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    The Safety Playbook: A Healthcare Leader's Guide to Building a High-Reliability Organization
    The Safety Playbook: A Healthcare Leader's Guide to Building a High-Reliability Organization
    The Safety Playbook: A Healthcare Leader's Guide to Building a High-Reliability Organization
    Ebook268 pages2 hours

    The Safety Playbook: A Healthcare Leader's Guide to Building a High-Reliability Organization

    By John Byrnes

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    About this ebook

    Each year, more than 200,000 patients die as a result of medical errors—the third leading cause of death in the United States.
    Although the numbers are staggering and the challenges great, this national healthcare crisis is solvable—and fixing it has become a personal mission for John Byrnes, MD, and Susan Teman, RN.

    Byrnes and Teman have a proven track record in helping hospitals and health systems transform into high-reliability organizations that aim to deliver error-free care at an affordable cost. In The Safety Playbook: A Healthcare Leader's Guide to Building a High-Reliability Organization, they lay out their process for building a safety program that can eradicate preventable medical errors.

    Written in a clear, conversational style, the book applies to all types of healthcare organizations and speaks to leaders across the spectrum—from board members and C-suite executives to clinical leaders; managers; and staff of quality, safety, and risk management departments. Readers of The Safety Playbook will:

    Review the current rate of medical errors and explore proven solutions, including high reliability
    Discover how transparency about errors and their causes makes a successful safety program possible
    Learn how developing internal safety experts saves time and money
    Examine safety tools and practices used effectively in high-reliability industries
    Understand why communication is the top cause of medical errors and how to improve it
    Explore guidelines used in other healthcare organizations that create a culture of safety
    Study a sample project plan and timeline for implementing a safety program

    Filled with compelling case studies and practical tools and strategies, this groundbreaking book can be a catalyst for transforming an organization's culture, delivering safer care to patients, and ultimately saving lives.

    The American College of Healthcare Executives and the Institute for Healthcare Improvement/National Patient Safety Foundation's Lucian Leape Institute (IHI/NPSF LLI) have partnered to collaborate with some of the most progressive healthcare organizations and globally renowned experts in leadership, safety, and culture to develop Leading a Culture of Safety: A Blueprint for Success. This document is an evidence-based, practical resource with tools and proven strategies to help senior leaders in healthcare create a culture of safety—an essential foundation for achieving zero harm. The guide, freely downloadable from the IHI/NPSF website, is an excellent complement to The Safety Playbook.

    With both high-level strategies and practical tactics, the guide can be used to help determine the current state of an organization's journey, inform dialogue with its board and leadership team, and help its leaders set priorities. Whether an organization is just beginning the journey to a culture of safety or is working to sustain its safety culture, Leading a Culture of Safety can serve as a useful guide for directing efforts and evaluating an organizati

    LanguageEnglish
    PublisherHealth Administration Press
    Release dateOct 13, 2017
    ISBN9781567939484
    The Safety Playbook: A Healthcare Leader's Guide to Building a High-Reliability Organization

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      Book preview

      The Safety Playbook - John Byrnes

      speech.

      PART I

      THE US PATIENT SAFETY CRISIS

      CHAPTER 1

      A Call to Action: The US Patient Safety Crisis

      ¹

      A SAFETY CRISIS is brewing in healthcare. Medical errors currently rank third among causes of death in the United States (exhibit 1.1), with 210,000 to 440,000 US residents dying each year from preventable hospital medical errors (Cha 2016; James 2013).

      Healthcare safety programs have evolved over the past 20 years, and many organizations have made progress. However, many more struggle to provide consistently safe, high-quality care. In its 2016 nationwide safety survey of hospitals, the Leapfrog Group found that 40 percent received a C, a D, or an F rating in hospital safety.

      CURRENT STATE OF SAFETY

      As part of an ongoing effort to determine the reasons so many hospitals receive poor safety grades, one of the authors (J.B.) conducted a workshop with about 30 finance leaders from hospitals across the United States. The specific aims were to (1) explore the organizational factors that lead to lapses in safety or occurrences of sentinel events and (2) find out where patient safety ranks as a priority for healthcare finance executives.

      To establish context for the discussion, the following information was shared with the group:

      Preventable adverse events account for roughly one-sixth of all deaths that occur in the U.S. each year (James 2013).

      More than 1,000 people die every day from preventable accidents in hospitals (McCann 2014).

      Errors of omission and commission, complications, readmissions, and avoidable mortality cost the US economy billions of dollars each year (Zajac 2009).

      On average, a hospitalized patient in the United States experiences at least one medication-related error—the most common type of error—each day (IOM 2007).

      In 2011, an estimated 722,000 hospital-acquired infections (HAIs) occurred in US acute care hospitals, and approximately 75,000 patients with HAIs died during their hospitalizations (CDC 2016).

      Among all US acute care hospitals, a report based on 2014 data found a 17 percent decrease in surgical site infections (SSIs). However, SSIs and pneumonia are still the most frequently occurring HAIs, afflicting an estimated 157,500 patients per year (CDC 2016).

