Achieving Safe and Reliable Healthcare: Strategies and Solutions
Michael Leonard, Allan Frankel, and Terri Simmonds, with Katherine Vega
Health Administration Press, 2004, $65.00, 205 pp., ISBN 1-56793-227-4

Audience: hospital staff, medical staff, board members

Key Words: data, medical error, protocols

This is a practical resource guide for hospital, medical staff, and board leadership to use in creating a culture of safety in their organizations. The foreword, written by Don Berwick and Lucian Leape, addresses the fact that improving patient safety is hard work. They acknowledge that the safety challenges in healthcare are in many ways greater than in most other industries. As a whole, the healthcare industry does not address the prevention and mitigation of errors as other industries do, and the high rate of change in healthcare compounds the problem. Achieving safe healthcare must occur at the level of the individual facility, driven by the organization’s receptiveness in adopting national polices and protocols for patient safety. Berwick and Leape acknowledge that implementation of national safe practices requires a huge amount of change and effort. The ability of clinicians, administrative staff, and others to work together effectively in reliable, honest, and open forums is critical in affecting this rate of change in an organization.

Several of the book’s authors have been on the front line of care and thus are familiar with the limitations of the current systems and the challenges associated with implementing change. In Part 1 they review key points of the Institute of Medicine’s 2000 report To err is human, noting that the healthcare industry today harms too frequently while routinely failing to deliver its potential benefits. The authors feel that failure to address and deal with the poor quality of healthcare delivery is undermining the standing of the medical profession.
The book compares the management of safety in the airline industry and the healthcare industry. High-profile events are used as case studies and provide models for other institutions to follow. The authors draw our attention to the fact that 0% of medical errors are system derived, and 95% of the errors that cause harm involve conscientious, competent individuals trying hard to achieve a desired outcome. They devote a significant number of pages to the limitations of human performance and the need for human factor training. The rhetorical question to be asked is “How will the predictable errors be detected and mitigated before they cause harm?” This question leads to a review of the limitations of human performance and a discussion of the concept of the normalization of deviance. This term was coined by Diane Vaughn in 1996 in her analysis of the 1986 Challenger space shuttle accident and refers to the cumulative effects of cutting corners over time. The question that should be asked in the aftermath of an accident is “How did we get here?”

The authors examine the ways that the culture of medicine profoundly influences the perception of medical errors and the dynamics surrounding their effects. The current culture in many organizations encourages hiding and minimizing mistakes and problems. When teamwork and collaboration are not priorities in these organizations, the framework to openly focus on safety is absent. Citing the work of Sharp and Faden 1998, they note that the “perception of quality and safety as a function of the individual physician and other care givers also extends to the institution.” The persistence of the perceived relationship between the physicians’ character and high-quality care can be seen commonly in hospital advertisements that tout the character and skills of the physician staff. Initiatives that have been successful in changing this culture are featured, with examples that the reader can use to begin the process in his or her own organization.

Part 2 of the book reviews the elements that facilitate the creation of an environment focused on patient safety. Organizational leaders, both administrative and medical, play a critical role in the promotion and support of teamwork and collaboration. Hierarchical organizations pose a significant barrier to safe care, because of the profound effect that such structures have on the willingness of staff to question decisions or report problems. Examples include the differences in communication styles of different healthcare professionals, management of the abusive physician, prior experiences of the members of the healthcare team, and cultural differences. A number of pages are devoted to ensuring successful nurse-physician communication, including differences in communication style and perceptions of teamwork, abusive behavior, differences in prior experiences, lack of conflict resolution relating to issues that nurses bring forward, and cultural differences. Examples of the various issues are given, along with strategies to create a culture based on teamwork and communication. One of the approaches is the SBAR Model (situations, background, assessment, and recommendations). This model is used to standardize the type of information to be reviewed; it establishes clear expectations and the associated critical thinking that needs to be done before physicians are contacted.

