Creating a System for Safety

Frank A Federico

Frank A Federico

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Frank A Federico works in the areas of patient safety, application of reliability principles in healthcare, preventing surgical complications, and improving perinatal care. A registered pharmacist, Mr. Federico serves as faculty for IHI's Patient Safety Executive Development Program and has co-chaired a number of Patient Safety Collaboratives.

It needs to be ensured that each and every patient receives evidence-based care, unless contraindicated, as part of everyday work. This means that safe care is provided. If safe care is delivered, the events that contribute to patient morbidity and mortality can be reduced. The opportunity for infections will also be reduced.

Is the existing environment sufficiently suitable for practising a better healthcare system? What measures have to be taken for better outcomes?

In order to build a system of safety, we must first all agree as to what we mean by patient safety. As with any work, unless we agree to a common definition and understand ‘why’ we need to improve a situation, we will not be able to build the system to support our goals.

The National Patient Safety Foundation defines patient safety as “The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare”. At the Institute for Healthcare Improvement (IHI) we have adopted the term ‘harm’ which includes any harm resulting from the delivery of healthcare, preventable and non-preventable.

With this definition we have broadened the discussion. As a result, it has also been more difficult to determine if we have made improvements in reducing that harm. We started with working on events such as wrong site surgeries, medication errors and falls. We expanded the work to include infections and pressure ulcers. Many continue to build on this work. And, as we become more sensitised to the patient experience, we are adding many more events that were in the past considered unavoidable, as in, ‘this is just what happens in healthcare.’

Attitudes toward patient safety continue to change. And, along with those attitudes the environment is also changing, although probably not as quickly as we would like to see. Remember that the healthcare system has a history of layering processes after processes on a system which must be rebuilt and redesigned to meet the challenges of today’s complexity.

We  have  developed new technologies, procedures, and medications that promise better outcomes. Yet, we have not worked enough to better understand the challenges these developments present to those who work in healthcare who must deliver this level of care.

I believe that we have a foundation upon which we can build. Leaders and providers have a better understanding of their role in developing improved healthcare systems.

We must continue to explore and address how humans interact with the system, each other, equipment, and the environment.

What will be the role of hospital leaders in creating a system for patient safety?

Hospital leaders at every level of the organisation including the board, senior leaders, middle managers, and leaders at the point of care, play a significant role in developing a system of safety. At IHI, we have developed a framework that has leadership as foundational to any patient safety effort. Leaders must engage key stakeholders such as the board of trustees, physicians, staff, and patients and families.

We believe that leaders must make safety a number one priority for the organisation. That is not to say that finances and efficiencies are not important. However, as healthcare providers, we are entrusted to ensure that our patients are not harmed by the care we deliver. That is paramount. As in any industry, the customer should be first and foremost in leaders’ minds. An airline can have the best ticketing system, best luggage handling, cleanest planes, and the best food but, if the planes are not safe to fly, then what is the purpose of the airline? It is the same in healthcare. We must have efficient and effective systems. We must provide care that is timely and equitable; we must provide care that is safe. From the highest level, governments must expect that the healthcare providers in their jurisdictions provide safe and effective care for the population they serve. And, leaders at all levels of the organisation and outside the organisation must be involved.