We are not getting the job done.
In the 10 years since the Institute of Medicine's To Err Is Human was published, little has changed in patient safety. In a report from its Safe Patient Project, Consumers Union stated, "Based on our review of the scant evidence, we believe that preventable medical harm still accounts for more than 100,000 deaths a year." Several other agencies also have reported on the overall poor progress to reduce patient harm.
Hospital care is not safer than before, but it is more complex, with its miasma of old policies, new protocols, core measure and documentation requirements, and the demands of multiple regulatory agencies.
In my prior role as CEO of a 575-bed health system, incredible hard work resulted in 28 percent fewer defects in care in one year. However, it still takes a mountain of effort to create a truly reliable patient care experience and outcome. The answer is not to just work harder.
Some organizations have made enormous strides in patient safety. They tend to be ones that started early, grasped that repairing the current care delivery system wasn't sufficient, invested years of phenomenally focused effort from leaders and staff, understood the Herculean task at hand, and reframed the top priorities of the CEO and the board as quality and safety.
Still, patient harm remains a reality in most organizations.
Enough. Let's stop using flyswatters to tackle the life-and-death issues of patient safety and better outcomes. More forms, policies and reports, tinkering with the delivery of care, increasing transparency, and ever more serious exhortations are not the answer.
What will power a more effective effort? I contend it is accountability at the highest levels of leadership—the CEO, board and senior teams of our hospitals. We should be held accountable for ending a culture in which unsafe behaviors and unreliable systems still prevail.
Our Cultural Inheritance
In health care culture, harmony, and more precisely, avoidance of conflict, is a subterranean but powerful force driving leadership decisions, priorities, the daily schedule and the size of ambition. In a conflict-averse culture, problems that require tough conversations to identify a solution tend not to get fixed, and creating a high-reliability, safe organization will demand many tough conversations.
This isn't the culture created by your current CEO. Instead, it's the thousand-year-old culture of Western medicine, and the 200-year-old culture of America's hospitals, which were frequently founded by the town physician, a benefactor, a religious group or some combination of the three. They were born in small towns, worlds of critical interdependencies.
Meanwhile, physicians have played a central role, bringing the know-how of medicine into hospitals patient by patient and gradually shaping our modern workshops. They have been the key power in hospitals since their inception and have contributed much to the quality and effectiveness of our hospitals today. Physicians' power was accompanied by steadily evolving governance influence and the arrival of leaders trained in hospital administration. This three-legged stool, as it came to be called, persists today, and its artful and nuanced management has been the source of CEOs' success and tenure. Political skills that enable CEOs to work effectively with constituencies are still crucial, but these leaders must focus on the most essential outcomes: quality and safety.
In our conflict-averse world, "ugly frogs," which are huge barriers to safer and better care, still exist. Some of the ugly frogs include defiantly poor or idiosyncratic care, "sacred cow" employees or a refusal to follow medical staff rules that impact patient care. They include every clinician or staff member who silently steps back from conflict when one or two clinicians make sufficient noise to scare everyone else, forcing the organization to back down on a requirement that would lead to safer care.
The ugly frogs show up as 20 to 40 percent compliance with evidence-based protocols, resulting in mortality rates that are significantly higher than they should be for a given population of patients, or as fatal infections occurring with monotonous regularity in the critical care unit. In all but a handful of hospitals, hand-washing rates are abysmal, so there can be no surprise at our infection rates. The question is, why do we permit so many clinicians and employees to ignore our policies?
A host of other forces consume leadership time and energy: too many priorities, a pileup of expectations for leaders that borders on the irrational, and chronic threats to fiscal viability. It's a jungle out there.
What Can We Change?
Is there a cure for how stuck we are? To paraphrase Albert Einstein, to get a different outcome we are going to have to do things differently and do different things. Starting points for this new journey—including radical transparency of leadership results and a no-holds-barred crucial conversation—are below.
1. Hold the CEO and senior team accountable. Boards should hire CEOs and CEOs should hire their subordinates for two qualities: the ability to deliver agreed-upon results and the ability to sharply discern performance. In other words: to keep the high performers on board and to shed the rest.
Accountability also means that tenure must be re-earned based on results in both areas. Senior team results should be posted throughout the organization. Non-performers, doubtless some of your nicest employees, will be extremely discomfited by this. Your results-oriented professionals will be energized.
2. Host a facilitated crucial conversation on patient safety and quality among the board, CEO and medical staff leaders. The board is in charge, and it must ask for what it wants: evidence-based medicine.
This direct approach can be anxiety-inducing for trustees, but no one else can effectively step forward to ask the medical staff to fulfill its fundamental obligation, which is to ensure high quality in the organization. It means creating mandated protocols for truly important things and no longer conceding to bullies who wish to opt out of safe practices.
It also means challenging the few employees or physicians who threaten to shut you down if you fool around with their way of life or with their comfortable but unsafe practices. To do so will set a tone and initiate much more loyalty from great staff and great doctors.
In addition to finding courage, trustees and physician and hospital leaders must agree on an aim worthy of the dedication of those in the room and worthy of those we serve. That aim should clearly define the goal and it should be a battle cry for excellence.
3. Support your CEO. Often CEOs are convenient targets when the medical community or other constituencies get angry because of changing policies. Only boards, united with their CEO and good medical staff leaders, can stand up to the power of the status quo.
4. Focus. This is another elusive key to a truly safe and high-outcome organization. Only the board and CEO can honestly discuss the barriers and "organizational confetti" that burden the leaders and remove them from the battle for great quality and safety. Focus means defining what you won't expect your CEO and others to do, as well as what should consume more than half of their time. When a CEO and key subordinates spend that kind of time, with their titles, power and skills, the entire organization will gain momentum.
5. Blow up the system. Leadership must resolve to banish workarounds in favor of full system redesign. We can no longer repair an obsolete chassis. This will give hope to your nurses, doctors and many others. Safety is a property of a well-designed system—before any humans use it.
6. Tell—and find a way to involve—your community. Tell your doctors, your employees, your contractors, your boards, your employees and the public about your goals. This takes courage, which will be inspirational to others, and your community's scrutiny will help keep you on task.
While progress has been made, we are still far from having safe and reliable care environments. It is time to gently lay our culture of genteel denial to rest. We must resolve to call out and repair or remove the errors, the bad systems, and those who insist on autonomy at the expense of patient lives. As leaders, we should begin by looking in the mirror. It begins with us.
Andrea Y. Coleman, FACHE (email@example.com), is a writer and former hospital and health system CEO.