The Foundation of Quality Is Safety

This month marks the 10th anniversary of the publication of the Institute of Medicine's To Err Is Human—a study that put a new focus on how patient safety is addressed in the United States. Though the report served as a clarion call to healthcare organizations to promote safety, many in the healthcare industry would probably agree that more still needs to be done at the local level.

Earlier this week at a forum sponsored by Consumers Union's Safe Patient Project in Washington, DC, Richard Shannon, MD, chair of the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia, provided health leaders with some insights on how to move their organizations forward to becoming high-performing facilities that can effectively address patient safety concerns.

Healthcare in the U.S. today is not "a high-performing organization," Shannon said. But it could be.

Shannon, borrowing pages from colleague Steve Spear's book, Chasing the Rabbit: How Market Leaders Outdistance the Competition and How Great Companies Can Catch Up and Win, suggests it could be different if healthcare organizations recognize—and try to change—a number of traits that hold them back:

• Many high-performing organizations "swarm and solve problems to build new knowledge—[where] problems are not things to be avoided," Shannon said. "They're learning opportunities." However, "in healthcare, we are the best work-around experts. We see problems every moment and absolutely do nothing about them . . . the antithesis of the high-performing organization."
• High-performing organizations tend to be "level" in structure—where individuals at all levels have a say. Many healthcare organizations, though, tend to be hierarchical—where decisions are made from the top down.
• High-performing organizations are constantly expanding the frontier of what they don't know. They must look for new ways and new ideas.

So what does this have to do with patient safety? Well, plenty. Before working at the University of Pennsylvania, Shannon was chief of medicine at Allegheny General Hospital in Pittsburgh, where he was instrumental in initiating a project that lowered central-line associated bloodstream infections and ventilator-associated pneumonia rates in the intensive care unit. He has continued with this work at Penn.

What he has discovered is that "in the end, the inability to understand in great detail how we do our work is the genesis" of many of the patient safety issues many healthcare organizations now encounter. Many times, the organization will look for the quick fix—hoping the problem goes away. "This characterizes one of the reasons why progress has been so slow," he says.

A new mindset needs to occur about patient safety. First, while it helps that patient safety is viewed as a priority, it is more important that it is seen as a "precondition of work," he says. "The foundation of quality is safety—and safety must be a precondition."

"There are hundreds of priorities that sit on my desk. If safety is one of them, it's in with the hundreds of others. But if it's a precondition, that means I begin work at 6:30 a.m. at the point of care asking 'did anything happen last night that could lead to the risk of someone getting a central line infection?’" he says. "That tells the workers that it's a precondition of coming to work."

Nurses need to be on the frontline with patient safety, he emphasizes. "It's fundamental," he says. "Nurses are the guardians of patient safety. They need to be empowered to do this. It's extraordinary what you can achieve when you partner with nurses."

Shannon recommends moving beyond data collected by the Centers for Disease Control and Prevention. This data generally does not deal with "fixing problems in hospitals." Instead, he suggests becoming a "deep observer of the current condition" within the healthcare organization.

For instance, it is important to know how a central line is "placed, maintained, and manipulated." And then, taking that knowledge and learning and "sharing it with everyone," he says. "As a leader, you must commit to fixing things that are there . . . to make sure [an infection] doesn't happen again."

And while comparative effectiveness has its benefits, it's not feasible when dealing with patient safety issues of waiting around five years or so for answers. "Safety is about making little changes at the point of care and then seeing if they worked," he says. This means listening to ideas of those on the frontline of delivering healthcare.