At Signature Health, a safety-net hospital in Brockton, Mass., daily huddles take place at every staff shift change to discuss mistakes and near-misses. The goal is to raise awareness and anxiety about errors.
In 2010, CEO Kim Hollon implemented the Lean method of process improvement throughout his organization. He added a safety-management system three years ago to improve how staffers think while performing potentially dangerous tasks, to protect both patients and themselves from harm. Among other things, that led to staff more consistently using patient bar codes during medication dispensing, which they would sometimes skip to save time.
Over 10 years, Signature has reduced its serious safety event rate for patients by more than 85%, Hollon said. Its employee injury rate fell by 90%. Workers’ compensation and medical malpractice costs dropped. He believes the cost of care in his system also has decreased due to a reduction in infections, pressure ulcers and patient falls.
The safety work, he acknowledged, has been “time-consuming and exhausting, has taken tremendous focus, and is very invasive to the organization.” But he rejected the argument that it’s too difficult or expensive for most healthcare organizations to implement.
“If you can do that in a safety net system, with a lot of Medicaid patients and low commercial rates, it’s not about money, it’s about how you manage,” Hollon said.
Signature’s example is a call to action for the healthcare industry, which has been far too complacent in the 20 years since the Institute of Medicine attempted to spark action on improving patient safety by reporting that at least 44,000 and perhaps as many as 98,000 people die in U.S. hospitals each year as a result of preventable medical errors. It estimated the cost in additional care, lost income and disability at $17 billion to $29 billion a year.
“Everyone sat up and said: ‘Wow, we’re not very good. Not only are we very expensive, we kill a lot of people,’ ” recalled Dr. Robert Wachter, chair of the department of medicine at University of California at San Francisco, who started writing about patient safety at that time. “If you were a hospital CEO or board member, you had to talk about patient safety and tell stories about terrible errors.”
That landmark report, To Err is Human: Building a Safer Health System, set a goal of reducing preventable errors by at least 50% within five years. It recommended creating a new federal agency to set national safety goals and track progress; establishing a nationwide and public mandatory-reporting system for adverse events leading to death or serious injury; and developing robust safety systems in all healthcare organizations.
But many of the report’s ambitious goals, such as creating a reliable system of measuring errors, were never realized.
The biggest hurdle? CEOs have not made safety and quality a top priority.
“Patient safety is uniquely the responsibility of the C-suite, but CEOs haven’t paid attention to it or acquired the necessary knowledge,” Hollon said.
The main roadblock, he added, isn’t front-line staff, who are eager to improve patient safety. “The problem is getting management at all levels to believe they have to change the way they manage,” he said. “We have to believe that if we change, we’ll see better results. It’s painful and difficult to change.”