Designing good systems that have fail-safe elements helps ensure high reliability and consistency, minimizing the number of errors that occur and mitigating the effects of errors that do occur. Cautions are given concerning the use of technology: technology  may increase safety and quality of care, yet it may also increase the risk of other types of errors. The authors stress that structured systems that help to prevent errors are crucial to achieving high reliability. They must be supported by leadership and monitored and adapted to the changing environment to ensure that these systems and tools are appropriately used.
Opportunities to involve patients in safety efforts exist, and the authors note a variety of feedback mechanisms. Forums and advisory councils are two examples; in addition, it is important to facilitate the support of patients by their family members and ensure that family members get complete and accurate clinical information. Several tools are highlighted including collaboration on clinical data collection, orientation to new equipment and devices, conferences, and customized discharge instructions.

Honest, compassionate, and open communication with patients and families when  unexpected outcomes occur—whether the result of a mistake, error, or process failure—is critical. Organizations are encouraged to have policies for such disclosures, and the benefits for the patient and organization are outlined. A number of approaches are offered, on the basis of the experience of organizations that have made the practice a part of the organizational culture. Case studies illustrate how various organizations have handled the disclosure of errors to patients and their families. Although the fear of litigation is real, the lack of timely, honest, and compassionate communication fuels frustration and mistrust and forces patients and families to look to the legal system for remedies. The authors note that when the Lexington Veteran’s Affairs Medical Center in Kentucky began to disclose information to patients about medical errors that caused injuries, the hospital began to pay more claims, yet the cost of each claim significantly declined.

Part 3 of the book discusses how to establish a culture of safety. A healthy culture is an environment characterized by teamwork and collaboration in which individuals feel that safety is valued. Attitudinal surveys and questionnaires on safety attitudes help provide a snapshot of the organization’s safety climate. An excellent safety climate can act as a buffer against threats and errors. Again, sample tools are provided as resources. A lack of common metrics for assessing the safety climate across institutions has been noted. A hallmark of a safety culture is an environment in which accountability for bad events clearly differentiates between individual causation and environmental or system influences. This premise leads to the discussion of the blame-free or nonpunitive culture. This culture does not offer freedom from blame, but it does ensure that system issues and influences will be considered. Intentional actions need to be addressed, and individuals need to be held accountable for their actions. To encourage individuals to come forward and admit when errors have occurred, the organization must develop concrete disciplinary policies that distinctly differentiate between criminal errors and other types of errors. If  the organization is to build trust and foster the practice of reporting errors, it must scrupulously abide by the policy whenever an error occurs.

The authors discuss adverse-event and potential-event reporting systems extensively. They outline types of reporting systems and ways of managing information and provide examples. They emphasize the value of safety leadership rounds and detail an eight-step process that is designed to elicit information from frontline staff. Sample questions and processes are included.
The book concludes with the review of the failure mode and effect analysis (FMEA) and the root cause analysis (RCA), with resources and tools provided to guide users through the process. Material is appropriate for the novice and the experienced. The examples clarify the use of the tools, and sample questions assist in further investigation of problems.

Part 4 ties the material together and illustrates how the theory is applied. A process improvement framework is used to define the culture and assess the current issues—prioritizing the initiatives and quantifying the level of importance, understanding the problem, mapping the process, identifying the key individuals, implementing the change, and defining the data to be collected that will determine whether an improvement has taken place.
Effective change is never quick or easy. The text makes a clear case that healthcare leaders and organizations must be proactive in making healthcare safer and provides resource materials in an easy-to-read format. Healthcare leaders are challenged to learn from the experiences of aviation, turn healthcare institutions into environments of high reliability, and provide the resources and support to make the environment safer for patients and staff.

