By Ted A James, MD, MHCM
June 28, 2018
“The goal in health care really needs to be zero preventable harm.”
Modern health care has been described as one of the most complex industries in the world. Advances in biotechnology, data analytics, and genomic medicine alone have enabled greater capabilities and more sophisticated care than any other time in history. The problem with complexity is that human beings are imperfect and fallible, leading to the potential for medical error and fragmented care. With greater complexity comes a greater risk of failure, making it challenging to deliver on the promise of safe, reliable, and effective health care.
An All-Too-Common Case:
The following case and discussion are adapted from “Leading a Culture of Safety: A Blueprint for Success,” a resource from The American College of Healthcare Executives (ACHE) and the NPSF Lucian Leape Institute:
Mr. Roberts is a 71-year-old man with recent shortness of breath associated with exertion. His primary care physician refers him to a cardiologist who orders a stress test. The test is positive; however, the results are not conveyed to the primary care physician or to the patient. In addition, the ordering cardiologist happens to be away at a conference. A few days later, Mr. Roberts presents to the emergency department with chest pain and is diagnosed with an acute myocardial infarction. Fortunately, the hospital has a good ‘door-to-stent’ time, and the patient receives a timely cardiac catheterization and stent placement. After a stay in cardiac rehab, Mr. Roberts has a full recovery. Unfortunately, following discharge his primary care physician realizes that Mr. Roberts was not continued on a new cardiac medication that was started by his inpatient team.
Is this good care? How can we achieve better outcomes? The way an organization responds to this situation is an important first step. Performing a root-cause analysis is standard. A mediocre response, however, would focus only on re-educating the cardiology staff on the policy for communicating test results. There would be no plan for sustainability, the information would not be shared outside the cardiology department, and neither the CEO nor the board would be aware of the incident. A superior response would include redesigning the process of communicating results with input from individuals involved in the adverse event. The institution would disclose the information throughout the organization (and to the patient), put in place transparent performance metrics for sustainability, and the hospital CEO would present the case to the board where patient safety issues are discussed alongside financial performance. Which response is more like your organization? In which would you prefer to work? In which would you prefer to receive care?
Managing Complexity Well:
“The goal in health care really needs to be zero preventable harm.”
What do nuclear power plants and the airline industry have in common? They manage complexity well. They operate with near failure-free performance despite unpredictability and intrinsically hazardous conditions. In order to achieve better outcomes in health care we need better systems capable of managing complexity well. Health care can strive to achieve this level of reliability, but it requires the right culture and the right systems.
The right culture embraces teamwork and collaboration as a core value; creates an environment where people are not punished for mistakes, yet are held accountable for adherence to standard conduct; makes it safe to raise questions or suggestions about patient safety; aims to identify potential errors before harm occurs; solicits input from front-line staff; learns from failures and near misses; and seeks to continually become better with time. In high-performance organizations, the right systems include providing training and coaching to support team members, optimizing daily operations, enabling rapid tests of improvement, implementing best practices, measuring what matters, and using defined strategies for sustaining improvements by incorporating them into the norms and values. These organizations design systems that leverage intrinsic strengths and compensate for inherent weaknesses.
One example of an organization making great strides in the journey to excellence is Cincinnati Children’s Hospital. Their organization focuses on improving outcomes through better process design, building a culture of reliability, and creating intuitive designs that help people do the right thing. They empower families to flag staff if they see a potential risk or perceive any concerns. Leadership conducts daily operational huddles around patient safety, and these meetings are accessible to parents. Performance metrics are not only monitored, but are made transparent. Through extensive training, they develop robust plans for the expected and the unexpected. In 2017, Cincinnati Children’s Hospital experienced a trial by fire—literally. A transformer accident in an electrical room of the hospital resulted in a four-alarm fire and power outage. No patients were injured. As stated by Chief of Staff, Dr. Derek Wheeler, “This is a very uncommon scenario—one that we’ve trained for.”
The Path Forward:
Achieving high performance requires change, growth, and resilience. Strong leadership is critical for success. Physicians, especially, can have a lasting impact on driving quality in their organizations by role-modeling best practices (e.g., structured communication, huddles, checklists), encouraging data-based decision making in QI, supporting systems-based approaches to improvement, and advocating for patient safety to be a key strategic priority at every level of the organization. In my own experience leading quality and patient safety programs, I have found that these steps can help mitigate unexpected complications, result in better patient outcome, and foster a culture of performance excellence. Our patients need your engagement and leadership to develop the culture and systems to support a framework of safe, reliable, and effective care.
- Leading a Culture of Safety: A Blueprint for Success. https://www.npsf.org/page/cultureofsafety
- Federico F. Is Your Organization Highly Reliable? Institute for Healthcare Improvement. Healthcare Executive. 2018
- Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A Framework for Safe, Reliable, and Effective Care. White Paper. Institute for Healthcare Improvement. 2017
- Decker CF, Lee TH. Cultivating “Systemness” to Create Personalized, High-Reliability Health Care. NEJM Catalyst. 2018
- Gandhi TK. Leadership and Vision for a Culture of Safety. NEJM Catalyst. 2018
Dr. Ted James is a medical director and vice chair at BIDMC/Harvard Medical School. He is an alumnus of the Harvard Health Care Management program and is involved internationally in leadership development and health care transformation. Follow Dr. James: LinkedIn / Twitter
Dr. James blogs about health care transformation. To see more of his posts, click on his name in the tags below.
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