One morning several years ago, I reviewed reports at my desk showing that my hospital remained at the absolute top of the universe in patient satisfaction and in the top quintile of publicly reported quality and safety measures. Then I walked down to a nursing unit and began to follow the care of a randomly chosen patient. Before the end of the day, I had seen 27 care processes that had happened in less-than-ideal fashion or gone completely wrong.
Sadly, this was just what I expected to find—and what most top executives would discover about the processes of care in their institutions if they did similar reviews.
For hospital leaders who bear the heavy responsibility of caring for our neighbors at their most vulnerable, I see two choices: Either we provide every patient with a skilled guardian to stand at the bedside and protect against the daily glitches and risks we have allowed to develop in our hospitals or we fix them.
At Wellmont Health System, where I have served as chief executive officer for two years, we are determined to become as error-free as possible by focusing our staff on patients and the processes that make the biggest difference in their eyes. Although still early in our journey, our improvements in efficiency and safety have been instrumental in turning a $15 million operating deficit into a $20 million operating profit.
We are determined to do nothing less than achieve complete safety and the delivery of ideal care throughout our health system. We are inviting national leaders in healthcare safety and quality to join with us to create the first beta site for the “safest hospital in American healthcare.”
Based on what we’ve learned, here is what we think it’s going to take: First we have to define in measurable terms the attributes of “the safest hospital.” Healthcare workers and physicians need tangible goals to reach specific outcomes. Currently there is no consensus on what hospital safe practice really means.
Next, we must charge everyone in our health system to aspire to error-free behavior in every action, every day. One reason no hospital has ever approached perfection is that no hospital leadership team has defined such behavior, led as if it was expected and supported people to achieve it in concrete terms every day.
Our leaders and clinicians are in the process of defining perfect patient care outcomes—and the processes necessary to achieve them—as the starting point to become a safe hospital. We will hold each other accountable for moving rapidly toward those standards over a 24-month period. We’re convinced by our own experience and by that of safety and quality leaders in other industries that 40% to 50% annual rates of progress toward perfection are possible.
The other half of our recipe to become error-free focuses on helping our staff progress toward our goals by making robust “rapid cycle” improvements in the daily work of the organization. That means approaching improvement differently than most healthcare organizations have come to practice it.
Our first break with common practice is vesting responsibility for progress in the chain of command and in those who control patient care, not in our quality and safety staff. Most hospitals tacitly hold their small safety and quality staffs responsible for making improvements, while often excusing the physician and nursing managers who actually control care. It’s no wonder we haven’t made more progress in improving hospital care over the past 20 years.
Second, we are embracing transparency and learning from things gone wrong. For the past year, we have piloted the open circulation of daily “problem logs” and “real-time root cause analyses” across our organization to warn others regarding risks that may be present in their own areas.
Third, we are building a structure that allows us to actually solve problems, not just patch them, during daily work. We have begun to learn from organizations like Toyota how the creation of “team leaders” and assistants who are available to help the care team immediately initiate true problem-solving can eliminate safety and quality problems.
We are also focusing on the daily role of leaders. At great organizations, leaders can be accessed quickly by managers and staff in a sequence designed to help get problems solved permanently. We call it the use of a help chain, and we are working hard to improve our roles and impact as leaders by changing our daily work to fit this model.
The final and most important characteristic distinguishing safe, high-performing organizations from their peers is an emphasis on making every staff member skilled in applying core principles for designing and improving work. We want our staff members to be “mini process improvement teams” in how they approach their tasks. Ultimately, the rate at which we achieve error-free processes will depend on how deeply and truly we invest in the thousands of people in our organization.
I know we will make mistakes and need to adjust along the way. But I believe America needs to see models like ours emerge as proofs and learning sites for what is possible. I invite comments on our thinking and partnership from those who seek to set a new standard in healthcare.
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