Sentinel event alert pairs leadership and safety
Sentinel event alert pairs leadership and safety
Data show leadership involvement makes difference
The Joint Commission issued its first sentinel event alert in August 2009. The issue: Leadership's role in committing to safety and promoting quality care. Ronald B. Goodspeed, MD, MPH, FACP, FACPE, is instructor on health care management in the department of health policy and management, Harvard School of Public Health and and former president of the Massachusetts Coalition for the Prevention of Medical Errors. He says the subject of the alert is "not a new thing. What's new and is actually somewhat sad is The Joint Commission had to put this out as a sentinel event."
Goodspeed says, "This idea that leadership is responsible in the form of the board, in the form of the CEO and senior leadership, in the form of the medical staff is not a new concept. But I think what's relatively new in the last two years has been a real full-court press by various parties in the country to sort of remind everybody of that." He sees the alert as part of that press.
Paul Schyve, MD, senior vice president of The Joint Commission, says the impetus for the alert came from its patient safety advisory group. "They said, 'Look, when you look at a health care organization that's really safe vs. one in which they don't emphasize safety, it almost always turns out that there's a significant difference in how the leaders take responsibility for safety and for a safe culture,'" he says.
In fact, the alert reads, "inadequate leadership was a contributing factor in 50% of the sentinel events reported to The Joint Commission in 2006." Schyve points out that the alert identifies leadership as the governing board, the CEO, other senior managers, and clinical staff leadership. One of the themes of the alert is that these groups work collaboratively and are accountable for the organization's safety.
He acknowledges the theme is far from new and is "embedded" in the new leadership chapter that became effective Jan. 1, 2009, but The Joint Commission wanted to draw special attention to it.
"It's interesting in the alert to make the point that you have to make it clear that finances do not trump safety and quality. I find that part sort of amusing," Goodspeed says, "because in the overwhelming number of instances, high quality is actually lower cost."
He does praise the alert for its suggested actions, which mirror a lot of what the Massachusetts coalition has been pushing for years.
Among the suggestions are:
- building a code of conduct and holding staff accountable to that;
- constructing an organization-wide policy of transparency in which discussion is open and there is no fear of recriminations;
- making safety a measurable part of leadership's evaluation;
- continuously monitoring and analyzing adverse events and close calls;
- communicating to staff when their work improves the safety of the organization.
(For more suggestions, see alert at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_43.htm.)
Schyve says defining the code of conduct "requires actually defining the characteristics that they want to particularly have in their safety culture, including how they are going to do that, what kind of actions they will take, and specifically will the leaders take time to build the kind of trust that encourages reporting?"
Quality improvement leaders, he says, are integral in measuring the "culture's safety" and being involved in monitoring and analyzing adverse events and close calls to cultivate the continuation of safety.
Are hospital leaders more aware of quality and that they are intimately responsible for it these days? "I think there's a full spectrum," Goodspeed says. "More and more, thankfully, hospital leaders or the board or the CEOs do understand." He says that is becoming more and more the way leadership function. But, he admits, "there's a lot of leadership people in hospitals who don't seem to get it or have gotten at least to the point where they feel they need to give it lip service but not necessarily turn it into action. So this alert I'm taking as really being directed at those folks who aren't on board yet."
The Joint Commission issued its first sentinel event alert in August 2009. The issue: Leadership's role in committing to safety and promoting quality care.Subscribe Now for Access
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