March 13, 2017

The fact that 125,000 fewer patients died due to hospital-acquired conditions in 2010-2015, resulting in a cost savings of more than $28 billion, shows healthcare’s capacity for large-scale improvement. Anesthesia’s long history of safety improvements and innovations includes some significant recent safety gains as well.  The percentage of anesthesia-related adverse events dropped from 11.8 percent to 4.8 percent of procedures between 2010 and 2013, according to the Anesthesia Quality Institute’s (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) of more than 3.2 million anesthesia cases.

Despite encouraging results like these, healthcare organizations still face a daunting array of hurdles, ranging from the growth of antibiotic resistance to new diseases and outbreaks to sepsis prevention. As part of that larger picture, anesthesia practitioners wrestle with their own set of serious perioperative safety issues, including everything from opioid-related respiratory depression to medication errors (the most common serious complication, according to NACOR).

Healthcare organizations’ ability to tackle safety problems and protect patients rests largely on the creation of an organizational culture that lives and breathes safety, and “without concerted and ongoing efforts by senior leaders to exemplify and cultivate that culture, the organization cannot change,” Ana Pujols McKee, MD, executive vice president and chief medical officer of The Joint Commission (TJC), said in a 2015 article in Healthcare Executive.  The same holds true for anesthesia leaders and practices.

As Charles E. Cowles, Jr., MD, MBA, put it in the June 2016 issue of the Anesthesia Patient Safety Foundation newsletter, “Leaders should be chosen based upon how they foster the safety culture.”

TJC recently reiterated its belief in the essential role of leadership in developing a safety culture in a Sentinel Event Alert.  “In any healthcare organization, leadership’s first priority is to be accountable for effective care while protecting the safety of patients, employees and visitors,” the Alert stated. “Competent and thoughtful leaders contribute to improvements in safety and organizational culture. They understand that systemic flaws exist and each step in a care process has the potential for failure simply because humans make mistakes.”

The Alert puts forth 11 Tenets of a Safety Culture (see summary below), all of which depend on active and sustained leadership support and participation. Although none of these ideas are anesthesia-specific, all of them can be readily adapted and used in your practices and surgical suites, in your safety initiatives with other departments and in partnerships with clinical and nonclinical senior executives.

High Reliability

When leaders don’t take full ownership of safety and exemplify it in words and actions on a daily basis, team members begin to see safety as “the flavor of the month” rather than as a core value that must permeate everything they do—and this complacency causes lapses and errors, healthcare consultant Steve Kreiser said in the Healthcare Executive article.

Kreiser noted that the key to creating a high-reliability safety culture—like those of high-performance industries with impeccable safety records, including aviation and nuclear energy—is balancing the need to hold people accountable when it is appropriate with a supportive environment that gives individuals and teams opportunities to learn from their mistakes.  “If you can establish clarity between the two, you will eliminate many errors,” he said.

TJC cites research in the Alert showing that the most effective safety culture is:  1) a just culture in which people are encouraged, even rewarded, for providing safety-related information, while distinguishing between human error and recklessness; 2) a reporting culture in which people report their errors and near misses; and 3) a learning culture based on willingness to use safety data to learn and implement improvements.

Specifically, a safety culture is one in which leaders and organizations:

1. Use a transparent, non-punitive approach to reporting and learning from adverse events, close calls and unsafe conditions.  This includes establishing an easy-to-use reporting system that is accessible to everyone.
2. Use clear, just and transparent processes to recognize and differentiate human errors and system errors from unsafe, blameworthy actions.  TJC cites the Incident Decision Tree developed by the United Kingdom’s National Patient Safety Agency as a model.
3. Adopt and model appropriate behaviors and champion efforts to eradicate intimidating behaviors.  Leaders should participate in safety improvement activities, implement safety-related feedback from staff as appropriate, and support fair and equitable accountability for all.
4. Develop policies that support a safety culture, enforce these policies and communicate them to all members of the care team.
5. Recognize team members who report adverse events and close calls, identify unsafe conditions and suggest ways to improve safety; and create a “feedback loop” that shares these “free lessons” with all team members.  TJC’s safety culture project identified shift and unit huddles and visual management boards as effective methods for providing feedback.  The project also found that when they didn’t receive feedback from leaders, team members stopped making suggestions.
6. Determine an organizational baseline measure on safety culture performance using a validated tool.  TJC suggests using the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture or the Safety Attitudes and Safety Climate Questionnaire.
7. Analyze safety culture survey results from across the organization to identify ways to improve quality and safety.  Data should be analyzed at the unit level and then shared across the organization with frontline team members and the board of directors.
8. Use safety assessment data and surveys to develop and implement unit-based quality and safety initiatives and strengthen the safety culture.
9. Embed safety culture team training into quality improvement initiatives and processes.  TJC recommends the Oro™ High Reliability Organizational Assessment and Resources as a tool to improve safety performance in high-risk areas, including the operating room, emergency room and intensive care unit.
10. Assess system strengths and weaknesses and prioritize them for improvement.  These include medication management systems and electronic medical records.
11. Repeat safety culture assessments every 18 to 24 months to review progress and sustain improvement.  Drill down to individual units, incorporate the results into strategic planning and report the results to the board.

A recent article in ASA Monitor proposed the creation of a new position in the OR—patient safety officer—that echoes many of the principles in TJC’s Sentinel Event Alert.  The safety officer’s role is to maintain a culture of safety, improve care through leadership and education, and enlist all care team members in creating a just culture—all with buy-in and support from senior executives.  “The role of the safety officer is to be a thought leader whose focus is preemptively creating an environment where adverse events are less likely through education and team-building.  When an inevitable crisis does occur, individuals and teams are more likely to be successful if there is a member of the team whose sole focus is safety,” according to the article.

The intense efforts by hospitals and anesthesia practices to improve patient safety have yielded impressive results in many areas, but, as all of you who practice anesthesia know, there is still work to be done.  Leaders—including those in anesthesia—who demonstrate commitment to safety in their behavior and decisions, foster an environment that supports learning and improvement, and cultivate an atmosphere of trust and respect will see the most promising results.

With best wishes,

Tony Mira
President and CEO