The ethical leadership challenge: creating a culture of patient- and family-centered care in the hospital setting

The growing number of medical errors and resulting preventable deaths in hospitals presents an ethical dilemma that must be addressed by health care leaders and managers. These medical errors and deaths raise questions about safety and quality issues resulting in rising public mistrust and patient dissatisfaction. Many of these medical errors and deaths could have been avoided by including the patient and family in the care. The ethical challenge for leadership is creating a culture of patient- and family-centered care as a means to improve quality, safety, patient satisfaction, and public trust. This article addresses ways to improve safety, quality, patient satisfaction, and cost and thereby reduce medical errors and deaths by implementing a patient- and family-centered care culture. The first critical step for improvement is for hospital leaders and managers to answer the ethical call to create a culture centered on patient- and family-centered care in the hospital setting.     

Increasing the relevance of research to health care managers: hospital CEO imperatives for improving quality and lowering costs

BACKGROUND: Evidence-based management assumes that available research evidence is consistent with the problems and decision-making conditions faced by those who will utilize this evidence in practice. PURPOSE: This article attempts to identify how hospital leaders view key determinants of hospital quality and costs, as well as the fundamental ways these leaders "think" about solutions to quality and cost issues in their organizations. The objective of this analysis is to better inform the research agenda and approaches pursued by health services research so that this research reflects the "realities" of practice in hospitals. METHODS: We conducted a series of semistructured interviews with a convenience sample of eight hospital and three health system leaders. Questions focused on current and future challenges facing hospitals as they relate to hospital quality, costs, and efficiency, and potential solutions to those challenges. FINDINGS: Nine major organizational and managerial factors emerged from the interviews, including staffing, evidence-based practice, information technology, data availability and benchmarking, and leadership. Hospital leaders tend to think about these factors systemically and consider process-related factors as the important drivers of cost and quality. PRACTICE IMPLICATIONS: The results suggest a need to expand the methods utilized by health services researchers to make their research more relevant to health care managers. Expanding research methods to reflect the systemic way that managers view the challenges and solutions facing their organizations may enhance the application of research findings into management practice. Finally, better communication is needed between the research and practice communities. Researchers must learn to think more like managers if their research is to be relevant, and managers must learn to more effectively communicate their issues with the research community and frame their problems in researchable terms.     

From the perspective of CEOs: what motivates hospitals to embrace cultural competence?

The quality domains of patient-centered and equitable care are increasingly relevant to today's healthcare leaders as hospitals care for patients with increasingly diverse cultural and linguistic needs. Hospital leaders face substantial tensions in defining their organization's strategic priorities to improve care for diverse populations with limited resources, increased competition, and complex regulatory and accreditation requirements. We sought to understand what motivates hospitals to focus on and commit resources to supporting the delivery of culturally competent care by analyzing interviews with chief executive officers (CEOs) in 60 hospitals across the United States. Hospital CEOs in our study most often embraced cultural competence efforts because doing so helped them achieve the organization's mission and priorities and/ or meet the needs of a particular patient population. Less often, they were motivated by perceived benefits and legal or regulatory issues. Many CEOs articulated a link between quality and cultural competence, and a smaller number went on to link cultural competence efforts to improved financial outcomes through cost savings, increased market share, and improved efficiency of care. However, the link between quality and cultural competence is still in the early stages. Fortunately, frameworks for hospitals to adopt and steps that hospitals can take to improve the quality of care for all patients have been identified. They begin with a commitment from hospital leaders based on understanding the needs of patients and communities and are propelled by data that reveal the impact of efforts to improve care. Leaders must communicate and shepherd organizations to align the congruence between improvement efforts and business strategies.     

A strategic approach for managing conflict in hospitals: responding to the Joint Commission leadership standard, Part 1

BACKGROUND: The Joint Commission's leadership standard for conflict management in hospitals, LD.02.04.01, states, "The hospital manages conflict between leadership groups to protect the quality and safety of care." This standard is one of numerous standards and alerts issued by The Joint Commission that address conflict and communication. They underscore the significant impact of relational dynamics on patient safety and quality of care and the critical need for a strategic approach to conflict in health care organizations. Whether leadership conflicts openly threaten a major disruption of hospital operations or whether unresolved conflicts lurk beneath the surface of daily interactions, unaddressed conflict can undermine a hospital's efforts to ensure safe, high-quality patient care. DEVELOPING A STRATEGIC APPROACH TO CONFLICT MANAGEMENT: How leaders manage organizational conflict has a significant impact on achieving strategic objectives. Aligning conflict management approaches with quality and safety goals is the first step in adopting a strategic approach to conflict management. A strategic approach goes beyond reducing costs of litigation or improving grievance processes--it integrates a collaborative mind-set and individual conflict competency with nonadversarial processes. UNDERTAKING A CONFLICT ASSESSMENT: Conflict assessment should determine how conflicts are handled among the leaders at the hospital, the degree of conflict competence already present among the leaders, where the most significant conflicts occur, and how leaders think a conflict management system might work for them. CONCLUSIONS: Strategically aligning a conflict management approach that addresses conflict among leadership groups as a means of protecting the quality and safety of patient care is at the heart of LD.02.04.01.     

