Developing a culture of safety in ambulatory care settings

The focus on medical error prevention has prompted forward-thinking healthcare providers to increasingly support an organizational culture that supports and promotes patient safety. A culture of safety is necessary before other patient safety practices can be introduced successfully. Various elements of a culture of safety are discussed. Some organizations have implemented survey tools to assess their safety culture. Assessing an organization's culture of safety is just the beginning. Setting priorities for action and identifying strategies to improve healthcare safety must follow with support of the organization's leaders and frontline staff. Recommendations for action are provided.     

Narrativizing errors of care: critical incident reporting in clinical practice

This paper considers the rise across acute care settings in the industrialized world of techniques that encourage clinicians to record their experiences about adverse events they are personally involved in; that is, to share narratives about errors, mishaps or 'critical incidents'. The paper proposes that critical incident reporting and the 'root cause' investigations it affords, are both central to the effort to involve clinicians in managing and organizing their work, and a departure from established methods and approaches to achieve clinicians' involvement in these non-clinical domains of health care. We argue that critical incident narratives render visible details of the clinical work that have thus far only been discussed in closed, paperless meetings, and that, as narratives, they incite individuals to share personal experiences with parties previously excluded from knowledge about failure. Drawing on a study of 124 medical retrieval incident reports, the paper provides illustrations and interpretations of both the narrative and the meta-discursive dimensions of critical incident reporting. We suggest that, as a new and complex genre, critical incident reporting achieves three important objectives. First, it provides clinicians with a channel for dealing with incidents in a way that brings problems to light in a non-blaming way and that might therefore be morally satisfying and perhaps even therapeutic. Second, these narrations make available new spaces for the apprehension, identification and performance of self. Here, the incident report becomes a space where clinicians publicly perform concern about what happened. Third, incident reporting becomes the basis for radically altering the clinician-organization relationship. As a complex expression of clinical failure and its re-articulation into organizational meta-discourse, incident reporting puts doctors' selves and feelings at risk not just within the relative safety of personal or intra-professional relationships, but also in the normative context of organizational coordination, accountability, planning and management.     

Toward human resource management in inter-professional health practice: linking organizational culture, group identity and individual autonomy

The literature on team and inter-professional care practice describes numerous barriers to the institutionalization of inter-professional healthcare. Responses to slow institutionalization of inter-professional healthcare practice have failed to describe change variables and to identify change agents relevant to inter-professional healthcare practice. The purpose of this paper is to (1) describe individual and organizational level barriers to collaborative practice in healthcare; (2) identify change variables relevant to the institutionalization of inter-professional practice at individual and organizational levels of analysis; and (3) identify human resource professionals as change agents and describe how the strategic use of the human resource function could transform individual and organizational level change variables and therefore facilitate the healthcare system's shift toward inter-professional practice. A proposed program of institutionalization includes the following components: a strategic plan to align human resource functions with organizational level inter-professional healthcare strategies, activities to enhance professional competencies and the organizational position of human resource personnel, activities to integrate inter-professional healthcare practices into the daily routines of institutional and individual providers, activities to stand up health provider champions as permanent leaders of inter-professional teams with human resource professionals as consultants and activities to bring all key players to the table including health providers.     

Measures to enhance patient safety. Importance of efficiency evaluation

Over the last 10?years, there has been increasing awareness of medical errors and harm to patients in healthcare. There is now widespread acceptance of the problem of medical harm and a determination to tackle major patient safety problems. Safety is defined as freedom from accidental injury. Thus, clinical risk management has been increasingly requested by professionals and their professional organizations to make healthcare safer. Clinical risk management is one of a number of organizational systems or processes aimed to improve the quality of healthcare, but one which is primarily concerned with creating and maintaining safe systems of care. A definition of this form ?C identifying, analyzing, and controlling risks ?C fits more comfortably with the culture and mission of healthcare organizations and is more likely to achieve the support and involvement of clinical professionals because it better reflects their purpose and values. Patient safety needs to become embedded in the culture of healthcare, not just in the sense of individual high standards, but a widespread acceptance of understanding of risk and safety and the need of everyone to actively promote patient safety. Measures taken to enhance patient safety encompass a wide range of activities with regard to the errors in the process of medication, to surgical errors and surgical outcome (??safer surgery saves lives??), and to hospitalism and hospital-acquired infections taking into consideration adherence to hand hygiene. An evaluation of the added value to patient safety, when processes are systematically changed and the patients become involved in making healthcare safer, is needed.     

