The Quality-Cost Connection: Develop a patient safety management system

Focus on gaining widespread support

By Patrice Spath, RHIT
Brown-Spath Associates
Forest Grove, OR

The establishment of a patient safety program, will not, in itself, necessarily result in "perfect" compliance with all critical human actions or an immediate reduction of adverse patient incidents. Care must be taken to ensure that the mere establishment of a patient safety program does not lull the organization into a false sense of safety. Effectively used, patient safety management (PSM) should enable a health care organization to improve its safety performance and avoid or reduce adverse events over time.

A heavy emphasis on formal procedures, excessive documentation, and record keeping may cause priorities to become misplaced.

The focus should be on gaining widespread support, planning effectively, defining roles and responsibilities, providing valuable training, and improving communications. This should involve reasonably frequent feedback loops to physicians and staff. This last in a series of three articles addresses the final phase of PSM: measuring, checking, and corrective action and leadership review. Checking and corrective action include monitoring and measuring critical patient care activities to assess performance and conducting audits and assessments. Corrective action is taken in the event that specified practices are not followed or in response to incidents. Administrative and medical staff leaders must periodically review the results of monitoring and corrective action procedures to ensure the suitability, adequacy, and effectiveness of the patient safety program. The PSM framework should allow the organization to achieve and systematically control performance that affects patient safety.

The questions in the Patient Safety Management Self-Assessment Tool are to be used to rate the last PSM phase in your organization.

The questions can be used to identify to what extent your measuring, checking, and corrective action activities conform to the generally agreed upon fundamentals of an effective program.

Consider the examples provided for each score in ranking your organization. A space is provided beneath each element to record your score.

Next steps

When you have completed the checklists found in this series of three articles, there are many different actions you can take depending on the results.

Don’t focus too much on the scores themselves; the numbers are intended mostly as a guide to help you do the following:

  1. gauge your relative position;
  2. focus on discrete program elements;
  3. facilitate discussion and support learning throughout the organization;
  4. prioritize patient safety program improvements.

First, take a careful look at your organization’s results and consider these types of questions:

  • Are there specific PSM elements with a low score that need attention?
  • Do you need to work on several elements or perhaps even all the elements?
  • Is there a logical starting point? Are there certain elements or sub-elements that present a high risk and need immediate attention?
  • Should you prepare a written "action plan" with specific tasks, assignments, and a schedule based on available resources and priorities?

Build upon existing systems whenever possible. For example, if you have an old environmental safety policy, consider updating and expanding that policy. Likewise, use existing safety or quality-related committees, manuals, or procedures as a starting point, if possible. Don’t reinvent the wheel.

Although each health care organization is unique, other facilities may have addressed many of the same issues you are now facing. See what other organizations are doing by speak directly with those responsible for patient safety in other health care facilities. Effectively used, a PSM system should enable a health care organization to improve patient safety and reduce adverse events over time.