Patient safety: the way we do the work.

THERE IS NO longer any question; the current state of patient safety is unacceptable and improving patient safety is a national priority. Across the healthcare system, the attitudes, level of engagement, and body language of those in the system have changed. No longer do providers and agencies launch large-scale challenges to the number of deaths or incidences from error that are reported in the media. Audiences are no longer full of attendees with arms crossed sending the message "Not about me or my place." seemingly every new study increases the rates of error, harm, and near misses and at all levels of healthcare, and in increasingly more organizations, the fact that suffering, death, harm, and near misses happen in the midst of exceptional care is accepted. Yet even with the declaration of patient safety as a priority or its visibility as a hot topic, organizations and individuals still struggle with the next steps. They know they have a problem and are asking the questions, "Now what do I do? "What is a balanced program?" "How much is enough...or too much?" "I can't do everything, so what should I do?" "What's a proven strategy?" "Should I be focusing at the strategic or the operational level?" Five- and ten-year retrospective studies (Leape and Berwick 2005; Wachter 2004) conducted on patient safety in the United States suggest that generally modest structural and process improvements have been realized, but transformational strategic and operational leaps have not been taken to make the healthcare industry safer. The journey is too slow. We have learned much and, as a result, gained a growing sense of how little we know. It is increasingly understood that so much more needs to be done, and the time to do it is now. The feature articles in this issue of Frontiers of Health Services Management by Bagian and by Winokur and Beauregard draw on the experiences of respected leaders and their organizations: the Veterans Health Administration (VA) and William Beaumont Hospital, respectively. Their approaches are complimentary, and their articles are not inclusive of all of their work on patient safety. Their organizations are not representative of all organizations, and the steps they are taking are not the only steps toward reducing harm and establishing a culture of patient safety. At the same time, these organizations are doing the work of patient safety leadership pioneers and can inform our personal practice and that of our institutions. Both organizations have built programs that are innovative, thoughtful, focused and comprehensive, and centered on objective measures and improvement. Both have received significant external recognition for their efforts. At the same time, I suspect, they would describe themselves as having a great deal more to accomplish. Without question, both of these programs demonstrate an absolute commitment to patient safety as a fundamental property of their care system. It is worthwhile to ground this commentary by listing the general elements of a culture of safety. Many such lists exist; the expanded set that follows is used by this author based on his own experience and that of his organization. It also draws extensively from many others, including the original work of Ken Kizer and the U.S. Department of Veterans Affairs (Kizer 2005). A culture of patient safety is not "plug and play," a switch to be turned on. It is a journey that * is based in trust, human rights, and forgiveness; * is patient and family centered; * has a shared vision for quality and safety, with leadership and staff working together in a balanced process that * draws extensively on leadership, and * expects, enables, and supports the highest levels of performance from all; * acknowledges the high-risk, error-prone nature of healthcare and the requirement of ongoing commitment and vigilence to patient safety as "the way we do the work" by * ensuring individual and shared acceptance of responsibility and accountability for safe delivery of quality care, * encouraging and facilitating reporting and open communication about safety concerns in a fair and just environment, * ensuring that organizational structures, processes, goals, and rewards are aligned with improving patient safety, and * putting in place systems to support safe practice, realize synergies, and mitigate the failures of teams; * embraces a focused, prioritized, data-driven, systematic approach; * stimulates a continual "tension for change"; * allows learning from errors and sharing stories of safety; and * recognizes itself as in an ever-evolving transformation. …