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Patient Safety Needs a Rescue

 |  By jcantlupe@healthleadersmedia.com  
   May 26, 2011

Reviewing the findings of HealthLeaders Media's intelligence report, the Drive to Patient Safety  one gets the sense that top health executives definitely want to steer in the right direction in terms of patient safety. But they also need to get in a faster lane.

Indeed, the survey shows that putting patient safety is among their top priorities, with 91% of the respondents saying it is a key concern. It is an area that health systems seek to be accountable for, says Bertine McKenna, COO of the Bassett Healthcare Network, in Cooperstown, NY, who reviewed the findings.

"That's definitely good news and shows a significant step in the right direction for many healthcare leaders," McKenna says.


Intelligence Report: The Drive to Patient Safety: Free Download.


But there are legitimate concerns over the health leaders' responses about communication and leadership structures tied to formulating patient safety plans. Those don't look good. They are issues that can significantly slow down the patient safety process.

Healthleaders acknowledged in the survey that communication is a potential stumbling block for improved patient safety initiatives as well as an area of risk to patient safety during transition of care.

About 49% of respondents said communication issues were among their strongest concerns. Moreover,  an alarming 56% of survey respondents said that important patient information "sometimes" is lost during shift changes. Another 12% said it "often happens," while  27% said it is a "rare occurrence"

When I asked Mary Anne Vincent, vice president of performance improvement at St. Joseph Hospital, in Orange, CA, she said those results are disappointing.

"Communication is a barrier in healthcare. So many times I see issues that could have been avoided or minimized with an extra minute or so of 'one-on-one Communications," Vincent says. In many systems, communication is broken down between nurses and physicians by merely the manner in which they  forward their information, she says.

During shift changes, for instance, for some healthcare workers "it's hard to let go of that control," says Shelby Harrington, outcomes specialist for Carolinas Health System, who examined the survey results. But letting go is what needs to be done, she says.


Intelligence Report: The Drive to Patient Safety: Free Download.


An important element in improving communication specifically related to shift changes involves patients themselves, Harrington says. "Giving (patients) a sense of ownership of their own care of what is happening." she said.

"We should be communicating to the patient exactly what we are doing and why we are doing it," Harrington says, "telling that patient, 'I know you've been asked this question, but to ensure your safety, we want to go through your allergy list again.'''

Communication is one thing – between staff and patients. And then there is another level of communication, among hospital staff themselves, and that also appears lacking, the survey shows. Healthleaders are uncertain as to the ultimate responsibility within an organization of who should oversee patient safety initiatives and monitor them.

The survey showed a wide variability of potential leadership for patient safety, ranging from: 25% for executive leadership collectively; 15% for a chief patient safety officer; 14% for a special patient safety committee; 11% for a CEO personally and a designated vice president, and 10% for a chief medical officer.

Lack of consensus is a "sad statement" that reflects potential disorganization in leadership oversight of patient safety, says Vincent. A hospital system can't afford to have a "chief executive who doesn't want to be bothered" with specifics involving patient safety issues," she says.


Intelligence Report: The Drive to Patient Safety: Free Download.


Comments from healthleaders reflect their feelings about the necessity of change and commitment to patient safety as a priority. "We approach it as an area that we do well in, but feel that we can be more effective," says a hospital CEO. Says another: "Patient safety is inextricably linked or tied to the clinical care process, so if patient care isn't the No. 1 financial priority, then the facility is in the wrong business."

The survey shows the manner of communication among staff, physicians and nurses should definitely be improved, McKenna says, "whether it's within a leadership structure on the C-suite level or between physicians and nurses in a hospital room because communication and quality go hand in hand."

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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