FIRST, DO LESS HARM: A Health Care Cultural Operating System Case Study to Improve Safety

By Ball, Debra A.; Kaminski, Brian et al. | People & Strategy, Winter 2016 | Go to article overview

FIRST, DO LESS HARM: A Health Care Cultural Operating System Case Study to Improve Safety


Ball, Debra A., Kaminski, Brian, Webb, Kevin, People & Strategy


In the decades since the Institute of Medicine (IOM) issued its landmark report, "To Err Is Human: Building a Safer Health System," there have been a number of successful efforts undertaken to improve patient safety in the United States (Leape & Berwick, 2005). Nevertheless, the nation remains far from realizing the vision of eliminating harm to patients from care that is meant to help them. This case study describes the progress that has been achieved by one organization committed to developing a culture of high reliability. ProMedica Health System is a nonprofit integrated health care delivery system headquartered in Toledo, Ohio. In 2012, we set out to transform our cultural operating system with the goal of "zero events of harm."

Every caregiver must recognize that high- and low-quality clinical care is the product of a system, not just an individual. To overcome the false notion that "personal effort controls everything," we encourage staff to view health care quality as a function of leadership, teamwork, training, distractions in the work environment, patient flow or departmental glitches and all forms of communication, among other factors. Each of these could contribute to or reduce harm, but for the most part are invisible to those who are not trained to look for them.

The focus on safety in health care, automotive, food service, aviation, and nuclear energy sectors exceeds that in most other industries. Given health care's unique interest in public safety, there are myriad leadership lessons that can be applied to change facilitation or to human performance management.

Fundamentally, safety should come first if organizations want a chance to serve customers and to sustain success. When caregivers in our error prevention classroom are asked, "Have you, your family, or anyone that you know ever been harmed or 'almost' injured from a medical mistake?" Seventy-five to 80 percent of participants admit knowing someone who has experienced preventable hospital errors. In a 2014 study, the Leapfrog Group indicated that hospital errors are the third leading cause of death in the U.S., with hospital safety scores improving slowly.

Organizational Context for Safety Improvement

ProMedica encompasses 13 acute-care hospitals as well as ambulatory care centers, physician/provider organizations, continuing care services, ambulatory clinics, and a managed care plan covering more than 300,000 lives. The organization employs more than 16,000 staff, including 1,950 physician/ providers and more than 400 volunteers in union and nonunion facilities.

Health care reached a turning point when the Affordable Care Act (ACA) went into effect. New technologies, increased consumerism, tougher compliance standards, and new reimbursement models are forcing health care systems to adjust their cultural operating models to accommodate these changes. Patients, employees, leaders, and funders of care are demanding more information, improved safety, greater transparency, and more value at an increasing rate.

Patient safety efforts are paradoxical. Patient safety is an action, not an achieved status. It's the avoidance of errors and creation of routines designed to minimize the chance that human error results in harm to a patient. Achieving safe care for patients demands specific actions and constant vigilance both at a worm's-eye and a bird's-eye view. These efforts are critical because the consequences of failing to ensure patient safety are real, costly, and often horrible.

Cultural Operating System

Patient safety means we must install a cultural operating system, which supports safety as a keystone to core values. In addition, that cultural operating system must support a constant focus on work design, staffing levels, the environment, training, intra-disciplinary professions, professionalism, management, communications, information technology, regulation, transparency, certification and testing (Weick & Sutcliffe, 2007). …

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