By Stephen G. Jones, MD
Strange. Our healthcare profession has among its ranks some of the brightest, most talented, highly-trained individuals to be found. We work in an environment utilizing cutting-edge science and technologies. Yet, we continue to fail at an alarming level in our pledged sacred mission to do no harm. Why?
As a profession, healthcare is often compared to the so-called high-reliability professions of aviation and nuclear power; then the question posed is, why we in the healthcare profession aren’t as good? Could it be that those industries were lucky enough to recruit all the exceptionally talented and gifted people, leaving healthcare with the B-list professionals? Of course not. Perhaps the individuals that work in aviation and nuclear power just care more about their work? Not a chance.
So why, 18 years after the release of the Institute for Medicine’s report To Err is Human, do we find ourselves as healthcare leaders asking the same questions?
Part of the answer may lie in the Joint Commission’s most recent Sentinel Event Alert, “The Essential Role of Leadership in Developing a Safety Culture” (Issue 57, March 1, 2017).
As a practicing physician with more years of experience than I care to admit, I have been witness to some remarkable changes in our field – many good, some not so good. The Joint Commission most certainly falls into the good category. Over the years, the Joint Commission has continued to evolve as an organization and build on its mission.
The Joint Commission has endeavored to work as more of a supportive partner to hospitals as opposed to regulatory policemen. More than ever, they seek best practices over citations, learning over blame, transparency over hiding. It can be argued that the Joint Commission now holds healthcare organizations to an even higher standard than it did in the past. The goal did not change, the approach did. Is there a lesson here for us?
The Joint Commission chose to build on their own success. In other words, the leadership of the Joint Commission did exactly what they are now fervently pleading with our own healthcare leadership to do:
• Develop and embed a culture of openness that is accountable and just
• Stop punishing well-intentioned employees who make an error. Instead, supporting them, and seeing the error not as an opportunity to blame, but rather to learn (partner vs. police)
• Foster an open and safe reporting system where everyone is encouraged to speak up without fear of reprisal
• Create an environment of shared learning that focuses on good system design and helping employees make better behavioral choices in a challenging environment
To be sure, the vast majority of very capable and gifted hospital leaders in our country don’t need a lesson from anyone, and certainly not me, on what’s important when it comes to patient care. And to be fair, hospital leaders today, unlike any time in the past, are faced with seemingly insurmountable and never-ending challenges. They operate in a volatile, uncertain, litigious environment often driven by external forces outside their control: hospital boards that expect (among other things) a beautiful environment, near perfect outcomes, a positive operating margin, and wonderful patient and employee satisfaction scores.
Nevertheless, this pivotal release by the Joint Commission is calling upon every healthcare leader to prioritize their efforts on developing a culture of safety, and utilize resources that drive, support, and maintain such a culture.
Building a true culture of safety, a Just Culture, is not easy. In fact it’s downright hard. It doesn’t happen overnight and doesn’t happen without passion and commitment from the very top leadership of any organization. And it certainly doesn’t happen by simply declaring you have a Just Culture and writing a policy around it. A Just Culture needs to be built from the ground up, with a model of systematic learning, and in an environment that wraps itself in the right system of justice.
I urge every hospital leader in America to read, share, and discuss this important Sentinel Event Alert with their extended leadership and embrace its recommendations. I encourage you to reach out to the many resources available to help you on this important journey.
The Joint Commission has provided a clear direction, but more importantly, a compelling challenge for establishing a culture of safety. More than ever, our patients, their families, our staff, all of us, need our top healthcare leaders to embrace this challenge. This country needs our healthcare leaders to lead.
Stephen G. Jones, MD
Medical Director of Safety
Yale New Haven Health System