Leadership is considered the main factor for an effective patient safety program. The Institute for Healthcare Improvement (IHI) developed a white paper, Leaders in Patient Safety, to assist healthcare leaders in the development of the patient safety program. This white paper recommends the following eight steps for leaders to achieve patient safety :
Establish Patient Safety as a Strategic Priority
Patient safety should be considered as one of the organization’s strategic priorities. This strategic priority and is included in all of the plans of the organization. The leadership must assess and establish a supportive patient safety culture, address the organization’s infrastructure, and learn about patient safety and improvement methods (Botwinick, Bisognano, Haraden, 2006).
Engage Key Stakeholders
The key stakeholders include the Governing Board, leaders, physicians, staff, patients and families. These individuals need to be educated about patient safety and engaged in discussions about patient safety.
The agenda of meetings should give patient safety the same amount of time as financial issues on the agenda (Botwinick et al., 2006).
Communicate and Build Awareness
During Leadership walk rounds throughout the organization, engage the staff, practitioners, patients, and others in discussions about patient safety.
Within the departments, there should be education and other activities that address patient safety in the department. This could include safety briefings, huddles, utilizing SBAR (Situation, Background, Assessment, Recommendation), and the utilization of Crew Management (Botwinick et al., 2006).
Establish and Communicate System-Level Aim
The strategic plan with identified goals needs to be communicated throughout the organization.
For example, the strategic plan includes the patient safety as a strategic objective, so education and IT departments should include organization goals regarding the implementation of new software needed. (Botwinick et al., 2006).
Measure Harm Over Time
Utilize a dashboard or balanced scorecard to observe data over time. Include triggers for adverse events, mortality rates, Root Cause Analyses (RCAs) and Failure Mode and Effects Analyses (FMEAs), and other such patient safety information (Botwinick et al., 2006).
Support everyone Impacted by Errors
The patient and family, as well as the staff who made an error, will all require support after a medical error occurs. The appropriate disclosure of information and an apology to the patient/family has a great impact on patient safety.
Align Strategy, Measures, and Improvement
The organization must align their strategic initiatives between various parts of the organization, such as between quality improvement and financial plans. There should be oversight of improvement projects, with monitoring and revising if changes are not forthcoming. The national initiatives must also be integrated into this process (Botwinick et al., 2006).
Redesign Care Processes to Increase Reliability
Reliability ensures that the patient receives the appropriate test, treatment, or medication at the appropriate time. This can be accomplished by the use of rapid response teams, CPOE systems with decision support, and many other means.
Another concept utilized is the decrease in variability. The standardization of care with guidelines and pathways leads to decreased variability and thus increased the reliability of care (Botwinick et al., 2006).
Leadership Guide to Patient Safety. Botwinick, L., B Bisignano, M ., Haraden, C. (2006).