What do health professionals think about patient safety?

Introduction  Patient safety is a main determinant of the quality of healthcare services. The literature shows that the occurrence of medical errors is quite important in countries where it has been measured. Various actions like legislative measures, financial, or educational measures may help, but they are not always effective in controlling the level of avoidable errors. That happens because patient safety is strongly related to the culture specific to healthcare organizations. This study is aimed at getting some perspective on the organizational culture in Romanian hospitals in regard to patient safety. Objectives  The main objectives are (1) to identify the views of healthcare professionals about patient safety in Romanian hospitals and compare them with other countries, (2) to identify to which extent the views about patient safety relate to the specific organizational culture in healthcare, and (3) find out if there are differences in perceptions of professional categories about their own work and that of the clinical team. Method  A survey was conducted, based on a questionnaire. The questionnaire was aimed at realizing a screening of the problem, to get some specific views of respondents from their work experience, and eventually to get suggestions on how to improve patient safety. The same questionnaire has been previously applied in four other countries: Australia, Singapore, Sweden and Norway. Overall views of hospital professionals from Romania were compared to those from the other countries. Also, views per professional categories—clinical vs. non-clinical staff, doctors vs. nurses, and senior vs. junior staff—were compared. Results  Answers from 100 respondents from Romania indicate that patient safety is a major concern of hospital professionals, and it should be improved. Basically, they show as much interest and willingness to improve as observed in the other countries. This indicates that no major differences in the organizational culture exist in regard to patient safety. However, differences among professional categories have been noticed; for example, nurses are more aware than doctors on the need to take action for improving patient safety. Conclusions  Patient safety is a major concern of health policy in many countries. In Romania, this study shows concern of professionals about patient safety, although they are facing many barriers such as inadequate leadership, lack of communication between professional categories, between senior and junior staff, and most of all with the patients. This is a problem of organizational culture, which requires complex, multi-level strategies, targeting a long-term change. Results of this initial study should be viewed as a baseline for a larger study.

Primary care in European Union countries: configurations and organizational reforms in the 1990s

During the 1990s, proposals to contain health expenditures and demands raised by changes in the epidemiological profile led to organizational reforms in primary healthcare services in European Union countries, aimed at promoting the coordination of services provided by the various levels of care. Based on a literature review, document analysis, and interviews with key informants, the current study analyzes the institutional configurations for first-level healthcare and discusses the pre-coordination organizational reforms in the European Union countries. First-level outpatient care is provided in these countries through a wide variety of institutional configurations, observing the different financing mechanisms, range of healthcare professionals, range of clinical services provided, and the position occupied by physicians in primary care within the healthcare system. Reforms in the last decade were accompanied by a diversification in the outpatient care organizational models, with an expansion in the clinical, healthcare coordination management, and financing functions of primary care professionals, indicating a process in transition, with a redefinition of the roles played by general practitioners as the leaders of patient care.     

Current strategies to improve patient safety in Canada: an overview of federal and provincial initiatives

Several major news stories in the past year have highlighted adverse events in Canadian healthcare and prompted questions about whether healthcare in Canada is safe and what is being done to improve it. While individual hospitals and regions are mounting patient safety efforts, these problems are systemic and require policy and organizational responses from governments and health regions, not just individual organizations.     

Fostering a culture of service excellence

Patients' level of satisfaction with healthcare providers can have profound implications for operational and clinical outcomes. Are your organizational leaders fostering a practice culture of "service excellence"? Has your organization defined what "service excellence" means? Do your employees have a clear understanding of your expectations for service delivery? Medical practice leaders can improve patients' level of satisfaction by adopting and fostering a culture of service excellence in their practice. Strengthening the practice-patient relationship through patient-service initiatives can lead to improved patient perception of care quality and overall satisfaction with their healthcare providers. When patients feel wanted and well cared for by their healthcare providers, they are less likely to be noncompliant and more likely to achieve positive clinical outcomes. Operationally, service-excellence initiatives will have a profound impact on patient retention and new referrals, and possibly a reduction of litigious risks.     

