When it comes to improving the welfare of patients in clinical settings, one major step forward — recognizing that there are safety problems in our health care system — has already been taken. This is largely due to a decade of eye-opening mortality and morbidity studies that have steadily raised awareness about medical errors and defects in care heavily embedded in health care delivery. The elevation of the job of Patient Safety Officer (PSO), to the upper ranks of hospital management in many instances, has been another good sign. But to safeguard patient care and spearhead the types of change needed across any hospital requires tremendous will and increasingly specialized training.
To help fill this need and accelerate the pace of improvement, the Institute for Healthcare Improvement (IHI) has designed a professional development course for PSOs. In the fall of 2004, IHI enlisted leaders and pioneers in patient safety to share their knowledge and skills with 43 Medical Directors, Risk Managers, and other executive professionals from acute care organizations across the US, Canada, and The Netherlands. The PSO Executive Development Program’s immediate goal: to multiply the value of the experts’ combined experience. Its long-range goal: to make patient care safer by improving the skills and support systems PSOs require.
The intensive eight-day program, held for the first time in September 2004, covers a wide range of patient safety essentials. The curriculum ranges from creating reliable systems designed to succeed, to battling the impulse to blame and shame anyone who makes a mistake, to establishing system backups for human fallibility, to meeting increasingly numerous compliance standards. As with much of IHI’s approach to creating change, the PSO program is a proactive blend of theoretical information and practical application. Participants submit in advance at least one actual safety problem facing their organizations. Throughout the first six days of the training, PSOs are encouraged to reflect, individually and in groups, on how the information and techniques they’re learning could help resolve their own and others’ safety issues.
Terri Simmonds, IHI’s Director for Critical Care and Patient Safety, is an architect of the curriculum and one of the PSO training’s seven faculty members. She says, "Content is designed to build on itself and the hands-on sessions let the participants start putting the lectures to use." Little by little, with the help of the faculty and other participants, each PSO devises a comprehensive and detailed action plan to address the specific safety problem(s) he or she brought to the meeting.
For Eileen Oswald, MPH, Risk Manager and Patient Safety Coordinator of Mayo Clinic in Scottsdale, Arizona, one immediate goal when she attended last fall's program was to identify activities providing the greatest return on investment and implement them as quickly as possible. She credits the PSO curriculum for spring-boarding new initiatives and enhancing existing activities in Scottsdale, including the use of a survey on intimidation in the workplace to track the potential negative effect on communication and teamwork, the piloting of IHI’s "Global Trigger Tool" to monitor the rate of adverse events in the inpatient population, and incorporation of James Reason's "Unsafe Acts" algorithm into Mayo Clinic's Patient Safety Champions Program curriculum.
Over 60 Patient Safety Champions at Mayo will engage in tabletop exercises using a "just culture" methodology to underscore the importance of organizational fairness in response to individuals' involvement in adverse events. "The program was the single most rewarding educational experience I've had in my professional career," declares Oswald.
One of Dr. Maurice Wright’s primary tasks as Chairman of the Emergency Department at Woodhull Medical Center in New York City is "influencing others to be passionate about patient safety." He came away from the PSO training convinced that even seemingly small shifts in perspective can elevate aspirations. For example: analysis of performance data. Now, he says, "We compare our data to best practices rather than to industry norms."
Since even the most skilled PSO is seldom the final authority on institutional policy, one uncommon aspect of the IHI program is the requirement that the Chief Executive Officer of each participant’s organization join him or her for the last day-and-a-half of the program. "To really move ahead, there has to be a strong partnership between the PSO and the CEO," notes Terri Simmonds. "Shared education is a way to build that collaboration." Once the top executives are on premises, the opportunity to test that collaboration comes quickly, as each participant lays out for the CEO the action plan designed to tackle a targeted safety problem at their institution.
Amy Steinbinder, RN, PhD, the PSO at Banner Thunderbird Medical Center in Glendale, Arizona, presented her CEO, Colleen Hallberg, with a protocol for improving communication between physicians and nurses or other care team members who sometimes feel intimidated or dismissed by the doctors. In addition to encouraging more careful listening, says Steinbinder, the protocol lays out a blueprint for making sure the listener understands exactly what is meant by what is said. "Steps include identifying the underlying emotion and giving feedback that determines what response is being requested," she explains.
Hallberg, who calls the PSO training a "jump start for a more complete approach to patient safety," was impressed by the diversity of the program participants. "We met people with a wide variety of experiences that Amy can network with and learn from."
Speaking at one of the joint PSO/CEO sessions, James Conway, Chief Operating Officer of the Dana Farber Cancer Institute in Boston, said top executives help most by taking ownership of safety problems. Dana Farber made headlines in 1994 when Boston Globe columnist Betsy Lehman died there from a chemotherapy overdose. "When you let the stark realities of medical practice, such as near misses, system failures, errors, and actual harm rise to the top of the organization and spread across it, you can unleash impressive energy to fix the problems," says Conway. Standing at a lectern to say we all have to do better will not accomplish much, he says, "Standing there and reviewing the last 10 patients harmed by medical errors and the systems needed to fix those errors, will get you a lot further."
Opportunities for professional growth don’t end when the PSO training does. In addition to opportunities for formal reunions, graduates of the course have a listserv for advice and support, plus a dedicated Extranet site on which to share tools of their exacting trade, courtesy of IHI. "Our plan was to prod into existence a community of people working toward the same goals, but it really formed all by itself," says Simmonds. "It has been an incredible experience to watch it grow."
Susan Bond, MS, the PSO at St. Anthony’s Hospitals in Denver, Colorado, agrees. Initially, Bond admits she was concerned that the training might not justify its cost in time and money. She says, she was "pleasantly surprised" to find just the opposite. "I feel that it’s my calling to improve patient safety but the pushback within an organization can be very frustrating. The contacts I made at the PSO training have turned out to be fantastic resources and they’re only an email away."