Picking up the scent: Wave of practice acquisitions by hospitals has antitrust regulators on notice

With the growing wave of acquisitions of practices by hospitals, antitrust regulators are putting the deals under harsh scrutiny to see if they're just a cover for raising prices rather than coordinating care and improving quality. "If there's an issue, I want to know about it now," says St. Luke's President and CEO Dr. David Pate, whose hospital met such a roadblock. "Let's just see if there are issues. We don't believe that there are."     

Creating a culture for health care quality and safety

Approximately 67% of hospital quality indicators require some type of laboratory testing to monitor compliance. Unfortunately, in many hospitals, laboratory data information systems remain an untapped resource in eliminating medical errors and improving patient safety. Using case scenarios, this article demonstrates potential consequences for patient safety and quality of care when information sharing between medical technologists and nurses is not a part of a hospital's culture. The outcome for this patient could have been avoided if a more inclusive health care quality and safety culture existed. Creating a culture for health care quality and safety requires consensus building by clinical and administrative leaders. Consensus building occurs by managing relationships among and between a team of independent, autonomous physicians, nurses, allied health professionals, and health care administrators. These relationships are built on mutual respect and effective communication. Creating a quality culture is a challenging but necessary prerequisite for eliminating medical errors and ensuring patient safety. Physician leaders promoting and advancing cultural change in clinical care from one of exclusive decision making authority to a culture that is based on shared decision making are a necessary first step. Shared decision making requires mutual respect, trust, confidentiality, responsiveness, empathy, effective listening, and communication among all clinical team members. Physician and administrative leaders with a focus on patient safety and a willingness to change will ensure a culture of health care quality and safety.     

High‐Reliability Health Care: Getting There from Here

Context

Despite serious and widespread efforts to improve the quality of health care, many patients still suffer preventable harm every day. Hospitals find improvement difficult to sustain, and they suffer “project fatigue” because so many problems need attention. No hospitals or health systems have achieved consistent excellence throughout their institutions. 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 health care. Adapting and applying the lessons of this science to health care offer the promise of enabling hospitals to reach levels of quality and safety that are comparable to those of the best high-reliability organizations.

Methods

We combined the Joint Commission''s knowledge of health care organizations with knowledge from the published literature and from experts in high-reliability industries and leading safety scholars outside health care. We developed a conceptual and practical framework for assessing hospitals’ readiness for and progress toward high reliability. By iterative testing with hospital leaders, we refined the framework and, for each of its fourteen components, defined stages of maturity through which we believe hospitals must pass to reach high reliability.

Findings

We discovered that the ways that high-reliability organizations generate and maintain high levels of safety cannot be directly applied to today''s hospitals. We defined a series of incremental changes that hospitals should undertake to progress toward high reliability. These changes involve the leadership''s commitment to achieving zero patient harm, a fully functional culture of safety throughout the organization, and the widespread deployment of highly effective process improvement tools.

Conclusions

Hospitals can make substantial progress toward high reliability by undertaking several specific organizational change initiatives. Further research and practical experience will be necessary to determine the validity and effectiveness of this framework for high-reliability health care.     

The pharmacy leadership competency gap: diagnosis and prescription

The purpose of this paper is to inform the health administration community and its educators about the importance of pharmacy leadership, the competencies associated with the role, and a suggested path to achieve a greater number of pharmacy leaders. The role of the pharmacy leader is often unrecognized or undervalued, yet it has significant implications for many facets of the healthcare delivery organization, including the cost of care, patient safety and quality, the influence and potential involvement of the pharmacist in the hospital or health system. Hospitals and health systems should recognize the power of an effective pharmacy leader, and strive to fill those positions. Unfortunately, should care leaders demand high performing pharmacy leaders, they will find that such individuals are in short supply, and will become more rare with time because of an aging pharmacy workforce. The health administration education community must respond to the demand by marrying pharmacy management education with the Master's in Health Administration degree (MHA). This article proposes the creation of a PharmD/MHA dual degree program, giving clinically trained pharmacists the skills they need to be effective managers and leaders in hospitals and health systems.     