Weaving spirituality into organizational life. Suggestions for processes and programs

Recent research has demonstrated a clear link between spirituality and health, but it remains a challenge for many organizations to weave spirituality into organizational life and make it an integral component of clinical care. Three dimensions of spirituality work together in healthcare: spiritual well-being of patients and families, spiritual well-being of workers, and spiritual well-being of the organization. To cultivate these dimensions in the life of healthcare organizations, several strategies may be employed. First, the definition of "spirituality" must be clear. Consider spirituality at the core of providing healthcare, instead of parallel to or part of clinical approaches. Separate spirituality from chaplaincy, since nurturing spiritual values is the responsibility of everyone in the organization. It is important to affirm what people already do spiritually, focus on what they have to offer instead of on deficiencies, and cultivate spirituality individual by individual. Organizational leaders must demonstrate spirituality in their personal and professional lives, and keep the organizational mission to the fore. When working to enhance organizational spirituality, create a vision within the organization of its spirituality and emphasize peer support and collaboration. Programs to help organizations inculcate spirituality include retreats or renewal programs for employees, forums to explore employees' spirituality, inclusion of spiritual issues in training and orientation programs, educational and development programs for working groups, regular review of spiritual well-being, training selected employees as spiritual facilitators, and supporting research on spirituality, health, and healthcare.     

The gap between macroeconomic and microeconomic health resources allocation decisions: The case of nurses

The allocation of healthcare resources takes place at two distinct levels. At the macroeconomic level, policymakers decide on budgets, staffing, cost‐effectiveness thresholds, clinical guidelines and insurance payments; at the microeconomic level, healthcare professionals decide on whom to treat, what the appropriate treatment is, how much time and effort should each patient receive and how urgent the need for care is. At both levels, there is a constant social need for just allocation. Policymakers are mostly guided by abstract principles of justice, thinking in terms of groups of patients, epidemiological data, impersonal statistics and economic costs. On the other hand, healthcare professionals understand the need for justice at a more personal level, as they interact with patients and, in a sense, put theory into practice. Nurses hold a unique position in healthcare systems, as, traditionally, they are closer to patients than other health professionals. This means that they have a firsthand view of the effect that their decisions have on specific patients and, therefore, nurses tend to get more influenced by their personal feelings, values and beliefs at the microeconomic level. This presentation shall examine the gap between abstract macroeconomic and concrete microeconomic health resources allocation decisions, with a particular emphasis on the role of the nurse.     

Closing the loop: follow-up and feedback in a patient safety program

BACKGROUND: As health care organizations establish patient safety agendas, attention has focused on creating less cumbersome systems for reporting errors. However, experience at Brigham and Women's Hospital (Boston) suggests that more emphasis needs to be placed on what happens after a report is submitted. FOLLOW-UP AND FEEDBACK: Follow-up includes prioritizing opportunities and actions, assigning responsibility and accountability, and implementing the action plan. Feedback entails (1) follow-up to those who report issues and (2) communication to the hospital staff and clinicians about events and actions taken. Responsibility and accountability for improvements need to be assigned by senior administration to hospital leaders who can effect the needed changes. Hospital leaders, not just the members of the patient safety team, must own these changes or improvements. Events that require follow-up action are brought to the attention of risk management and the patient safety team through several mechanisms, including voluntary reporting of adverse events through a computerized safety reporting system, root cause analyses, and Patient Safety Leadership WalkRounds. DISCUSSION: Developing and maintaining a systematic method for feedback represents more of a challenge than the completion of any single recommended action item. However, it is the feedback to the reporter that perpetuates the influx of information and closes the loop. Developing the information-tracking database has made providing feedback easier and more reliable but significant effort is required to keep the database current.     

Establishing values-based leadership and value systems in healthcare organizations

The importance of values in organizations is often discussed in management literature. Possessing strong or inspiring values is increasingly considered to be a key quality of successful leaders. Another common theme is that organizational values contribute to the culture and ultimate success of organizations. These conceptions or expectations are clearly applicable to healthcare organizations in the United States. However, healthcare organizations have unique structures and are subject to societal expectations that must be accommodated within an organizational values system. This article describes theoretical literature on organizational values. Cultural and religious influences on Americans and how they may influence expectations from healthcare providers are discussed. Organizational cultures and the training and socialization of the numerous professional groups in healthcare also add to the considerable heterogeneity of value systems within healthcare organizations. These contribute to another challenge confronting healthcare managers--competing or conflicting values within a unit or the entire organization. Organizations often fail to reward members who uphold or enact the organization's values, which can lead to lack of motivation and commitment to the organization. Four key elements of values-based leadership are presented for healthcare managers who seek to develop as values-based leaders. 1) Recognize your personal and professional values, 2) Determine what you expect from the larger organization and what you can implement within your sphere of influence, 3) Understand and incorporate the values of internal stakeholders, and 4) Commit to values-based leadership.     

