Involve governing board in patient safety effort
Educated members can be powerful ally
By Patrice Spath, ART
Brown-Spath Associates
Forest Grove, OR
It’s hard for health care consumers to miss today’s newspaper headlines about patient care mishaps, and some of those same consumers serve on the governing boards of hospitals. They are asking, "Could this kind of adverse event happen in our facility?" While the question may be directed at caregivers, the board members must understand that they play a role in preventing medical accidents.
The hospital governing board’s involvement in patient safety improvement initiatives should consist of more than passive observation. The board must form a dynamic and collaborative partnership with hospital and medical staff leadership. Improving patient safety requires commitment by the board to visibly support the organization’s risk-reduction strategies.
Achieving that commitment requires the education of board members. An effective patient safety improvement initiative starts by changing the facility’s culture from "who to blame" to "what to blame." The governing board can support this new culture by intervening when it appears that people are being singled out as the cause of problems. Orient the board to the systems focus of error management, emphasizing that improvements in hospital functions and processes are the goals, not punitive measures. The board is still legally responsible for ensuring the competency of physicians and staff, and therefore will continue to receive performance data on individual clinicians and departments. However, even when individual practitioners are suspected of marginal performance, the first area of investigation will be focused on process changes designed to improve those individuals’ performance as well as the performance of all caregivers.
Systems improvements, sharing policies
The board also must promote implementation of systems improvement activities that will reduce the chance of human errors, or if errors do occur, ensure that they are caught and corrected before patient harm occurs. This means the organization should establish safety improvement goals for high-risk processes.
While board members will not personally be involved in using the process improvement techniques, they should be briefed on what can be done to minimize the risk of patient mishaps. Be sure they know about:
• reducing reliance on memory;
• simplifying the process;
• setting standards;
• computerizing;
• improving transfer of information;
• reducing hand-offs in the process.
The board also should be made aware that hospital staff and physicians may need specialized systems improvement training, with the board being asked to approve funding for this training.
The hospital’s sentinel event policy should be shared with the board to obtain their input on such issues as reporting events to outside organizations such as the Joint Commission on Accreditation of Healthcare Organizations. The board should be briefed about the hospital’s options and may be asked to be involved in reporting decisions on individual incidents. The board also should be made aware of any mandatory federal or state reporting requirements. Members should be familiar with the hospital’s crisis management plan and may receive periodic training in media relations. Listed below are the issues that should be shared with the governing board to ensure that they understand the organization’s sentinel event policies and crisis management strategy:
• purpose of the sentinel event policies and crisis management plan;
• when and how the policy/procedures shall be implemented;
• the responsibilities of staff and physicians in reporting incidents and sentinel events;
• the types of events for which a formal root-cause analysis will be conducted (see article on running a root-cause analysis, p. 105);
• the role of managers, staff, and physicians in root-cause analyses — research and fact-finding, information exchange, corrective actions;
• how the results of sentinel event investigations will be shared with staff and physicians to minimize the likelihood of future events;
• the lines of authority and accountability for the sentinel event policy and the crisis management plan;
• the internal contact person who will interact with external groups in the event of a serious patient mishap.
The hospital governing board should be provided with regular reports about the hospital’s patient safety improvement initiatives. These reports can be part of overall performance management information, but for added emphasis, it may be advantageous to create a separate report such as the one shown in the sample patient safety improvement report accompanying this article. (See chart, p. 113.) Be sure to give the board members some education about the information in the report. If you are using a severity rating scale to categorize patient incidents, be sure the board understands the difference between the different levels. Error management efforts will benefit from educated involvement by the board.
Members must oversee patient safety improvement activities. For example, when reviewing the report, they should ask questions such as:
• Do these data show that the organization is lowering the risk of an adverse patient event, or is the organization merely maintaining the status quo?
• How does performance compare to the patient safety improvement goals approved by the board?
• Are the projects resulting in measurable improvements?
• If a project appears to be stalled, what needs to be done to get it back on track? What can the governing board do, if anything, to help get the project back on track?
Better reporting may boost incident numbers
It is important for the board to understand that a low number of patient incidents may not be desirable because that may be a signal that incident reports are not being filled out for all patient care variances. Without adequate knowledge of the various types of incidents, it is not possible to identify error-producing situations needing investigation. The goal in many organizations is to improve reporting, thus increasing the number of incidents that appear on the board reports. Many hospitals are establishing dial-in hotlines and anonymous incident reporting. These practices are likely to cause the number of reported incidents to increase. It’s important that the board understands this is due to better reporting, not an increase in the actual number of incidents.
The hospital may provide board members with comparative data from other organizations. While such data may have some use, be sure board members understand the limitations of comparing patient incident rates.
Generally, databases that rely on voluntary reporting of adverse events have a high probability of inaccuracy, even when reporting is mandated by state or federal regulations. Blind use of comparative data to benchmark incident rates and establish targets can easily lead to erroneous conclusions and inappropriate actions. It may be more useful to communicate to the board how the hospital is using information available in mishap databases such as those maintained by the Institute for Safe Medication Practices, the Joint Commission, the Food and Drug Administration, and the American Society of Anesthesiologists’ Closed Claims Project.
When the hospital becomes aware of adverse patient events involving the same drugs or equipment or the same patient care tasks, improvements should be undertaken to prevent similar incidents. These improvements can be summarized on the patient safety improvement report (as illustrated in the chart on p. 113).
The hospital governing board can be a powerful ally in advancing improved patient safety goals. Educating the members in their role is the first step toward creating the dynamic, collaborative partnership you want to achieve. The next step is to give them regular updates on the status of patient safety improvement initiatives and risk-related performance measurement results. Don’t wait for a significant patient care event to occur; start involving your governing board in patient safety issues now.
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