Leader Tools to Prevent Medical Errors

Virginia Mason Institute

What health care leaders can do to reduce the number of medical errors in their organization:

It starts with culture. A culture of empowerment enables an organization’s frontline staff — the people with the most timely exposure to potential medical errors — to signal the presence of an error or defect and work together with their teams to resolve it. One of our most important questions for leaders is this: How are you enabling your staff to raise their hands and identify the mistakes in your processes?

One way leaders can learn about what’s happening is to invite frontline employees to bring patient stories to the leadership meetings; at Virginia Mason, we even bring patient stories to board meetings. Early in the journey leaders can expect that when they ask staff to tell them about positive and negative patient experiences, many of the stories will be positive — but leaders also need to understand how we haven’t met our patients’ expectations. If an organization is a learning organization, all employees need to understand the patient experience, both positive and negative, if they are to make meaningful improvements. Patient stories about adverse events present great learning opportunities, especially if the patients or the frontline employees are the ones telling the stories.

“A culture of empowerment enables an organization’s frontline staff — the people with the most timely exposure to potential medical errors — to signal the presence of an error or defect and work together with their teams to resolve it.”

How does the behavior of health care leaders affect this culture of empowerment?

Leaders set the tone for the organization. People pay attention to what the leaders pay attention to. A leader’s focus is especially important when an organization starts its journey to transform health care. If leaders are paying attention to the organization’s stated priorities — whether that includes sepsis, venous thromboembolism, HAIs or the recruiting cycle — then the rest of the organization will pay attention to those priorities. When leaders want their organization to be a patients-first organization, with goals to improve safety and quality, how are they communicating that message?

If a leader is always asking for progress against near-term financial targets, that’s where the staff will focus. But if the leader is always asking for metrics on waste elimination, the leader will get that — and the cost improvements will follow. We know this from experience at Virginia Mason and the other organizations we work with.

Who is responsible for the problem solving work in a culture in which everyone is empowered to speak up?

The traditional model of problem-solving, where a leader tells staff how to do their work and is responsible for fixing any problems that arise as a result, doesn’t show respect for the staff on the front line who know and understand the problems the best. An empowered culture has to be explicit about what to do with problems. Health care leaders need to decide: Are we going to frame or solve the problem? If leaders continue to solve problems for their frontline employees, the employees don’t believe they have permission to solve their own problems.

Over time, when leaders continually frame the problems for the staff to solve, the staff will work in teams to solve the problems. They generate ideas, test the ideas and then measure the results to see if their solutions work. Along the way, the leader’s role is to remove barriers, which can be done during rounding on the front lines. And like everything else in culture change, it is powerful when the executives model this behavior of problem-framing for managers and supervisors — really, for everyone.

Making lasting change in health care when the potential for errors every day is so high

There is no one person who can catch everything every day. It’s a question of capacity. We encourage executives to imagine: What if everyone was watching out for threats to patient safety? How can leaders change the culture so that it’s everyone’s job to catch errors — where nobody can say, “It’s not my job”? People act according to what they feel their responsibility is. In an empowered culture, the most important part of anyone’s job in health care is to keep patients safe.

How culture impacts the way providers and staff deliver care to patients

Historically, in many cultures, ours included, providers have been expected and encouraged to have all the answers — to be all-knowing and all-solving. They’ve been the ones standing between the patient and the possibility of death. How can they say “I don’t know?” even if they don’t? A provider’s job has been to be definitive.

How can we change this model? If the CEO doesn’t have all the answers, then other people are permitted to not have all the answers. It’s a huge burden lifted. It means that providers, staff and patients can form teams to solve problems together.

That’s not to say there isn’t accountability — the provider is not less of a provider. But it’s a different mindset. It’s about inclusive behavior – inclusive of the patient, the support unit and the other care providers. With an empowered culture, other team members are expected to have ideas and contributions, whereas before they weren’t permitted to contribute. And the patient becomes a participant in his or her care.

When an organization achieves a culture shift, its employees can and do speak up, resulting in care that is continuously improving toward zero defects.

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