Responding to health care reform: preparing tomorrow's practitioners

At a time when all of healthcare is undergoing change and evolution, the healthcare education community has so far escaped intense public scrutiny. To remain valid, we must address the education and the reeducation of healthcare professionals. Baccalaureate health administration programs, in particular, can step in and respond to the changing needs of the industry, the market, and of healthcare professionals by creating articulation formats that provide flexible verti for associate degreed healthcare professionals. Such programs enable a diverse constellation of healthcare professionals to obtain the managerial and organizational skills that are cal and horizontal access key to career mobility in today's turbulent healthcare arena.     

Le comité de retour d’expérience (CREX) : une méthode pour l’amélioration de la sécurité des soins

BackgroundAn experience feedback committee (CREX, Comité de Retour d’EXpérience) is a method which contributes to the management of safety of care in a medical unit. Originally used for security systems of civil aviation, the method has been adapted to health care facilities and successfully implemented in radiotherapy units and in other specialties.MethodsWe performed a brief review of the literature for studies reporting data on CREX established in hospitals. The review was performed using the main bibliographic databases and Google search results.ResultsThe CREX is designed to analyse incidents reported by professionals. The method includes monthly meetings of a multi-professional committee that reviews the reported incidents, chooses a priority incident and designates a “pilot” responsible for investigating the incident. The investigation of the incident involves a systemic analysis method and a written synthesis presented at the next meeting of the committee. The committee agrees on actions for improvement that are suggested by the analysis and follows their implementation. Systems for the management of health care, including reporting systems, are organized into three levels: the medical unit, the hospital and the country as a triple loop learning process. The CREX is located in the base level, short loop of risk management and allows direct involvement of care professionals in patient safety.ConclusionSafety of care has become a priority of health systems. In this context, the CREX can be a useful vehicle for the implementation of a safety culture in medical units.     

Treading Water: The No-Growth Investment in Health Services Research

There is a “perfect storm” brewing in the American healthcare system. Healthcare spending has grown faster than our economy for many years and is projected to double in as little as 10 years. In spite of what we spend on healthcare, research tells us that we only receive appropriate care half the time. We are simply not getting what we are paying for. Health services research provides the data and the evidence needed to make better decisions, design healthcare benefits, and develop effective policies to optimize healthcare financing, facilitate access to healthcare services, and improve healthcare outcomes. Despite what we know and what we can learn from health services research, federal funding for this important field continues to erode. This article provides a primer on the federal budget process and summarizes findings from the Federal Funding for Health Services Research 2007.Health services research (HSR) explores healthcare costs, quality, and access and seeks ways to improve healthcare delivery, safety, availability, and affordability. HSR has been defined as a “multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to healthcare, the quality and cost of healthcare, and ultimately our health and well-being.”1 In particular, HSR identifies what treatments work best when, for whom, and at what sites of service; it evaluates how best to finance healthcare and control spending; it helps inform healthcare benefit design; it translates the innovations from basic bench science into medical practice, allowing providers, health plans, and patients to make more informed health choices. HSR is the link between research and patient care.Since 2003, the Coalition for Health Services Research (coalition) has been tracking the federal government''s investment in HSR by collecting budgetary data from federal agencies that principally fund HSR. The coalition has been collecting annual budgetary data from the federal agencies that fund HSR. In the past 5 years, we have found that despite what we can learn from HSR, there has been an erosion of federal funding for this field, in part because of competing federal priorities, a constrained fiscal climate, and polarizing partisan politics. These trends have likely hindered the ability of the researchers to examine the healthcare system and identify innovative and effective solutions. If left unchecked, the declining investment in HSR may have further implications for the study of health and patient care in the future.This article provides a primer on the federal budget process and summarizes findings from Federal Funding for Health Services Research 2007, the fifth annual report of HSR expenditures.2Federal agencies have not developed or adopted a uniform definition for HSR or standard categories for collecting and reporting data about reimbursement and funding methodologies, health disparities, patient safety, and chronic disease management. Therefore, questions remain about the breadth and scope of activities included in the funding totals presented in this article. Investments in what any one agency has self-reported as “health services research” may not be equivalent to what is reported by another agency. For example, budget numbers can reflect entire agency budgets, including overhead costs or a rough estimate of dollars spent on HSR. Nevertheless, our data offer the best available estimate on the federal government''s investment in this area.     

