How to cite this paper:
Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety.
IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2006. (Available on www.IHI.org
The numbers are now widely known: 44,000 to 98,000 Americans die each year as a result of medical errors. Since these staggering figures were published by the Institute of Medicine (IOM) in the 1999 report, To Err Is Human,
much pioneering and innovative work has been done to reduce adverse medical events and eliminate the harm they cause. This paper shares the experience of senior leaders who have decided to address patient safety and quality as a strategic imperative within their organizations. It presents what can be done to make the dramatic changes that are necessary to ensure that patients are not harmed by the very care systems they trust will heal them.
This paper presents eight steps that are recommended for leaders to follow to achieve patient safety and high reliability in their organizations. Each step and its component parts are described in detail in the sections that follow, and resources for more information are provided where available.
- Step One: Address Strategic Priorities, Culture, and Infrastructure
- Step Two: Engage Key Stakeholders
- Step Three: Communicate and Build Awareness
- Step Four: Establish, Oversee, and Communicate System-Level Aims
- Step Five: Track/Measure Performance Over Time, Strengthen Analysis
- Step Six: Support Staff and Patients/Families Impacted by Medical Errors
- Step Seven: Align System-Wide Activities and Incentives
- Step Eight: Redesign Systems and Improve Reliability
The concepts are based on the experience the Institute for Healthcare Improvement has gained through years of guiding organizations in improving patient safety. Although the focus of this paper is on the acute care setting, most of the concepts apply to other settings of care as well. It is understood that organizations will be at different stages of development, and thus will move at different paces through the improvement process. An organization with significant experience in improvement methodology and a successful portfolio of previous safety work will be able to make progress at a faster pace than an organization that has yet to build the infrastructure and commitment to safety at all levels.