Frontiers of Health Services Management - Spring 2013 - (Page 36)

Historically, health professionals, government regulators, and private quality organizations have led the way toward identifying the highest-priority healthcare quality and safety issues and developing actions to address them. for example, the centers for Medicare & Medicaid Services’ value-Based Purchasing Program and the Joint commission’s national Patient Safety goals and core measures have given hospitals and other healthcare organizations targets for focusing efforts to gain the greatest improvements in specific safety and quality areas. Many hospitals and other types of healthcare organizations already devote sizable resources to address quality and safety improvements. Yet, major shortfalls continue to be seen in numerous areas of safety and quality, which cause significant harm and result in excessive cost. toussaint and Kaplan assert that only a true transformation can enable sustainable achievements toward zero harm. Creating a Safety Culture one fundamental element required to move beyond previous efforts and toward a future of better healthcare is creating and sustaining a culture of safety. Practicing mindfulness and striving for perfection—two factors referenced in both articles—help build a culture in which small, point-of-care improvements and attention to details are celebrated. Mindfulness refers to the acute awareness that staff and leaders in a high-reliability organization must have every day. all are mindful that even a small failure in a safety process or procedure can lead to a catastrophically adverse outcome. originally described by University of Michigan professors Karl Weick and Kathleen Sutcliffe (2007), mindfulness involves the constant searching by staff for the small- est indication of a flaw or hazard that may lead to failure if some action is not taken to solve or prevent the potential problem. those flaws, or holes in the swiss cheese model described by reason (2000), can snowball into an adverse sentinel event. Mindfulness leads organizations to find flaws at earlier stages, where they can be more easily fixed, rather than after they have caused harm. Perfection in reliability of care delivery is the standard to which healthcare professionals and healthcare organizations must continually aim. for example, 99 percent performance is not good enough. consider that errors in 1 percent of 10 million inpatient surgeries annually represent more than 100,000 surgical errors, and errors in 1 percent of 35 million medication orders per year equal more than 350,000 medication errors (based on data from cosgrove et al. 2012). thus, we understand the importance of striving for Six Sigma process reliability and beyond. the concepts of being mindful and striving for perfection are aligned with the 2012 institute of Medicine’s discussion paper titled A CEO Checklist for HighValue Health Care (cosgrove et al 2012). Healthcare organizations and leaders have an obligation to embrace opportunities to improve the quality of care delivered to patients. Having the courage to declare that good enough is unacceptable requires healthcare organizations and leaders to adopt a credo of commitment and accountability that results in significant, durable change. as the ceo checklist and the articles by toussaint and Kaplan make clear, one of the toughest challenges in transforming healthcare into a high-reliability industry with a safety goal of zero defects is a culture characterized by a lack of willingness or desire to 36 • f ro ntier s o f h ea lth s e r vic e s ma na g e m e nt 29 :3

Table of Contents for the Digital Edition of Frontiers of Health Services Management - Spring 2013

Frontiers of Health Services Management - Spring 2013
Contents
Frontiers of Health Services Management - Spring 2013
A Management, Leadership, and Board Road Map to Transforming Care for Patients
Pursuing the Perfect Patient Experience
Adapting to the New Healthcare Market
High Reliability: Truly Achieving Healthcare Quality and Safety
Making Lean Progress Last: Why Sustaining Excellence Requires the Right Leadership Framework

Frontiers of Health Services Management - Spring 2013