      Key Takeaways

      As discussion ensued at the workshop, several key issues became apparent. More than a handful of leaders were unaware that preventable adverse events in hospitals rank so highly among the leading causes of death in the United States. Although all the participants knew the ranking was higher than acceptable, their lack of awareness about exactly how high signaled a great need to educate healthcare organizations—from the board to the front line—about this crisis.

      Furthermore, many of the finance leaders in attendance did not realize they already had most of the data needed to study their organization's own errors, complications, readmissions, and mortality rates. Much of this information can be found in the incident-reporting and finance or cost accounting systems of every hospital.

      Most acknowledged that their physician and nursing leaders likely lacked adequate training in safety science, the characteristics of high-reliability organizations (HROs), and process design to feel comfortable tackling the reduction of patient harm. Safety science and HRO design were not part of the clinical and educational curriculum when most individuals currently serving in leadership positions were trained in their clinical discipline.

      When asked how much money the finance leaders were willing to invest to remove medical errors as a leading cause of death nationwide, several said, Whatever it takes. But some were noncommittal when pressed to name an investment level they would support.

      About half the leaders in attendance felt patient safety was a priority in their organization. But only a few described it as the top priority. By the end of the workshop, most felt it should be the number one priority, given the facts they now had in hand.

      Finally, when asked, Is safety discussed at every executive leadership meeting? most said no. While the workshop survey was not scientific, the discussion seemed to align with the findings of most reported hospital safety scores.

      SOLUTIONS WITHIN REACH

      Many organizations still have significant work ahead to solve the safety crisis, requiring a focused effort, committed executive teams, and the willingness to invest the necessary resources.

      That said, the resource investment is less significant than many executives expect. For instance, in the authors’ experience, among average-sized community hospitals, the net addition of three or fewer full-time-equivalent (FTE) staff members can help achieve gains in safety. However, although only a few new staff may be needed, they—along with the entire workforce—need to be trained in safety science and operational process redesign.

      The healthcare workforce is missing an entire body of knowledge in safety science and process redesign, and gaining that knowledge is the most obvious solution to the healthcare safety crisis. Once organizations gain the necessary skills to operate safely and efficiently, the healthcare system will have solved a huge part of the problem.

      In addition to strong, effective senior leadership and unwavering commitment, then, the effort requires a cultural transformation (the topic of chapter 2) to an HRO-level status and investment in organization-wide training.

      To solve this crisis, each individual in the organization is responsible for accomplishing and sustaining zero patient harm. We know the US healthcare system can do better. Together we can make healthcare much safer for everyone.

      NOTE

      1.Portions of this chapter have been adapted from Byrnes (2015b) and Byrnes (2015c).

      CHAPTER 2

      Transformation to a Safety Culture

      CULTURE HAS BEEN defined as the arts and other manifestations of human intellectual achievement regarded collectively. Another definition is the sum of ways by which a particular population lives that has been built over time and transmitted from one generation to the next.

      The notion of patient safety culture was introduced following publication of the Institute of Medicine's (IOM) landmark report, To Err Is Human: Building a Safer Health System, in 2000. This report encourages healthcare systems to create an environment in which safety is a top priority driven by leadership. It describes a safety culture as one that focuses on preventing, detecting, and minimizing hazards and error without attaching blame to individuals.

      Thus, understanding patient safety culture and how to achieve it is a relatively new area of study. Research conducted thus far generally supports a number of components in the process of building a culture of safety, but as with any sociological element, culture can be highly correlated with the people who are a part of it (Sammer and James 2011), meaning the people involved are seen as the cultural bundle in healthcare, just as clinical practices have process bundles.

      KEYS TO SAFETY CULTURE TRANSFORMATION

      Leadership is a key aspect of success in improving safety culture outcomes. Senior leaders must collectively commit to integrating high-reliability tactics into their own daily work. Such tactics include rounding to influence, whereby leaders are visible and interact with operations and frontline staff at the microsystem level on a regular basis. In an HRO, structures are set in place to inform senior leaders of any safety risks and to update them on safety metrics and improvement efforts. Deference to the expertise of individuals—staff and leaders alike—is another requirement for an organization to achieve improvements in safety, and it is cultivated through regular, open discussions with all levels of leadership and staff. Such ongoing vigilance is the only way to sustain initial gains that take place. Leadership is also responsible for engaging the physician community and providing education, resources, and opportunities to be involved with safety culture improvements. More leadership tools and tactics are discussed in chapter 9.

      A balanced and right culture for staff and physicians is an important factor as well (Marx 2017). Often referred to as a just culture, such an environment allows the organization to differentiate between individual and system failures, helping improve transparency and error reporting in conjuction with individual performance management. Healthcare has traditionally been a punitive environment, but punishing staff for errors prevents individuals from reporting concerns and mistakes, which then remain cloaked in secrecy. As the organization continues to encourage nonpunitive reporting, its leaders must keep in mind that some individuals may not be in the right role or the right department, as they have developed unsafe practices that put patients and the organization at risk. The concept of just culture is explained at length in chapter

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