Creating a Roadmap for Your Patient Safety Journey

Patient Safety Quality Monthly

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April 15, 2006

Dear Colleague,

At the beginning of this year, Mr. Ken Rohde joined The Greeley Company as Senior Consultant for Patient Safety and Process Improvement.  Ken has spent much of his career working to improve processes and practices in nuclear power, manufacturing and healthcare and brings an "engineering" perspective to our practice. For this month's column, I have asked Ken to discuss the planning and development of a strong Patient and Employee safety program.

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Like any successful journey, a successful Patient Safety Program begins with a good roadmap of where the organization wants to go. If you don't know where you are and where you want to end up, it is almost certain that you will get lost somewhere along the way.

To assist our clients, we have developed a simple Roadmap with 10 steps that are needed for success in making breakthrough improvements in safety and reliability.  This letter provides a brief overview of these steps. Future letters will provide more detail.

Step 1: Assess where you are today: If you don't know where you are, it is hard to make sure that the improvements that you are planning will be the correct ones.  Typical assessment steps include:

•  Evaluation of your safety culture - How does your organization view safety? Is your culture ready for change?
•  Evaluation of your Performance Improvement systems - Will your internal performance improvement and quality systems support a change?
• What are the underlying common causes that lead to the majority of your issues?

Step 2: Create your vision for tomorrow: A patient safety improvement program is designed to take your organization to a new place - do you clearly know where that new place is?  What it looks like?  Can you describe it to your staff & leadership? Are your safety goals realistic or are they accidentally driving you in the wrong direction?

Step 3: Engage Your Leadership: Leadership, Physicians, Employees and Stakeholders need to be engaged.  First priority is leadership engagement.  What drives them?  How will show them the benefits of a Patient Safety Program?

Step 4: Engage Your Physicians: Your physicians are often driven by different needs than your leadership. Physician champions are vital to getting physicians to use the error reduction tools.

Step 5: Prevent Errors: Every error you prevent is a good thing, but if you want your Patient Safety Program to be successful, you need to lay the foundation first.  Once the foundation is strong, then the focus becomes developing safe behaviors and safe systems, processes, equipment and methods. This occurs by implementing of strong behavioral expectations, good error reduction tools, pro-active process evaluation and improvement and effective FMEAs.

Step 6: React to Errors: Even if we prevent a majority of our significant errors, but in reality, we will always need to be able to quickly respond to significant errors and implement corrections and improvements in a timely fashion.

• Does your Cause Analysis process get to the real underlying cause?
• Is your occurrence report data an early warning system?  Do you see problems coming or do they keep surprising you?

Step 7: Focus & Execute: In many organizations, this is a real stumbling block on the road to success.  Improvements get defined but just don't seem to get done. Areas to focus on here are accountability and prioritization.  Other high risk industries and the manufacturing sector have developed some excellent tools to help make sure actions get appropriately prioritized and completed on time.

Step 8: Transition from external drivers to internal drivers: Most organizations are still highly driven by external requirements (JCAHO, state regulators, etc.)  But at some point, for a truly successful and sustainable Patient Safety program, the drivers must come from within.  If we implement the first seven steps, compliance with the external requirements becomes an outcome of our own process, not the driver. 

Step 9: Capture the ROI: Patient and employee Safety is the right thing to do, it is the moral thing to do, and it is also "good business".  Every safety error weakens your business effectiveness and is reflected, ultimately, in the organizations reputation, market share, and financial performance. Improved safety can have a significant return on investment and positive impact on the bottom line - but you have to be able to show that to your leadership and employees.

Step 10: Build Sustainability: There will never be a time where we can go back to a period of "less safety". Sustaining a program in the long haul is a real challenge.  Start planning now to make your Patient Safety Program a continuous process.

When you look at a good roadmap, it helps you have a clear view of the journey, that helps us be prepared for the trip and reach our destination successfully. 

Regards,

Bob Marder, MD
Practice Director, Quality and Patient Safety
The Greeley Company

For more information on our Patient Safety and Quality consulting services, click here or contact Christine Beringer by e-mail, cberinger@greeley.com, or by phone at 888/749-3054, ext. 3174.

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