An exploration of the leadership attributes and methods associated with successful lean system deployments in acute care hospitals

The lean system has been shown to be a viable and sustainable solution for the growing number of cost, quality, and efficiency issues in the health care industry. While there is a growing body of evidence to support the outcomes that can be achieved as a result of the successful application of the lean system in hospital organizations, there is not a complete understanding of the leadership attributes and methods that are necessary to achieve successful widespread mobilization and sustainment. This study was an exploration of leadership and its relevant association with successful lean system deployments in acute care hospitals. This research employed an exploratory qualitative research design encompassing a research questionnaire and telephonic interviews of 25 health care leaders in 8 hospital organizations across the United States. The results from this study identified the need to have a strong combination of personal characteristics, learned behaviors, strategies, tools, and tactics that evolved into a starting adaptable framework for health care leaders to leverage when starting their own transformational change journeys using the lean system. Health care leaders could utilize the outcomes reported in this study as a conduit to enhance the effective deployment, widespread adoption, and sustainment of the lean system in practice.     

Scotland's successful national approach to improving patient safety in acute care

What does it take to transform the safety of health care across a nation, even a small one? The Scottish Patient Safety Programme, mandated by the government, began in January 2008 with the aim of reducing mortality in Scotland's hospitals by 15 percent in five years. With the collaboration of political leaders, senior health care managers, clinicians, and patients, the program has improved the quality and safety of hospital care. At the halfway point, in-hospital mortality rates have declined by 5 percent, and infection rates for certain hospital-associated infections have been cut by more than half. The Scottish Patient Safety Programme continues to prove that a national strategic approach can lead to unprecedented improvements in patient safety.     

The effects of cardiac specialty hospitals on the cost and quality of medical care

The recent rise of specialty hospitals--typically for-profit firms that are at least partially owned by physicians--has led to substantial debate about their effects on the cost and quality of care. Advocates of specialty hospitals claim they improve quality and lower cost; critics contend they concentrate on providing profitable procedures and attracting relatively healthy patients, leaving (predominantly nonprofit) general hospitals with a less-remunerative, sicker patient population. We find support for both sides of this debate. Markets experiencing entry by a cardiac specialty hospital have lower spending for cardiac care without significantly worse clinical outcomes. In markets with a specialty hospital, however, specialty hospitals tend to attract healthier patients and provide higher levels of intensive procedures than general hospitals.     

Putting the ‘patient’ in patient safety: a qualitative study of consumer experiences

Background Although patient safety has been studied extensively, little research has directly examined patient and family (consumer) perceptions. Evidence suggests that clinicians define safety differently from consumers, e.g. clinicians focus more on outcomes, whereas consumers may focus more on processes. Consumer perceptions of patient safety are important for several reasons. First, health‐care policy leaders have been encouraging patients and families to take a proactive role in ensuring patient safety; therefore, an understanding of how patients define safety is needed. Second, consumer perceptions of safety could influence outcomes such as trust and satisfaction or compliance with treatment protocols. Finally, consumer perspectives could be an additional lens for viewing complex systems and processes for quality improvement efforts. Objectives To qualitatively explore acute care consumer perceptions of patient safety. Design and methods Thirty‐nine individuals with a recent overnight hospital visit participated in one of four group interviews. Analysis followed an interpretive analytical approach. Results Three basic themes were identified: Communication, staffing issues and medication administration. Consumers associated care process problems, such as delays or lack of information, with safety rather than as service quality problems. Participants agreed that patients need family caregivers as advocates. Conclusions Consumers seem acutely aware of care processes they believe pose risks to safety. Perceptual measures of patient safety and quality may help to identify areas where there are higher risks of preventable adverse events.     

Regional task force aligns health groups against rising costs

The hospitals, health care associations, HSA, and Blue Cross of Northwest Ohio have formed a task force through which they have conducted successful joint cost containment projects. Some of these projects include a voluntary "cap" on price increases, promotion of hospital cost containment committees, sharing of cost containment ideas for inhospital implementation, educating the public about its role in health care cost control, and communicating with political and business leaders about cost control.     

Taxation as metaphor. The hospital and public responsibility

In the debate over the tax status of voluntary hospitals, most hospital executives and trustees do not seem to comprehend--or want to comprehend--the underlying issues. First, the terror of being associated with a tax hike has led many politicians to seek other "revenue enhancements" that are more ingenious than they are honest. On the other hand, many of these governments have legitimate financial problems and are seeking new sources of revenue. A second, related issue is uncertainty over what should be done about the uninsured and Medicaid populations. In the absence of an acceptable solution, we will continue to provide direct public support to public hospitals and indirect public support to private providers--including charitable tax exemptions. The third underlying issue is hospitals' curiously narrow view of their private-sector status. Most of the functions hospitals provide are not only publicly funded; they are, in fact, public functions. Finally, hospitals believe they are inherently moral organizations because they provide an inherently moral service. But hospitals grew to their present role in society almost by accident; their services are neither unique nor ethically superior. It is in how hospitals provide care that their morality can be measured, not in the fact that they provide some kind of care to somebody. An honest appraisal of these issues will help each hospital answer the basic question: As an ethical and moral matter, should this organization be paying taxes? But is this fight really about taxes? I believe society and government are using taxation as a metaphor for trust in hospitals.     

