One person leading the pursuit of
patient safety is a fruitless task.
Organizations must learn to leverage
their workforce so that hundreds and
thousands pairs of eyes are searching
for errors and so that everyone feels
comfortable identifying and reporting
safety issues.
LACK OF AWARENESS
We watch leaders of the tobacco,
automobile, and accounting industries
sit before congressional hearings to
get to the root of their problems. How
would healthcare executives fare
under such questioning? Would they
deny knowledge of their hospital’s
incidence of wound infection or of the
percentage of their patients with acute
myocardial infarction discharged
without recommended drugs? Can
they respond to questions about how
well they are doing at eliminating
medical error and adverse outcomes?
If leaders are not knowledgeable
about the details of the patient care
provided and the outcomes of that
care, they cannot begin the journey to
improvement of quality and
elimination of adverse outcomes.
Therefore, the first thing they need to
understand is that ignorance is not an
option.
Being aware of the results of
patient care processes requires
consistent and comprehensive
analysis of processes and outcomes
and a well-developed communication
plan. This entails allocation of
significant resources to ensure that
data are collected and that
information is generated and reported
in a timely fashion. The organization
must develop a philosophy of not
only addressing errors when they
occur but also of looking for means to
improve processes to prevent mistakes
from happening in the first place.
NARROW FOCUS
Healthcare executives and boards are
most comfortable dealing with the
organization’s finances because they
are easily measured and do not
require much interpretation, unlike
clinical processes. However, just
because something is easily measured
does not mean it is what one should
be measuring. An inordinate focus on
financial performance sends this clear
message to everyone in the
organization: This is what is
meaningful. Financial success is,
however, only a byproduct of
excellent patient care, which is where
the emphasis should be.
LEADERSHIP ROLE | 19