Academic journal article Frontiers of Health Services Management

Patient Safety: Mindful, Meaningful, and Fulfilling

Academic journal article Frontiers of Health Services Management

Patient Safety: Mindful, Meaningful, and Fulfilling

Article excerpt


Five years after the landmark report of the Institute of Medicine To Err Is Human (Kohn, Corrigan, and Donaldson 2000), many are asking, "Is U.S. healthcare safer?" A number of articles addressing this question have been written, interviews with nationally recognized patient safety leaders have been published, and governing boards of many healthcare organizations are examining reports of care provided by their institutions. Robert M. Wachter, writing in the November 2004 issue of Health Affairs, concludes that, "At this point, I would give our efforts an overall grade of C+, with striking areas of progress tempered by clear opportunities for improvement."

We describe in this article the pursuit of a culture of safety at William Beaumont Hospital in Royal Oak, Michigan. Our experience has offered us the opportunity to ponder a number of key questions: How does leadership guide an organization toward a culture of safety? Does culture truly drive behavior, or is it really the reverse? How can a culture of safety be measured or observed? What levels of resources and commitment are required for success? Is safety all about systems and processes, or are core values also involved? What role does the patient play in ensuring safe care? We attempt to offer guidance, and share lessons learned, for each of these important questions.


Our industry and our hospital cannot afford not responding to this study /To Err Is Human] and making the necessary investments to assure patient safety. While Beaumont Hospital practices many of the recommendations already, we still make mistakes that cost us millions in dollars and tragedies in human terms. IfI had to make one investment in 2000 it would be in physician order entry! Thanks for the material but 1 have a copy of To Err Is Human on my desk.


This note was written to Steven Winokur, M.D., on December 27 of 1999 by Kenneth Matzick, executive vice president and chief operating officer of Beaumont Hospital in Royal Oak, Michigan. He wrote in response to a note from Dr. Winokur one week prior, which provided him the executive summary of the Institute of Medicine (IOM) report To Err Is Human (Kohn, Corrigan, and Donaldson 2000). Dr. Winokur had written, "I would appreciate your thoughts on this, as many of these recommendations would require significant commitment and resources."

At the beginning of 1999, Beaumont began a comprehensive one-year review of its quality management program. A strong infrastructure of multidisciplinary peer review and administrative and personnel support for numerous quality improvement teams, database management, and concerned leadership had been in place for at least two decades. Accolades were accumulating, such as reviews received "with commendation" from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), inclusion in the top-ioo-hospitals lists and US News and World Report rankings, and independent survey best-hospital ratings for the southeast Michigan region. Yet it was clear to our leadership that a great deal of work remained to be done to achieve the level of performance excellence that we feel our patients deserve. Perhaps what made us somewhat unique in our ability to respond to the IOM report was that we were ready to assume the challenges it presented to all of healthcare: how many hospital executives had a copy of To Err Is Human on their desk in December 1999?

Although we had already pursued and accomplished many of the IOM recommendations, we had not actively nor formally used the term patient safety to describe our quality management or performance improvement activities. Therefore, our initial efforts were to define patient safety; communicate to and educate our entire organization about patient safety; and develop an effective, high-profile infrastructure supported by updated and yet-to-be-developed patient safety policies. One of our very first steps was a presentation to our Board of Directors about the IOM report in early 2000-what it meant and where we stood. …

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