Partnership for Patient Safety Introduces Patient Safety Advantage

New approach "accentuates the positive" in producing solutions for better patient safety performance.

CHICAGO, July 26, 2004 - Nearly five years have passed since the Institute of Medicine published its call to action on patient safety, To Err is Human (November 30, 1999). Describing the situation for the first time as a public health crisis, the IOM's landmark report estimated medical error in hospitals to be the 4th to 8th largest cause of preventable death in the United States, and it underscored the importance of a transformative approach to managing care that is systems-based and patient-centered. Despite the intense scrutiny provoked by the study, both in healthcare and among the broader public, most hospitals continue to struggle with imbedding a systems approach to ensuring patient safety.

In response to this continuing challenge, the Partnership for Patient Safety (www.p4ps.org) is introducing Patient Safety Advantage (PSA), a new approach for embedding best practices and creating sustainable cultures of safety and reliability in healthcare. The PSA design combines proven features from strategies implemented by healthcare winners of the Baldrige National Quality Award plus intervention techniques from the field of Appreciative Inquiry. Based on that foundation, the parallel threads of cultural/human growth and clinical/technical innovation run throughout the PSA process.

Most of the response to the IOM study thus far has focused on developing technology such as electronic medical records and bar-coding systems to ensure a high reliability environment. However, the industry has been slow to adopt these measures because of cost constraints. Many institutions have also developed policy statements and safety rules, but putting those standards into practice throughout the organization has been slow and met with resistance.

"Even if funding for technology were available, the defensive barriers inherent in most hospitals are likely to undermine the development of the cultural foundation needed to ensure transparent patientcentered care and improved patient safety," says David P. Seifert, PSA principal and former CEO of the 800-bed St. Anthony's Medical Center in St. Louis. "Most safety experts encourage patients and their families to take a greater advocacy role in their own care. Few medical professionals would question the value of doing that, but a patient in pain should not have to be their own advocate. Hospitals and families have to work together in a climate of mutual trust and support. PSA helps hospitals imbed that type of culture."

For hospital boards, the need to find effective solutions to the patient safety challenge is essentially a call to accountability. Neither the public nor the media that continue to sound the alarm about medical errors feel that hospitals are responding adequately to what they perceive to be a healthcare crisis in this country. As the governing bodies responsible for the focus and direction of America's hospitals, failure to respond aggressively and effectively to the prevalence of medical errors could be interpreted as an abrogation of responsibility for which they might eventually be held legally accountable. Aside from the accountability issue, hospital boards also must concern themselves with the financial stability of the hospitals they serve.

For hospital administrators, future success in patient safety is being driven by at least two compelling, competitive factors. First, patients, their families, and others in the community increasingly are able to rate hospitals on their performance, and those ratings are rapidly becoming available publicly. As an example, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently announced that they will make data available on-line on an array of performance factors for individual hospitals, including patient safety records. Second, the substantial financial expense associated with medical errors - let alone the human costs - will make it difficult for poor performing hospitals to survive in an increasingly competitive and transparent healthcare market.

"Hospitals seeking effective safety solutions have to take a broad-spectrum approach that addresses the dynamic interplay between human, cultural, technical and clinical factors," says Martin J. Hatlie, President of Partnership for Patient Safety and former tort reform lobbyist for the American Medical Association. "The IOM study emphasized that every hospital is prone to failure because of the complexity and inherent risks of healthcare work. But the response from the healthcare community sentinel event of their own. So we asked ourselves at p4ps what can be done proactively to grow cultures that are reliably safe and both non-blaming and patient-centered. That inquiry spawned the development of PSA."

The PSA process begins by shifting the foundation that underlies a hospital's cultural climate. "Using Appreciative Inquiry (Ai), the PSA team works with the hospital to build on its positive core, tapping into the collective wisdom, passion, and vision of its people for patient safety," says Nancy J. Wilson, BSN, MD, MPH, principal of PSA, former Medical Director for VHA Inc. and creator of an array of patient safety initiatives. "During this first phase, people at all levels of the hospital are engaged in a positive process for embedding a culture of safety based on what they already do well and what they aspire to create more of in the future. Then in phase two, best-in-class safety practices are woven into this revitalized core and ultimately into the overall care-giving process."

The PSA approach is rooted partly in the realities of human nature and organizational change. Studies show that about 75% of all organizational development efforts fail to achieve their intended results, and about 50% of strategic decisions from those efforts fail to be implemented. "One reason for those poor results is the lack of an integrated, participatory approach that encompasses both the subjective (fears, hopes and emotional responses) and the objective (goals, standards and measurement) aspects of the organization," says Seifert. "Without system-wide balance and participation, a new strategy, a reorganization plan, or virtually any other change initiative will face countless barriers and usually fail to achieve sustainable results. The PSA process melts those barriers and creates cultures of safety and reliability across silos throughout the entire hospital community."

The PSA team is a confluence of varied expertise and experience. In addition to Dr. Wilson, Mr. Seifert and Mr. Hatlie, principals include Roger Fritz and Les Landes of Leadership by Design, Inc., a St. Louis based consulting firm which has played an active role working with executive leaders and governing boards engaged in advancing the patient safety movement; Mike Simms, former senior manager with Baldrige-winner Wainwright Industries of St. Peters, MO and consultant to SSM Healthcare System, the first healthcare organization to win the prestigious Baldrige award; Stephen Fitzgerald, PhD and Ravi Pradhan, both partners in Appreciative Inquiry Consulting with extensive experience in collaborative, organizational change.

A common factor that brings the PSA team together is their own personal experiences as patients or witnesses to medical errors that have harmed or nearly claimed the lives of their loved ones. "We have a phenomenal group of highly experienced people involved with PSA, who are deeply and personally committed to our mission," says Hatlie. "What's more, the disciplines we integrate have produced an approach that will have a significant impact in fostering effective and sustainable patient safety. With PSA, hospital communities discover that culture change is genuinely achievable, not just an amorphous aspiration. They are able to give shape to it and generate concrete improvements in all measurable safety areas. In the end, PSA helps foster an honest and constructive culture of trust, compassion and success. When that happens, everyone wins."

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