THE QUALITY - CO$T CONNECTION

Maintain accountability in patient safety efforts

Make sure each person fulfills responsibilities

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

Focusing on a blame-free environment to promote a culture of patient safety is important; however, it also can have an unintended and undesirable effect on accountability.

Hospitals have ultimate responsibility for the safety of patients, and everyone in the organization must share responsibility for certain elements of safety. An accountability system is essential if all the hard work and effort you spend in designing safer patient care processes is not to be lost. Accountability must be inherent in any patient safety improvement effort.

The aim of a health care organization’s system of accountability is to ensure that each person fulfills his or her responsibilities. An effective accountability program teaches managers, supervisors, and staff to take personal responsibility for their actions and the subsequent effect of these actions on the patient.

The purpose of an accountability program is to help all employees understand how critical their performance is to the safety of patients and to teach them how to minimize the risk of errors. Accountability ensures your patient safety improvement program is not just a paper tiger with no real power to achieve improvement goals.

Set departmental objectives

Patient safety improvement objectives for departments should be based upon performance measures. These are indicators that tell you whether the person or department performed as expected. The following considerations will help you set reasonable objectives:

Aim your objectives at specific areas of performance that can be measured or verified.

"Improve patient safety in my department next month," is too general an objective to be useful. A better objective would be, "Reduce patient falls by 10% over the next month." Even more measurable are those objectives over which the manager or supervisor has complete control, such as, "Hold 30-minute patient safety meetings for all employees in my department every Monday afternoon."

Objectives should be realistic and attainable but also should represent a significant challenge.

— Appropriate authority is necessary. Example: A patient safety director’s objective to reduce medication administration errors is not directly attainable, because achievement is dependent on the performance of the nurse managers and staff members. An objective to determine specific patient safety training needs for members of the nursing department, develop the training, and notify supervisors of its availability is within the bounds of the patient safety director’s authority and, therefore, is achievable.

— Adequate training is necessary. Example: A supervisor’s objective is to investigate all near-miss incidents that occur in his/her unit and ensure future prevention. This objective may be unattainable if the supervisor has not received training in incident investigation and process improvement techniques.

— Appropriate resources must be available. Example: A manager’s objective is, "Ensure that all equipment is safe to operate." That objective will be unattainable without an appropriate budget for replacement parts and capital improvements. Similarly, if the housekeeping supervisor is held accountable for clean nursing unit areas at the end of each day shift but is not given enough staff to complete all tasks and finish the cleanup, an objective of clean nursing areas at day shifts’ end will be unattainable.

Objectives need to be understood by all concerned parties.

Use clear, understandable language that leaves no doubt what someone is required to do. Example: An objective is, "Investigate near-miss incidents to determine multiple causation." This may be unclear to a supervisor. "Investigate near-miss incidents to determine all causes and take corrective action within 48 hours of the accident," is a clearer, more specific objective.

Objectives should be agreed to by those with responsibility for achieving them.

Even when managers and staff appear to agree on most issues, it is important for managers to openly discuss patient safety performance objectives and secure staff agreement or cooperation. Give a copy of the performance objectives to employees and incorporate them into future performance discussions with employees.

Determine the safety role of positions

What role do you want each position or group of positions to play in your patient safety program? What level of authority will the person holding this position need? While authority is built into managerial and supervisory positions, you may want to make changes specifically relating to your patient safety program.

Here are some examples of patient safety roles:

The board and CEO: Establish and provide the leadership and resources for carrying out the stated patient safety policy.

Managers and supervisors: Maintain patient-safe conditions within their respective jurisdictions.

Employees: Exercise care within their work area to prevent errors and unintended patient harm.

Vendors and subcontractors: Comply with all patient safety requirements while on the premises.

Some individuals may have some additional general duties. For example:

Patient safety department: Be fully responsible to the CEO (or other senior leader) for the direction and day-to-day operation of the patient safety program.

Biomedical engineering: Ensure all biomedical equipment that could affect the safety of patients is selected, installed, and maintained in a way that eliminates or controls potential hazards.

Purchasing: Ensure equipment and supplies are purchased in a timely manner and new supplies and equipment are analyzed for potential patient safety hazards so preventive measures or controls can be implemented.

It may be useful to combine all these written statements of patient safety responsibilities into a single document, then post it or circulate it to all employees involved. Discuss the responsibilities in face-to-face meetings with the staff members who will be responsible for meeting the expectations. Keep a copy of this document and periodically refer to it when meeting with individuals for performance reviews.

Review performance

Managers periodically should review the patient safety performance objectives to make sure the desired performance and results are being achieved. For instance, if a supervisor meets the objectives but the department continues to have too many incidents, too many close calls, or no improvement in safe outcomes, then the objectives need to be revised. Performance evaluation can be verbal, written, or both.

An effective evaluation will include the following critical elements:

It should be performed at specified intervals.

As managers and staff become accustomed to working toward defined patient safety performance objectives, the intervals between evaluations can be lengthened. The evaluation can become an opportunity to provide encouragement and refresher training.

The evaluation always should be performed against a backdrop of previously defined patient safety objectives.

There should be no surprises to the person being evaluated regarding what was expected. Should problems develop, it may be necessary to modify the objectives to ensure they are understandable, measurable, and achievable.

Ideally, the evaluation is an opportunity for exploring ways of improving both the system and the performance of the individuals in the department.

Negative attitudes, such as refusal to listen to one another, animosity, blaming one another, or fear and intimidation will limit the evaluation’s usefulness.

The goal of evaluation should be to encourage personal responsibility and the individual’s efforts toward improving the safety performance of the team.

Give positive reinforcement for a job well done.

If the evaluation determines that patient safety performance did not meet expectations, changes must be made.

Sometimes, the required changes will be obvious. In other cases, it will be necessary to carefully explore the reasons for the objective not being met and discuss possible solutions.

Perhaps the wrong person was assigned a particular responsibility.

A simple change in assignments may alleviate the problem. Perhaps the level of authority of the assigned person needs to be increased.

The objectives themselves may need to be modified and employees helped to develop capabilities or skills that they do not presently possess.

There must be a point where some predetermined consequences for unacceptable patient safety performance begins.

Some task monitoring may be necessary to support the performance evaluations. For example, monitor a supervisor’s investigations after each near-miss incident until it is clear that the supervisor has developed the necessary evaluation and process improvement skills.

Set consequences

Consequences need to be appropriate to the situation. Firing a manager for the first poorly conducted near-miss incident investigation is an obvious example of overreacting to a problem. Gradually, though, the consequences of poor performance should be increased. One common disciplinary system consists of:

1. verbal warning;
2. written warning;
3. suspensions;
4. (as a last resort) termination.

Eventually it may be evident that an individual is not capable of handling the assigned patient safety responsibilities, and the maximum degree of consequence must be enforced. Otherwise, other employees will conclude that consequences for unsafe acts or failure to adhere to performance expectations are not to be taken seriously or do not apply equally to everyone.

That belief among managers and staff will destroy any chance for an effective patient safety accountability program.