In 2003, the Institute for Healthcare Improvement and the Robert Wood Johnson Foundation launched Transforming Care at the Bedside, a framework to deliver better care based on improvements in four categories:
- safe and reliable care
- vitality and teamwork
- patient-centered care
- value-added care processes
RWJF and IHI proposed that hospitals needed to work in all four categories simultaneously to truly improve care: "Hospitals cannot meet the current challenges on medical and surgical units by fine-tuning the status quo or exhorting staff to work more diligently — they must establish new models of care."
Why is it so difficult to effect change in the hospital environment? Much more is known about how to reduce patient harm than is routinely being practiced. The responsibility for closing this gap between knowledge and practice rests with hospital leaders in cooperation with the clinicians and staff who are delivering care.
With that in mind, I suggest applying a system that works in one environment and adapting it to a new environment — health care. I believe it will enable hospital leaders and medical professionals to discharge their responsibilities to their patients by providing hospital care substantially more free of harm than is currently the case.
Centralized, Integrated Efforts
The E.I. DuPont Co. began making gunpowder in 1802 in Delaware. While safety had been a serious concern from the company's inception, DuPont spent more than a century developing its safety management program, which was adopted in 1928.
This program is based on two core principles: management is responsible for the prevention of injuries, and all injuries can be prevented. Based on these principles, the program relies on a central safety committee and subcommittees. It fully integrates all the safety efforts within the organization, from workplace safety groups up to and including the chief executive officer. It provides a clear path for ideas that are developed at the front lines — where the action takes place — to be adopted throughout the organization, thus institutionalizing best practices as they are developed. Employees at every level become invested in the process and its results.
This safety management system has been very successful in a range of environments, including chemical plants, slaughter houses, railroads and digging the tunnel under the English Channel. DuPont itself has been a leader in safety performance for many years. Its employee safety record has hovered around a lost-time frequency rate of one or fewer lost-time injuries or illnesses per two million exposure (or work) hours.
A Central Safety, Health and Environment Committee, known as a CSC, comprises the top manager as committee chair and all of the top manager's direct reports (or middle managers) in the safety unit. The safety unit includes all the employees under these middle managers. For a stand-alone manufacturing plant, the chair would be the plant manager, and in a corporate headquarters, the chair would be the CEO.
The CSC is a decision-making body. Its investigative work is performed by its subcommittees, each of which is chaired by a member of the CSC. The other members of these subcommittees are staff from throughout the organization who are not normally in the subcommittee chair's organization. Subcommittees study problems and recommend work procedures, rules and standards to the CSC. Then, the CSC decides and provides the supervision needed for implementation and enforcement. This arrangement provides for input from throughout the organization, but keeps management accountable for results.
Membership on subcommittees requires time and effort. Assignment to a subcommittee is an important role that may compete with an employee's regular workload. Senior leaders need to understand, support and include this assignment in the employee's performance evaluation. Decisions made by the CSC are carried out by line management. The CSC usually meets once per month, during which it hears reports from its members regarding the safety performance of their respective organizations and recommendations from subcommittees. Standing subcommittees might include: emergency preparedness; adverse events; medication safety; national patient safety goals and practices; infection prevention and control; team training; credentialing; and restraint use.
The designation of a safety unit is central to this organizational concept. In most cases, the safety unit is the entire organization located at a single site. However, at sites in which large and diverse organizations with multiple purposes exist, the designation of safety units should be guided by the concept of organizational cohesiveness, or the organizational unit that employees see themselves as being a part of or with which they identify. For example, if a hospital cancer center has its own leader and its employees largely stay within the center, it would constitute its own safety unit.
In some cases, an identifiable, cohesive organization might have employees at more than one location, but because these employees share work assignments and supervision largely independent of other employees, such as in geographically convenient physical therapy facilities, employees at multiple locations might be appropriately identified as a single safety unit.
On the other hand, a regional hospital may have one or more outlying facilities. Each might well be considered safety units with their own CSC and subcommittees. In large hospitals with multiple large departments, it might be appropriate that each of these departments would be designated a safety unit, with its own CSC that addresses safety issues within the department.
Safety issues that substantially overlap departments would be addressed by a higher level CSC. For example, initiatives like flu shots for hospital caregivers, safety during construction or refurbishment, or a campus no-smoking policy are hospitalwide issues that would be handled by a CSC comprising all department heads and, as chair, the person to whom they report. The critical issue here is that employees see the chairperson of the CSC as the top manager of a cohesive organization to which they belong.
Implementing a CSC structure in a hospital environment will require careful study of the existing organization in order that safety units can be established rationally. Other complex organizations have done so. I believe the CSC and safety unit idea can be adapted successfully for hospitals.
James R. Thomen, Ph.D. (firstname.lastname@example.org), is a retired site manager for DuPont Co., and the author of Leadership in Safety Management (1991). He lives in Wilmington, Del.