The Structural Dynamics of Patient Safety

For the last fourteen months, Art of the Future principal, Michael Sales, has been working on a mammoth patient safety initiative at the Massachusetts General Hospital. This program, entitled Engaging Leadership in Patient Safety, is sponsored by the Hospital and by the Donaghue Foundation. It has provided participants with in-depth insight into the structural dynamics underlying hospital systems in relation to patient safety issues. Structural dynamics identifies and connects the driving forces comprising the elements of a system. Intervening one or more of those factors impacts the entire system. Virtually every single feature of a hospital system is related to patient safety, and the importance of this issue is truly enormous. Every year, there are thousands of fatalities and serious injuries that result from preventable lapses in patient safety within hospitals. Unfortunately, hospitals can be very dangerous environments. In addition to the heart-wrenching human costs of patient safety problems, the social costs are very high. Think of skyrocketing malpractice insurance rates and their impact on health care costs.

This research initiative focuses on the role of leadership as a driving force in hospital systems impacting the quality of both clinical and non-clinical group's patient safety performance. The effort has been led by Dr. Sara Singer, a professor of Health Care Management and Policy at the Harvard School of Public Health. Sara's research on the construction of patient safety culture is extensive, involving a national consortium of 135 hospitals prior to her work at MGH. Building on her previous research and the work of others as well, Sara's model for hospital leadership in support of patient safety emphasizes seven interrelated elements:

1. The unquestionable demonstration that hospital leadership really cares about patient safety.
2. Hospital leadership displays a welcoming response to the expression of patient safety concerns by any staff member
3. Leadership acts in a way that encourages the discussion of patient safety
4. Leadership is skilled at facilitating communication and teamwork about patient safety
5. Leadership takes visible action directly related to patient safety
6. Leadership mobilizes the information needed to support patient safety initiatives
7. Leadership seeks input from relevant stakeholders before and after taking actions related to patient safety.

Singer's hypothesis is that hospitals where leaders focus on these seven factors will become learning systems in which everyone will be active protectors and protagonists of patient safety.

The research project has been testing this thinking by running multiple groups through an intensive training program called Healthcare Adventures based at the Center for Medical Simulation, a collaborative effort of Harvard, MIT and a number of other players. Michael has been one of the chief designers and trainers associated with Healtcare Adventures, along with our close colleague, Jay Vogt of Peoplesworth, Sara, and members of the staff of the Center. In this particular version of Healthcare Adventures, Singer will compare and contrast the performance of these groups on a number of measures with those of others who have not been exposed to the training after the passage of one year and the results will be the subject of a variety of planned reports.

Among the components of the training, the leadership groups going through the training are exposed to an intense teambuilding experience in the form of a simulation that challenges them to act as leaders confronting a complicated patient safety situation. They also spend time reflecting on their own practices as patient safety leaders and planning a significant intervention in support of patient safety that will be monitored and measured over a period of time. All of this is accomplished over the course of a full day of training.

Additionally, each participating group gets a two hour follow up session in the form of a structured Booster Shot that looks in on their successes and learnings since the completion of the one day training and reviews their activities related to their intervention project. The preliminary results of these Booster Shots have been quite encouraging. Not only have the teams made significant progress in their specific patient safety activity, but they have also come out of the follow up training session charged up to function together more effectively as a leadership team. It is striking to see how powerful a brief structured follow up can be to a training session. It is so often the case that a training experience is treated as a "one off" activity that might have resulted in learnings for the day but recedes quickly into the drift of life. Periodic reviews of what was learned and what results were accomplished are very much worth the investment. Many times groups will discover they got a lot more out of a training than they thought they did when they look back upon it through the lens of subsequent action.

The impact of this research project is just beginning to be appreciated. It may become one of those rare, high leverage activities occurring at the right time and in the right institutional context to have far reaching effects on the delivery of health care in hospital settings. If so, it will to a great extent due to the focused attention of the project's champion, Sara Singer, and two well-connected sponsors, Prof. Jeff Cooper, Executive Director of the the Center for Medical Simulation, and Dr. Gregg Myers, MGH's SVP for Quality and Patient Safety. The positive connection of project champion and sponsor is one of the important factors contributing to this effort's success.

What could be more relevant to Art of the Future's focus on Life Sustaining Environments than patient safety in hospitals? Stay tuned for more progress reports!