not flavor-of-the-month training—substantial commitment is required. Leadership needs to agree to train all staff, provide financial support to backfill their positions while they are attending training, and ensure that they are trained in multidisciplinary teams, which must include physicians. In healthcare, TeamSTEPPS must also include members of the C-suite as well as physician and other clinical leaders.
Following this methodology, Northwell has trained more than 45,000 employees. A second round reinforced the original training. This team approach is necessary to drive lasting cultural change throughout the organization.
Teamwork requires a just culture: “a values-supportive model of shared accountability” (Brunt, 2010). The aviation industry often is held up as the gold standard for safety that healthcare should emulate, and nonpunitive reporting of errors is integral to aviation’s safety culture.
Although a just culture allows for a nonpunitive environment, accountability is not disregarded. In a just culture, reckless behavior—a choice to disregard an unjustifiable risk (i.e., not slips, mistakes, or errors in judgment, which are inadvertent actions)—may still result in disciplinary action. Thus, leadership promotes transparency while holding staff accountable.
To support a just culture, an organization must encourage caregivers to speak up, as taught in TeamSTEPPS. At a Northwell hospital, for example, a nurse did not allow a patient to leave the operating room when a count was not correct. She escalated the matter all the way to the chairman of surgery. The situation was resolved appropriately, and the nurse was later praised by administrative and clinical leaders as well as the board. Reinforcement of the culture by leadership at all levels is vital to culture change.
Performance improvement activities often are reactive—undertaken in response to the last adverse event. Leadership needs to take a proactive approach to safety by promoting transparency, adopting a just culture, and supporting those who speak up to prevent harm. 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.
The following checklist will help healthcare leaders ensure that all the elements in a process for promoting patient safety are addressed in a systematic, orderly way:
* Embrace a patient safety culture as a core strategy for your organization.
* Demonstrate your commitment by personally participating in patient safety rounds and patient safety calls.
* Go out on the units and listen.
* Administer a safety culture survey to measure where your organization is positioned.
* Measure continuously to track the effectiveness of your interventions.
* Use tools such as TeamSTEPPS to hardwire teamwork and effective communication into your corporate culture.
* Promote transparency and a safe environment for reporting both errors and near misses.
* Employ a just culture.