Reviewed by Judith R. Sands, BSN RN LHRM CPHQ CCM ARM CLC

Ethics in Health Services Management, 4th Edition
Kurt Darr, JD ScD FACHE,Health Professions Press, www.healthpropress. com, 2005, $36.95, 408 pages, ISBN 1-878812-99-8

Audience: risk managers, directors of quality improvement, healthcare administrators and board members

Key Words: ethics, legal and statutory issues, public policy

This reference book, now in its fourth edition, offers a wealth of material on the wide-ranging ethical aspects of healthcare management. The first two chapters lay the groundwork for the remainder of the book by providing information about ethics from a broad historical perspective. The remaining chapters focus on ethics in the organizational, administrative, and biomedical areas and on emerging ethical issues.

Numerous case studies enhance the value of this book. For example, in discussing the responsibilities of institutional review boards, Dr. Darr includes a case study about a hospital in the late 1960s that injected an infected serum to cause hepatitis in facility residents with mental retardation. Several case studies on the patient decision-making process are included,  most notably the Karen Ann Quinlan and the Nancy Cruzan cases.
Several models of institutional ethics committees are offered, which should prove useful to much of the intended audience. Other sections cover developing a mission statement, establishing ethical codes for managers and caregivers, and defining an organizational code of ethics.

The most in-depth discussion is devoted to the topics of consent, death and dying, patient autonomy, and physician-assisted suicide. The chart on definitions of death was particularly informative. The chapter on emerging ethical issues addresses marketing and managed care, ethics in resource allocation, and social responsibility.
This book is an excellent reference for risk managers, directors of quality improvement, and healthcare administrators. Because it is reasonably priced, it would be a valuable asset to anyone involved in health services management.

Reviewed by Pamela K. Scarrow, CPHQ

The Baptist Health Care Journey to Excellence
Al Stubblefield, John Wiley & Sons, Inc., 2005, $24.95, 240 pp., ISBN 0-471-70890-9

Audience: healthcare leaders, quality professionals, human resource managers

Key Words: quality improvement, culture, customer service, Baldrige Award

The Baptist Health Care Journey to Excellence is a story about one healthcare organization’s rise to superior performance culminating in the receipt of the National Baldrige Award. Stubblefield tells his story in simple language that makes the reading actually fun. He mentions names of people in the organization with specific examples just as he would acknowledge these same people in the halls of Baptist Health Care. I have met Al several times, and he writes as easily and honestly as he talks. His commitment to the WOW! Culture is strikingly evident throughout the book.

The book presents the perspective of Baptist Health Care during its struggles of  the 1990s and demonstrates the cultural transformation that has been gradually adopted by all of its employees. Their journey started with the realization that status quo performance was no longer adequate and that, without significant change, the organization was at risk for closure, purchase by a competitor, or other catastrophic consequences. The realization of the need to change and the risks taken to achieve goals is illustrated in many examples. The WOW! Culture is still strong today, evidenced by results of low turnover, high customer satisfaction, and other metrics.
The book is organized into five “keys” to achieve excellence: (1) creating and maintaining a great culture, (2) selecting and retaining great employees, (3) committing to service excellence, (4) continuously developing great leaders, and (5) hardwiring success through systems of accountability.

This book’s value lies in its description of the many innovative ideas that have been implemented throughout this organization. If you are looking for examples of programs, sample forms, and processes from a high-performance organization, you’ll want this book as a resource. Successes achieved by a variety of external organizations, such as Ritz Carlton, and used as benchmarks are also described and can be adopted or further adapted to your organization. Among the numerous ideas shared in the book are these:

 • core values and the daily line-up
 • bright ideas program
 • service excellence
 • service recovery program and database
 • the Bridges Program and the development of Baptist University
 • systems of accountability
 • strategic planning process and 90-day plans.

One section discusses the involvement of physicians in the journey. Strategies used to develop staff (increased communication, reward and recognition programs, leadership development and measurement, and accountability) were applied to physicians. Physicians are not really treated differently, according to the author, but rather their similar human needs are met through programs based on the same principles used with employees.

This book is a great true story and a wonderful resource that provides many tools for organizations to model in their own journey to excellence.

Reviewed by Susan V. White, PhD RN CPHQ FNAHQ

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