Leading for quality in healthcare: development and validation of a competency model

Increased attention to healthcare quality and impending changes due to health reform are calling for healthcare leaders at all levels to strengthen their skills in leading quality improvement initiatives. To address this need, the National Association for Healthcare Quality spearheaded the development and validation of a competency model to support healthcare leaders in assessing their strengths and planning appropriate steps for development. Initial development took place over the course of several days of meetings by an advisory panel of quality professionals. The draft model was then validated via electronic survey of a national sample of 883 quality professionals. Follow-up analyses indicated that the model was content valid for each of the target samples and also distinguished differing levels of job scope and experience. The resulting model contains six domains spanning three organizational levels.     

Lessons learned from building a culture and infrastructure for continuous quality improvement at Cabarrus Health Alliance

This case study describes a local public health agency's multiyear effort to establish an infrastructure and organizational culture for continuous quality improvement, using data from interviews with the agency's senior leaders, managers, and frontline staff. Lessons learned include the importance of setting stretch goals, engaging leaders at all levels of the organization, empowering frontline staff to make changes, providing quality improvement training for staff and leaders, starting with small projects first, spreading quality improvement efforts to involve all parts of the agency, and sustaining momentum by creating a supporting infrastructure for continuous quality improvement and continually initiating new projects.     

Workplace diversity: a leadership challenge. Managing diversity is a social, financial, and moral imperative

Fostering workplace diversity is about building an organizational culture that embraces personal differences and encourages heterogeneous persons to work together toward a common end. Setting in motion the transition to a more inclusive and productive workplace is an uncommon challenge and the primary responsibility of leaders, especially in Catholic healthcare. The origins of diversity can be found in creation itself. Not only are we united as a people of God and as members of the body of Christ, we are bound together through our shared humanity. Three values are especially relevant to promoting diversity in the workplace: respect for human dignity, the common good, and distributive justice as participation in the common good. Economic incentives strengthen the theological and moral motives for developing a diverse work force. Organizations' financial success will depend ultimately on how well diversity is integrated into the organizational culture. As a process, managing diversity enables healthcare leaders to discover new ways to develop the potential of all employees and at the same time improve performance and production. At the heart of managing diversity lies the reform of internal systems, structures, and processes. Managing diversity also requires the transformation of the organization's culture. Initiatives that are useful for setting a positive future course include conducting a cultural audit, establishing a cultural diversity task force, and putting in place a diversity "champion" who is accountable directly to the chief executive officer.     

国内外患者安全事件报告系统研究与启示

构建患者安全事件报告系统对于提高医疗质量、保障患者安全具有重要作用。对美国、英国、澳大利亚、日本以及我国的患者安全事件报告系统进行阐述,并从报告性质、事件类型、填报内容、报告途径等方面进行比较。对比分析了我国患者安全事件报告系统的不足,提出了以下建议:完善分类标准,优化上报流程;营造非惩罚的患者安全文化,建立自愿上报系统;建立反馈机制,定期发布预警信息;搭建学习和知识共享平台;建立层级管理模式等。     

Healthcare Chaplaincy as a Companion Profession: Historical Developments

Chaplains, like professionals in a range of industries, have long sought to maintain and build occupational power by articulating their professional mandate and advocating for their work. I describe how leaders of the Association of Professional Chaplains and its predecessor organizations used multiple strategies to articulate and re-articulate their professional mandate between 1940 and the present to become a companion profession, one that comes alongside another without seeking to challenge its jurisdiction. I find chaplains seeking to develop an economic base, aligning interests across distinct segments of the profession and creating new professional associations, lobbying for legislative support, and offering their services in institutional voids. They further adopted the language of healthcare around questions of identity, charting, and accreditation and, chaplains used not just the frameworks but the methods of healthcare—evidence based research—to try to demonstrate their value. This history can help chaplains and chaplaincy leaders today to form a more comprehensive sense of their history and think more strategically regarding how to make the case for their profession going forward.