by Mary Beth Edmond, RN, MBA, senior nurse executive, and Jonathan Flanders, MHSA, BSMT, MT (ASCP)
Ensuring patient safety is one of the most vital and challenging jobs in healthcare today. Organizations such as the Institute of Medicine recommend healthcare professionals strive to create a culture of safety and report medical errors without fearing their reports will be used against them. The Joint Commission (formerly JCAHO) works continuously to improve the safety and quality of patient care through the provision of healthcare accreditation services that support performance improvement in facilities. Public reporting of preventable medical errors forces hospitals to account medical error numbers accurately and to improve the quality of care being delivered.
Despite this emphasis on patient safety, error occurs. Patients may receive the wrong medication or fall getting out of bed, both causing serious safety events. These events arise as a result of the untimely combination of high-risk actions (human error or lack of compensatory actions) and high-risk conditions (environments or situations that increase the probability for error).
But facilities can work to reduce human error and process barriers to improve patient safety. The chief nursing officer (CNO) is often the person assigned to be the patient safety officer (PSO) who is responsible for the organization's strategy and operational plan for improving patient safety. While CNOs have extensive clinical, quality, and risk experience, they are often underprepared to meet the challenges of the role of PSO. Many also lack the methodology and tools needed to drive a successful patient safety program.
Hospital leadership and PSOs must collaborate to build a culture in which all organization members place patient safety as the highest priority in their hearts, minds, and actions. Patient safety should be embedded into the organization's culture and PSOs must provide support at every level of delivery and reinforce behavioral expectations that promote the safety of patients, families, and staff.
Measuring performance improvement
Performance measurement—where data is gathered, analyzed, and presented to staff—is the backbone of an effective patient safety program. Performance improvement baselines or targets for patient safety should be established with benchmarks, historical trends, and management objectives for what management thinks it can control. It is essential to communicate the measures to all staff in the organization.
The PSO is responsible for identifying safety performance measures, but when selecting a measure, it is important that it drives the right behaviors and is not selected simply because it always has been. Safety performance measures should be kept to a vital few and assigned a process owner.
Supporting patient safety with board members
Board members must fully embrace and endorse the transformational patient safety strategy of an organization since they bear ultimate responsibility for all services provided and outcomes achieved. In doing so, board members must own their duty to oversee patient safety with the same level of vigilance they have for strategic planning and hospital finances otherwise patient safety will not be positioned as a strategic imperative in the organization.
It is the responsibility of the board to:
- Put the appropriate structure in place to oversee patient safety (e.g., patient safety steering committee and quality committee).
- Place the right people on the committee. At least two or three board members should have a background in quality or safety.
- Educate themselves on best practices in patient safety.
- Engage with medical staff early on in the development of a patient safety program. Invite a few key physician champions to be active members of the committee.
- Set the expectation for patient safety performance standards and provide clear direction to the PSO about what results must be achieved and why they are important to patients, the community, and the committee. The board should develop an accountability model so that the PSO and leadership team understands who is responsible for what results and by when. Reviewing the patient safety accountability model should be a standing agenda item at each patient safety committee meeting.
- Provide guidance and support to the PSO and maintain the commitment to improve patient safety.
The PSO must have access to the board at all times, and together they can shape a culture that promotes patient safety behaviors and improves patient safety outcomes. Only when patient safety receives the highest level of attention will the organization know it is a top priority.
Communicating a culture of safety
Facilities can also increase patient safety by partnering with patients, families, and the community. Key themes in accomplishing this are awareness, education, and participation. Facilities should provide multimedia education outlining why certain practices such as site-marking, positive patient identification, hand hygiene, and the five rights, are performed in the hospital.
In addition, facilities can encourage patient and family participation by asking them to remind staff to perform basic patient safety practices (e.g., hand hygiene and positive patient identification) as a form of peer accountability.
Although many organizations oppose posting patient safety performance measures on their website or in their staff newsletter, it is vital to improving the patient safety culture for the organization to be transparent about performance. Not only does this help promote a just culture, but it also helps grassroots staff relate their individual behaviors to the organization. Additionally, it helps organizations learn from mistakes by transporting root causes and action plans across departments and professional groups.
Organizations that tend to hide their faults tend to make the same mistakes or have the same sentinel events occur repeatedly. Improved patient safety is achieved faster and more effectively when everyone works together.
Editor's note: Edmond and Flanders are certified Lean Six Sigma Black Belts at Juran Institute in Southbury, CT