Hospitals lack culture of safety

While the ultimate goal of zero patient harm in hospitals has been largely elusive, there could be hope for progress by adapting lessons from high-risk industries.

In a paper published in the Milbank Quarterly, authors Mark R. Chassin, MD, president and CEO of The Joint Commission and the late Jerod M. Loeb, PhD, the Joint Commission’s former executive vice president for healthcare quality evaluation, examined high-reliability industries and hospitals and laid out a framework to put hospitals on a path toward achieving high reliability.

[See also: Barriers to patient safety still exist]

High-reliability science is the study of organizations in industries like commercial aviation and nuclear power that operate under hazardous conditions while maintaining safety levels that are far better than those of healthcare.

In the article, the authors concluded that the ways that high-reliability organizations (HROs) generate and maintain high levels of safety cannot be directly applied to today's hospitals. That’s because hospitals “do not exhibit the features of resilience that characterize HROs,” the authors wrote.

“In a high-reliability environment,” the authors wrote in their analysis, “errors and unsafe conditions are recognized early and prevented by rapid remediation from causing harm. But in health care, uncoordinated and poorly designed and maintained mechanical systems (like medical device alarms) are tolerated, even though they are not safe.”

Furthermore, the authors said, intimidating behaviors among the staff inhibit reporting and hospitals do not allow the most expert individuals to implement solutions, relying instead on hierarchies.

“Although no hospital has been able to achieve high reliability, there are some very practical changes that can be made to improve safety and quality,” said Chassin in the report. “The time is now to start taking the steps needed to get from where we are today to where we want to be.”

Chassin and Loeb have outlined a framework for hospitals consisting of 14 components categorized in three major domains: leadership, safety culture and robust process improvement. Highlights of those components include:

• Hospital leadership must commit to the ultimate goal of high reliability or zero patient harm rather than viewing it as unrealistic.
• Hospitals must create a culture of safety that emphasizes trust, reporting and improvement.
• Hospitals need new process improvement tools and methods in order to make far greater progress toward eliminating patient harm.

Establishing a safety culture is paramount to success, said Kerry Johnson, founding partner and chief innovation officer of Health Performance Improvement, a healthcare consulting firm.

“Without a reliable culture, all of our processes are built on quicksand,” said Johnson.

But there are challenges.

“It gets very expensive when you start to deal with human factor integration,” said Johnson. “You have to get with manufacturers of supplies and equipment and things like that to error-proof them. As an industry, the push is going to have to come from everybody to make vendors change. If you have to change hospital walls and spaces where people work from a human factor standpoint, that’s where it’s very expensive.”

The Joint Commission is developing an assessment tool that will help hospitals to measure their current state of maturity across each of the high-reliability framework’s 14 components. In addition, The Joint Commission is field testing tools that can be used to work toward high reliability.