Demanding a Health Care Culture of Safety

by Judith Riess, MTM Editor

At recent medical meetings developing and mandating a culture of safety for health care was seen as the major priority.  This is necessary not only because human lives are at stake but because we are facing a world healthcare crisis with costs spiraling out of control.

At this year’s annual Association of American Medical Colleges (AAMC) meeting speaker’s stressed the need to have patients actively involved in their care and that open discussions should take place between all members of the patient’s healthcare team including the patient. The theme throughout was how to provide the best education for medical personnel while reducing cost and developing a more sustainable model for today’s healthcare environment.

Dr. Kirch (outgoing President) and Dr. Roy Wilson (AAMC Board of Directors) both addressed the need to reduce cost while developing strong healthcare leaders with an enhanced sense of the community they serve. Dr. Rana  Awdish discussed her own critical illness and recovery and how it changed her perspective on how unintentional language by the caregiving team can alienate the patient.  She discussed issues that created barriers in her own care and how medical training needs to encompass CLEAR conversations, a curriculum developed by Henry Ford Hospital (CLEAR: Connect, Listen, Empathize, Align, Respect) to narrow the gap between doctor and patient.

At the SIM-one annual meeting in Calgary they shared ‘Falling Through the Cracks:  Greg’s Story’. Greg Price died tragically after falling through many healthcare system cracks, before being given a chance to receive treatment for a highly treatable condition (testicular cancer). After the film an expert panel discussed how Greg’s experience can be used to train healthcare providers in teamwork which could have prevented Greg’s tragic death, not from testicular cancer but from a blood clot.

At the National Modeling and Simulation Coalition Annual meeting held at the University of Nebraska, i-EXCEL, UNMC Chancellor, Dr. Jeffrey Gold, showed the harrowing 1977 crash of the KLM and Pan Am 747’s on Tenerife, Canary Islands which resulted in the deaths of 538 passengers and crew and remains the worst airline disaster in history.

This seminal event changed the course of the airline industry.

Dr Robert Amyot of CAE Healthcare drew upon corporate knowledge of the airline industry to point out the dramatic reduction of the airline accident rate since that event due the changes it wrought from 1 death per million miles in 1977 to 1 per billion miles in 2015; all the time while the real cost of airline travel continued to fall.

At all three conferences it was stated that “the time (for healthcare to become a safety led concern) is now and it can be done.”

Adpoting a culture of safety for patients and providers has been touted since  2000, when  To Err Is Human: Building a Safer Health System called for health care organizations to develop a “culture of safety,” with personnel and processes focused on safe and reliable care. Since 2015-16 many healthcare organisations have renewed the call.

However, hospital safety reports still indicate that in many organizations, staff still feel that reporting errors or mistakes will be held against them.  This must cease and it is time for healthcare organizations to follow the CANDOR model and step up to the plate.

https://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/introduction.html

For those that worry that this means more cost and tighter margins it should lead to higher safety and higher returns, if done properly, as the Alcoa example shows.

In October 1987, Paul O'Neill gave his first speech as CEO of Alcoa. “I want to talk to you about worker safety,” he began. Surprisingly, that impact extended beyond worker health. One year after O'Neill's speech, the company's profits hit a record high.

https://www.businessinsider.com/how-changing-one-habit-quintupled-alcoas-income-2014-4