MGR: What Makes For a Safe Healthcare Institution?

Submitted by Frederique Verly, Lead Quality Improvement Data Coordinator, PPSQ

FrederiqueIn celebration of Patient Safety Awareness Week, the Program for Patient Safety and Quality and Management Grand Rounds put together the following panel of four incredible healthcare leaders to discuss: What Makes For a Safe Healthcare Institution?

Allen Kachalia, MD, JD – Chief Quality Officer at Brigham & Women’s Hospital

Don Goldmann, MD – Clinical Professor of Pediatrics, Harvard Medical School, Professor of Immunology and Infectious Diseases, and Epidemiology, Harvard School of Public Health, and Chief Medical and Scientific Officer at Institute for Healthcare Improvement (IHI)

Sue Gullo, RN, BSN, MS – Managing Director, Institute for Healthcare Improvement (IHI)

David Cutler, PhD – Harvard University, Professor of Applied Economics

Moderator: Jon Finkelstein, MD, MPH – Vice Chair for Quality and Outcomes, Department of Medicine at BCH

While this panel featured a broad range of experience and expertise, the panel discussion often circled back to the themes of measuring performance and target-setting, as well as the importance of culture in promoting safety in healthcare institutions.

David Cutler, noting that he has no medical training, started the panel discussion from a management consulting point of view, detailing the four dimensions that define good organizations.  These dimensions evaluate how organizations use specific processes, identify goals and set targets, track and communicate targets, and promote employees.  Firms that do better in these areas are more profitable and have fewer defects.  Quality and safety are aspects of a good, well-run healthcare organization, and hospitals that do better on the above dimensions have better outcomes.

What may come as a surprise is that healthcare organizations as a whole actually rank near the bottom of well-run institutions when measured by these dimensions.  In fact, David Cutler mentioned, if healthcare were any other industry, it would fail and go out of business!  Unlike other industries that survive and thrive based on giving customers excellent experiences and products that work 100% of the time, healthcare organizations seem to get by on their reputation rather than a response of the patients.  Nevertheless, this may all be changing as patient and financial pressures begin to force the healthcare industry to adapt and do better.

Don Goldmann continued the discussion stressing the necessity of targets to inform the following questions: How do we know how good we think we are?  How do we know we’re the center of excellence?  Without targets, an institution cannot know how well it is doing compared to other institutions.

Sue Gullo followed with the idea that people will meet the targets you set for them.  The key to promoting this behavior is to create a learning system within the institution.  Fostering a culture of continuous learning is critical to achieving this.  The leadership must create a learning environment where the staff feels safe to ask questions and innovate; staff psychological safety is essential.  Additionally, there needs to be a framework within the system such that departments and divisions can easily interact with and learn from each other.

Allen Kachalia seconded the importance of building this culture and furthermore emphasized tackling the infrastructure of the institution such that people are better able to do their jobs properly.  For example, we need to ask more from our electronic health records.  Allen Kachalia recognized that there is genuine interest in making safety-promoting culture changes, but the infrastructure change is still missing. We need to figure out how to change our systems rapidly enough to keep up, and to do this, we need more resources.

Finally, the panelists reminded the audience that patient safety is not about us (as healthcare providers, staff, etc.); it is about the patients.  Asking questions from the patient perspective will drive our quality improvement efforts.  We need to seek active participation from patients and families, and in doing so, we will see that the discussion of patient safety and quality can really evolve.  The patient perspective is invaluable.  Nevertheless, Allen Kachalia reminded us that while there is no question that we need patient input and involvement, patients cannot be our “backstop”.  It is imperative that we do our jobs correctly and fully the first time.

While the panelists brought different insights and recommendations to the discussion on safety in healthcare institutions, the themes were clear and similar ideas echoed among the participants.  Jonathan Finkelstein concluded the panel with the remark that we are on the right track to get better at using targets and shifting culture to promote patient safety, but we are not at the end of the journey yet.

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