放射医疗设备的应用安全与质量控制要求

放射医疗设备在大中型医院的医疗设备中占有较大份额,其诊疗作用也相当突出,因放射辐射安全的特殊性,其应用安全与质量控制是各级卫生主管部门、环境保护部门、医院各级领导以及放射诊疗工作人员和医学工程管理人员都非常关注的问题。本文从放射辐射设备的引进论证、机房设计建设、安装验收、运行调试、质量检测、维修保养、报废处理等整个设备生命周期的全过程中的每个环节的安全要求进行分析说明,确保放射辐射设备在整个生命周期中的安全,充分发挥其在医院的诊疗作用。     

Culture, language, and patient safety: Making the link.

It has been well recognized internationally that hospitals are not as safe as they should be. In order to redress this situation, health care services around the world have turned their attention to strategically implementing robust patient safety and quality care programmes to identify circumstances that put patients at risk of harm and then acting to prevent or control those risks. Despite the progress that has been made in improving hospital safety in recent years, there is emerging evidence that patients of minority cultural and language backgrounds are disproportionately at risk of experiencing preventable adverse events while in hospital compared with mainstream patient groups. One reason for this is that patient safety programmes have tended to underestimate and understate the critical relationship that exists between culture, language, and the safety and quality of care of patients from minority racial, ethno-cultural, and language backgrounds. This article suggests that the failure to recognize the critical link between culture and language (of both the providers and recipients of health care) and patient safety stands as a 'resident pathogen' within the health care system that, if not addressed, unacceptably exposes patients from minority ethno-cultural and language backgrounds to preventable adverse events in hospital contexts. It is further suggested that in order to ensure that minority as well as majority patient interests in receiving safe and quality care are properly protected, the culture-language-patient-safety link needs to be formally recognized and the vulnerabilities of patients from minority cultural and language backgrounds explicitly identified and actively addressed in patient safety systems and processes.     

Nurses' reports on hospital care in five countries

The current nursing shortage, high hospital nurse job dissatisfaction, and reports of uneven quality of hospital care are not uniquely American phenomena. This paper presents reports from 43,000 nurses from more than 700 hospitals in the United States, Canada, England, Scotland, and Germany in 1998-1999. Nurses in countries with distinctly different health care systems report similar shortcomings in their work environments and the quality of hospital care. While the competence of and relation between nurses and physicians appear satisfactory, core problems in work design and workforce management threaten the provision of care. Resolving these issues, which are amenable to managerial intervention, is essential to preserving patient safety and care of consistently high quality.     

Performance-based payment incentives increase burden and blame for hospital nurses

We interviewed hospital leaders and unit nurses in twenty-five hospitals between June and October 2008 to explore the effect of performance-based incentives. Interviewees expressed favorable impressions of the impact that incentive policies have on quality and safety. However, they raised concerns about the policies' effects on the nurse workforce. Their concerns included the belief that performance-based incentives would increase both the burden and the blame for nurses without corresponding improvements in staffing levels, work environment, salaries, or turnover. To maximize the intended policy impact without jeopardizing the workforce that holds the key to their adoption, we recommend that policy makers invest in implementation support, redesign hospital incentives to reward teamwork, and involve nursing leaders in the design of future incentive policies.     

高校附属医院院务公开的现状与思考

目的 :分析高校附属医院院务公开工作的现状,思考深化院务公开的方法。方法 :就院务公开相关内容,访问上海市7家高校附属医院9名行政领导、24名中层干部、90名职工,对访问结果进行总结与分析。结果 :高校附属医院院务公开工作存在思想认识参差不齐、实效和时效性不强等不足。结论 :高校附属医院院务公开工作存在不足,通过多种举措促使医院深化院务公开,全方面改进医疗服务质量,推动医院持续健康发展。     

Providers link health with human service

This issue's cover story looks at a handful of hospital leaders who appear to be radically redefining their hospital's role, but who are really just returning to the basics of hospital management and the basic hospital mission of community service. These CEOs of innercity hospitals are taking a leadership role in community development programs, ranging from literacy to housing. They bring together community groups to solve problems, work to find funding for projects, and attract new business to the hospital's service area. They also provide community residents with a sense of hope and a sense of stability. But their actions have ramifications that extend beyond their communities. These leaders may also be providing other health care executives with an approach to strategic planning that will add new meaning to the term "community hospital" in the 1990s.