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CEOs Poised to Lead a Culture Shift to Safer Patient Care

Ken Smithson, MD, and Linda DeWolf, for HealthLeaders Media, July 9, 2008

Providers of healthcare are increasingly finding themselves in the crosshairs of public scrutiny and heightened concern over patient safety. The latest salvo from payers: the June announcement from Massachusetts and its largest private health insurer that they will no longer reimburse hospitals or doctors for 28 medical errors. With the announcement, Massachusetts joined the likes of the Centers for Medicare and Medicaid Services and private insurers like CIGNA and WellPoint who have announced over the last year that they would no longer pay for "never events."

While these payment decisions have hammered home the urgency for tightening up quality controls and the need for active CEO participation, the truth is that many CEOs already feel a personal stake in addressing patient safety. A May national survey from the VHA Foundation found that nearly two-thirds (65%) of hospital leaders have faced a significant patient safety event in the last three years. These CEOs say the experience is a defining moment that shapes not only their legacy, but also the long-term relationship between the community and the hospital. For many, the realization that they are ultimately accountable for a preventable death or injury -- even though they rarely spend time in the operating room or neonatal intensive care unit -- is a life-altering event.

With this as a backdrop, CEOs are focusing on improving patient care. They are making significant investments in patient safety programs, education, information technology, and internal process improvements. But at the end of the day, there is little evidence that patients are safer. What's more, the same VHA Foundation survey also found that 70% of hospital CEOs agreed that consumer concerns about patient safety are justified.

So, what is the missing link that will create real change and better outcomes for hospitals and patients?

Lessons from high-reliability industries

Hospitals are not alone when it comes to dealing with safety issues. In fact, there are a number of industries that can be case studies for hospital leaders that succeed in avoiding catastrophes in an environment where normal accidents could be expected due to risk factors and complexity. What are hospitals learning from these high-reliability industries like airlines or nuclear power plants?

Analysis of safety practices of high-reliability industries reveals that process-related improvements -- like those hospitals have been implementing -- only seek to eliminate variation in repetitive activities. Safety accidents, however, are rarely the result of predictable and consistent events. Rather, they usually stem from a cascade of unforeseen actions. So, behavioral modifications, not process changes, are needed to improve the safety environment.

While vastly different in many ways, all high-reliability organizations require a fundamental ingredient for creating sustainable improvement: a culture of safety where senior leadership values and makes personal commitments to safety. Cultural elements such as communication and motivation drive the organizations' ability to deal with safety events by shaping behavioral changes.

Culture of safety in hospitals

Lessons learned from high-reliability industries illustrate that safety efforts hinge on the attitudes and behaviors of individuals and those are shaped by the culture in which they work. The culture is ultimately a reflection of the CEO and his/her priorities. Like it or not, the CEO is the chief safety officer of the organization and is accountable for the safety of employees as well as the patients.

To move the needle on patient safety, senior healthcare leaders need to signal their personal commitment to the issue. It is their responsibility, in partnership with employees, physicians, and other stakeholders to establish a culture of safety in their organizations where everyone -- from the CEO to the admitting nurse -- shares responsibility for patient safety and continually strives for opportunities to reduce the risk of injury.

While favorably disposed toward improving safety, most leaders are understandably skeptical about vague concepts such as "transforming culture." When possible, they prefer tangible solutions. This is one reason there have been huge investments in information technology, such as computerized physician order entry and electronic patient records. What we have learned from implementation of those systems is that without a change in organizational culture there is no evidence that improved IT will improve safety; in fact, it may make things worse.

There are some very tangible things CEOs can do to get the ball rolling:

  • CEOs can get smart: Very few hospital leaders have any sort of formal education in safety science. VHA has recently introduced networks for CEOs to help build their knowledge and share experiences around patient safety called the Health Care SafetyNetwork -- CEOs Committed to Patient Safety.
  • CEOs can emphasize accountability for patient safety through their direct reports all the way to the bedside. The VHA Foundation survey found that 80% of CEOs now have explicit safety goals, in addition to their clinical and financial goals. Hospital boards then are clearly aware of the issue and expectations are growing. This level of accountability must be evidenced at every level of the organization.
  • CEOs can be visible in their concerns for safety. Executive walk-rounds in which each senior leader spends a half-day a month on a clinical unit, understanding the work and the risks, is an excellent way of learning, while at the same time sending a clear message of personal commitment.
  • CEOs can share their experiences. In our discussions with CEOs it became evident that they all have stories, sometimes sensational, sometimes bizarre, but unfortunately always tragic. Given the legal concerns and their role in the organization, they seldom have anyone with whom they can share those stories. As a result, the very expensive lessons their organizations have learned are not being used to help other organizations avoid similar calamities.
  • CEOs can ensure that the people that report to them, many of whom will become hospital CEOs in their own right, have the knowledge and skills to deal with the issue so that when their time at the helm comes, they are well prepared for the challenge. CEOs can act as mentors to rising CEOs and can also ensure all staff understand their own accountability and access appropriate training and education opportunities.

Given what we know about patient injuries, it's not a matter of if it will happen at a given hospital, but when and where. And while investing in a culture of safety takes time and commitment, there is nothing more important than the results it can mean for patients, their families and hospital staff.


Ken Smithson is vice president of clinical improvement services at VHA Inc., an Irving, Texas-based healthcare alliance that provides supply chain management services and supports the formation of regional and national networks to help members improve their clinical and economic performance. Linda DeWolf is the president of the VHA Foundation, a 501 (c) (3) focused on promoting leadership and innovative solutions to improving health and health care. Smithson and DeWolf are currently working on the VHA Foundation's Health Care SafetyNetwork, a program designed to transform hospital leaders into confident safety leaders through a number of learning opportunities. For more information, visit www.vhafoundation.org.

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