Hospitals have been focused on patient safety for a decade, but the focus has been magnified in recent years. Reimbursement is now tied to important patient care metrics. Hospitals have adopted checklists, airline and manufacturing processes and hired scores of experts and consultants. In spite of all of these efforts, the most recent results have been characterized as “depressing.” What’s missing?
HealthLeaders Media provided a summary of the most recent hospital safety grades from the Leapfrog Group:
"So far, these numbers aren't really moving," said Leapfrog Group president and CEO Leah Binder. "It's depressing," she added, because even though the scores for acute care facilities reflect measures from 2011 and 2010, long before her group launched the safety score last year, hospitals for years have been saying they are trying to make care safer.
For example, she said, "we have demonstrated that hospitals can get to zero central line infections, yet we're still seeing thousands of them reflected in this score.
"And it's very disturbing to still see 'never' events, like air embolism or retained objects in surgery. We understand that things that should never happen sometimes do. They should be extraordinarily rare, but that's not what we're seeing. They're far more common than they should be."
The problem might be that all of the new programs and processes fail to address the most important variable – human performance and error. Here’s an example – we had a hospital call us after several critical nursing errors put patients at risk. Senior leadership wanted to know if we could test for critical thinking. Of course we can, but the nurses, if tested, would obviously tell you that what they did was not consistent with established safe practices. It wasn’t a knowledge or critical thinking problem. It’s an attention to detail problem. It’s a willingness to take risk problem. It’s a behavioral problem. Why haven’t we eliminated central line infections when it’s been shown to be possible? Because some organizations don’t hire people who will follow the proven procedure every time and hold colleagues accountable to do the same!
It seems so obvious. Industries that really value safety not only implement safe processes, but they also very specifically hire and develop people who are more prone to BE safe and then reinforce those behaviors. Healthcare has been so enamored with clinical skills in the selection process that we are only now getting around to thinking about behavioral competencies. Safety is about more than a checklist – it’s about people. It’s about behaviors.
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