Wednesday, August 14, 2013

Making Patient Safety a Key Hospital Priority

Making Patient Safety a Key Hospital Priority                               

Patient safety in hospitals and other healthcare delivery settings is a major public health problem. Several distinctive challenges combine to create a high-risk environment for patients that can result in grave - and costly - personal and organizational consequences. 

A Training Team Works on a Mannequin 
Michael and co-authors Dr. Jeffrey Cooper, Dr. Sara Singer and Jay Vogt recently published an article in Reflections Magazine discussing how defensive behaviors among hospital leaders, managers, and staff aggravate the risks to patient safety in hospitals.  Here is a link to the article, "The Journey to Patient Safety," in which we describe a multidimensional training program, Healthcare Adventures™, in which the exploration of so-called "automatic defensive routines" figures as an important focus. Healthcare Adventures combines a simulation of a traumatic patient safety event with structured reflection. Taken together, these kinds of learning opportunities support collaborative inquiry and appreciative engagement by the members of healthcare management teams around important issues such as patient safety.  (You have to scroll down into the PDF a couple of pages to come to the body of the article.)  

Michael, Jay, Jeff and Sara have been working together for a number of years in the under the auspices of the Center for Medical Simulation, a training institute based in Charlestown MA that has the support and engagement of a number of hospitals and research institutions, such as Partners Healthcare, the Massachusetts General Hospital, Brigham and Women's Hospital, MIT, and the Harvard School of Public Health.  CMS was one of the world's first healthcare simulation centers and continues to be a global leader in the field. CMS is approved by the American College of Surgeons (ACS) as a Level 1-Accredited Educational Institute, and is endorsed by the American Society of Anesthesiologists (ASA).  Jeff Cooper, the founder and executive director of CMS, is also the recipient of a number of awards for his pioneering work in the field of patient safety.    
Tom Bigda-Peyton

Healthcare Adventures is an on-going project.  Our thinking is closely aligned with Dr. Tom Bigda-Peyton, managing partner of Second Curve Systems, who focuses on the alignment of functions, technology and people throughout a hospital or other healthcare delivery organization to bring better and safer results to the patient and more positive experiences to clinical and administrative teams.  Second Curve Systems offers a paradigmatic shift in the way healthcare is delivered and in the expectations that people have of healthcare systems.  

Consider this: the recent airline crash in San Francisco in which two lives were lost constitutes the first such fatal crash in the United States since 2009.  Contrast that with the fact that something like 45,000-95,000 people die in American hospitals every year as a result of preventable safety accidents and issues.  What if hospitals were as reliable as commercial airlines?  That is the sort of high reliability outcome Second Curve is going for.  Second Curve's thinking about the overall context of healthcare combined with Healthcare Adventures capacity for build trust in hospital teams so that they can grapple with and resolve the complex issues confronting patient care looks like a potent and much-needed combination.  

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