While a strong hospital patient safety program requires multiple elements that may differ depending on the specific organization, there are several core features that every patient safety program should have. Michael McKenna, MD, vice president of medical management and CMO of Advocate Lutheran General Hospital in Park Ridge, Ill., shares five must-haves for a hospital patient safety program.
1. Safety is a core value. Patient safety needs to be a core value of the organization to support a patient safety culture and engage employees in patient safety initiatives. "It's not a project, it's not something that's nice to have; it has to be part of the values of the organization," Dr. McKenna says. Lutheran General has three principle values: safety, quality and service, with safety being the most important, according to Dr. McKenna.
2. Safety is led from the top. Hospital leaders' active commitment to patient safety is another key element of patient safety programs. Leaders' visible involvement in patient safety initiatives demonstrates the importance of safety for the organization and provides a model for physician and staff involvement.
Lutheran General senior executives lead patient safety efforts in a variety of ways. Providers hold daily safety huddles with representatives from every department to review safety events and near misses in the past 24 hours; most days, the president leads the huddles, according to Dr. McKenna. Lutheran General leaders also conduct executive safety rounds to talk to front-line workers about their safety needs and concerns. Leaders then act on those concerns and provide feedback to staff.
3. Safety events are reported. An often-repeated, but no less true, maxim is that you can't fix what you can't measure. Hospital leaders need to know the gaps in patient safety and errors that occur to best develop strategies to eliminate the gaps and prevent errors. To encourage physicians and staff to report near misses and safety events, hospital leaders need to create a "just" culture, one in which people who report errors are not punished, according to Dr. McKenna.
"Ninety-nine percent of the time when a safety event occurs, it's not something a person deliberately failed to do; it's that the system failed them," he says. "Make sure people understand that the vast majority of the time there is no discipline, it's just about fixing something the system let them down [on]." The rare occasions on which people would be disciplined for a safety event may include an employee harming a patient due to intoxication, for example, explains Dr. McKenna.
In addition to establishing a non-punitive environment, hospital leaders should make it as easy as possible for people to report safety events. For example, a secure website that enables people to report an event may encourage employees to speak up.
Reporting the problem is only the beginning of an improvement cycle, however. Leaders need to respond to the event and then follow-up with the reporter to share the action taken, says Dr. McKenna.
4. Safety is transparent. Transparency is essential to a patient safety program because it promotes communication, shared learning and trust. One way to be transparent in patient safety is to share results of patient safety initiatives across the organization, both within a hospital and between hospitals of a system. For example, a department that developed a successful strategy to prevent patient falls should share lessons learned with other departments so they can quickly and easily implement the strategy. "Events get repeated in other hospitals [of a system] or inside the hospital in other areas because they haven't shared [results] across," Dr. McKenna says.
5. Safety events are disclosed. In addition to being transparent with hospital physicians and staff about safety, leaders should be transparent with patients and their families when a safety event occurs. "If you're serious about safety, create a disclosure program to share with the patient and family what happened," Dr. McKenna says. "Through disclosure, you can more readily discuss [the problem] as an organization and make the changes to create a safer environment."
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1. Safety is a core value. Patient safety needs to be a core value of the organization to support a patient safety culture and engage employees in patient safety initiatives. "It's not a project, it's not something that's nice to have; it has to be part of the values of the organization," Dr. McKenna says. Lutheran General has three principle values: safety, quality and service, with safety being the most important, according to Dr. McKenna. 2. Safety is led from the top. Hospital leaders' active commitment to patient safety is another key element of patient safety programs. Leaders' visible involvement in patient safety initiatives demonstrates the importance of safety for the organization and provides a model for physician and staff involvement.
Lutheran General senior executives lead patient safety efforts in a variety of ways. Providers hold daily safety huddles with representatives from every department to review safety events and near misses in the past 24 hours; most days, the president leads the huddles, according to Dr. McKenna. Lutheran General leaders also conduct executive safety rounds to talk to front-line workers about their safety needs and concerns. Leaders then act on those concerns and provide feedback to staff.
3. Safety events are reported. An often-repeated, but no less true, maxim is that you can't fix what you can't measure. Hospital leaders need to know the gaps in patient safety and errors that occur to best develop strategies to eliminate the gaps and prevent errors. To encourage physicians and staff to report near misses and safety events, hospital leaders need to create a "just" culture, one in which people who report errors are not punished, according to Dr. McKenna.
"Ninety-nine percent of the time when a safety event occurs, it's not something a person deliberately failed to do; it's that the system failed them," he says. "Make sure people understand that the vast majority of the time there is no discipline, it's just about fixing something the system let them down [on]." The rare occasions on which people would be disciplined for a safety event may include an employee harming a patient due to intoxication, for example, explains Dr. McKenna.
In addition to establishing a non-punitive environment, hospital leaders should make it as easy as possible for people to report safety events. For example, a secure website that enables people to report an event may encourage employees to speak up.
Reporting the problem is only the beginning of an improvement cycle, however. Leaders need to respond to the event and then follow-up with the reporter to share the action taken, says Dr. McKenna.
4. Safety is transparent. Transparency is essential to a patient safety program because it promotes communication, shared learning and trust. One way to be transparent in patient safety is to share results of patient safety initiatives across the organization, both within a hospital and between hospitals of a system. For example, a department that developed a successful strategy to prevent patient falls should share lessons learned with other departments so they can quickly and easily implement the strategy. "Events get repeated in other hospitals [of a system] or inside the hospital in other areas because they haven't shared [results] across," Dr. McKenna says.
5. Safety events are disclosed. In addition to being transparent with hospital physicians and staff about safety, leaders should be transparent with patients and their families when a safety event occurs. "If you're serious about safety, create a disclosure program to share with the patient and family what happened," Dr. McKenna says. "Through disclosure, you can more readily discuss [the problem] as an organization and make the changes to create a safer environment."
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