Executive Director, Strategic Partners, Institute for Healthcare Improvement (IHI), USA
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.
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.
The highest level of leadership within an organisation, such as the board of trustees, must set a vision and goals for the provision of safe and effective care. That vision must penetrate flow down to all departments and services in the organisation. Middle managers and clinical leaders must operate their areas of responsibility in a manner that supports the vision. The people who directly provide care are also leaders and must understand their roles in identifying defects and poorly functioning processes which need improvement.
Reasons that many are not involved in quality improvement include not having the encouragement to identify defects and to fix them, not having the skills to improve, and the fear that improvement means ‘change’ is quite a disruption for the workers themselves. This suggests another level of responsibility for leaders: in order to achieve safe care it is necessary to ensure that the appropriate infrastructure and culture are in place.
Leaders have responsibility to facilitate and mentor teamwork, improvement, respect for patients and all workers, and psychological safety. Psychological safety is defined as feeling safe to speak up, safety in taking risks in a team setting, and trusting that your voice will be heard.
Communication and building awareness about patient safety are also vital. Leaders can carry the banner for patient safety through Walk Rounds, an opportunity to visit with care providers where they do their work. Safety briefings at the ward and department levels offer another opportunity to discuss and deal with safety issues.
Communication breakdowns have been identified as a contributor to patient harm. Implementing a communication tool such as SBAR, a structured communication tool, is helpful in providing clear, concise, and actionable information.
Leaders must also set the stage for the development of teamwork training.
Maureen Bisognano, CEO of IHI, asks leaders to consider the following: “Do we know our outcomes or how good we are?” “How do we compare with the best?” “Do we know where the variation lies in our care?” “Are we improving fast enough?” To answer these questions it is necessary to have a system to measure and track performance over time.
A common complaint is that we have so many projects and so much work to do. Where do we start? Leaders must organise and manage the portfolio of projects and activities that must also be aligned with the aims of the organisation.
Patients and families and staff are impacted by the outcomes of medical errors. It is the responsibility of the organisation to support each person who has been impacted by harm related to the delivery of healthcare.
We cannot continue to do the same activities and expect different results. To provide safe and reliable care we must redesign and improve the systems of care we have today. Leaders must demand that improvement is more than new policies, more training and education, and merely asking people to be more vigilant. We must change how we do our work.
Our experience is that many middle managers, the group of people responsible for translating the vision of the organisation to those who provide care, are often not trained in quality improvement. Many are so overwhelmed with meetings, messages, and reports that they have little time to focus on those who report to them. In order to be successful, middle managers must know improvement science and how to coach teams who are working on improvement efforts.
At the same time, middle managers must relinquish control and allow those who do the work to test different methods for improving the completion of their task. I realise that this is a difficult change for many managers. However, we have learned that successful changes are those that originate with those who are closest to the work. Once various methods are tested, the best one can be standardised. This will then ensure that the process will deliver the care we want our patients to receive, support training and competency testing, and help us continually learn and improve.
We tend to think of patient safety as a special project that we must undertake. I suggest that we look at patient safety as something we should be doing every day. That is, we should not make following evidence-based practice a special project. What we should be doing is ensuring that each and every patient receives evidence-based care, unless contraindicated, as part of our every day work. If we do that, we will provide safe care.
Systems designed to deliver safe care must also be designed to be efficient and easy to use. As a result, staff will have the time needed to provide care. Processes that are not well designed complicate daily work and result in rework.
If we deliver safe care, we will also reduce the events that contribute to patient morbidity and mortality. We will reduce the opportunity for infections and all of the associated work that goes along with treating the infection.
All of the above contributes to safer, more efficient, more effective and timely delivery of care. There will also be cost benefits realised.
A benefit that is not often discussed is the joy in work that results when systems are designed to make it easy to do what is correct for the patient. Teamwork and proper communication help all who are delivering care by fostering a community of care. Elimination of rework helps with efficiencies. Ensuring the safety of the workforce is a key element of safety. A safe and respected workforce is one that works to ensure that patients are safe and respected.
At IHI we believe that in order to make changes, there must be the will or a desire to change. Many still deny that they have a patient safety problem. Even if an organisation has not had a serious event, leaders must ask “Can it happen here? Are our processes capable and reliable to ensure that every patient receives safe care? How do we know?”
One must also have ideas about what changes should be tested. And, the ability to get results. That is, does the organisation use an improvement methodology? We find that in many organisations there is a desire to improve, and there are many ideas. The point at which many are having difficulty is executing or getting results.
Each organisation must examine where its own challenges are along this continuum.
It is the responsibility of all leaders and providers to challenge the status quo. All must gather new ideas from each other, other organisations, the literature, and places like IHI. Then the organisation must use an improvement method that engages the workforce in the redesign of care. Written policies, asking people to work harder and to pay attention, training, and education may be necessary to varying degrees, but they are insufficient.
The recommended approach of using standardisation and simplification will always apply. We are learning more about applying human factors research and using methods that develop resilience. High reliability organisations are implementing huddles as a way of raising situational awareness. We are beginning to study prediction, the skills to predict where we might have issues, better identifying those patients who might be more likely to deteriorate.
As we focus on improvement, we are learning to move away from the project by project approach to one that makes patient safety and quality improvement the way work is done every day.
We are also examining patient safety from the perspective of the continuum of care. Until now, most of the work has been conducted in silos of care. That is, we have focused on harm in the hospital, in the ambulatory setting, and in long-term care. We must now look at harm across all these areas as part of the patient’s journey. We may be able to prevent harm in the hospital if we work to keep the patient safe at home or in the doctor’s office.
Recently a colleague shared his experience with the healthcare system. He was not feeling well and walked into a hospital so someone could check on symptoms. From the outset, his concerns were not addressed; the doctor dismissed them even though the patient, a doctor himself, attempted to draw attention to things that were being ignored several times. The doctor spoke disrespectfully to the patient and his wife. Those of us in healthcare entered the profession to help patients. We become so caught up in the day-to-day activities that we often forget the patient to be a person. I believe that it is only when we experience the healthcare system as any person does that we begin to understand that being taken seriously, being seen and heard, is as important to healing as is the science of medicine. Let us not forget that each patient is an individual who is in need of respect and empathy. I am pleased to note that Beth Israel Deaconess Medical Center in Boston, in the United States, now recognises psychological harm of the sort I’ve just described as real harm which too many patients endure. And, this respect should not stop with patients. It must extend to everyone who works in healthcare, too.
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.