Searching for ways hospitals can ‘do no harm’

Collaborative efforts among researchers from Vanderbilt's Owen Graduate School of Management and the Medical Center point to the need for significant workplace changes in health care facilities.

After a landmark study in 1999 showed that medical mistakes caused nearly 100,000 deaths and over a million injuries in the United States each year, health care organizations rushed to adopt new safety processes and procedures.

But a new article in the New England Journal of Medicine suggests that those efforts have led to little or no improvements. Reporting on the findings, The New York Times writes, “About 18 percent of patients were harmed by medical care, some more than once, and 63.1 percent of the injuries were judged to be preventable. Most of the problems were temporary and treatable, but some were serious, and a few -- 2.4 percent -- caused or contributed to a patient’s death.”

Publication of the study caused a stir among health care organizations, and put a spotlight on efforts to continue searching for organizational changes that could help limit medical errors.

Several researchers from across Vanderbilt University are looking for new ways to improve patient safety. In mid-December Julie Morath, Vanderbilt University Medical Center’s Chief Quality and Safety Officer, arranged a two-day roundtable at Vanderbilt focused on the need for restoring joy and meaning in work to advance workforce and patient safety in health care. This event is part of a series of roundtables on transforming health care chartered by the Lucian Leape Institute (LLI) of the National Patient Safety Foundation (NPSF).  Julie Morath is a founding member of LLI and a member of NPSF’s board of governors.

Ranga RamanujamThe roundtable at Vanderbilt brought together leading figures from health care, business, and academia, including former Treasury Secretary and Alcoa CEO Paul O’Neill. Vanderbilt Owen Graduate School of Management Dean Jim Bradford also took part in the discussions, as well as Owen professors Ranga Ramanujam and Tim Vogus, both of whom study operational issues focused on safety in health-careTim Vogussettings.

Ramanujam says the wide-ranging discussion centered on what it would take to establish meaningful work and employee safety as preconditions to creating cultures of excellence and eliminating harm in medical care. As a follow up to the roundtable, Vogus and Ramanujam are enlisting MBA students at Owen to gather data for a white paper that will lay out an agenda for research and action. The participants at this roundtable plan to reconvene in June 2011 to advance this agenda.

Ramanujam says the wide-ranging discussion centered on the connection between employee safety -- taking into account issues like burnout among medical staff -- and patient safety. He is now working with Vogus and several MBA students at Owen to gather data for a white paper summarizing the main points that emerged out of the event. The group plans to meet again in Boston in June 2011.

In the meantime, Vogus just published one of the first papers to examine the need for cultural changes within hospitals in the November 2010 issue of Academy of Management Perspectives. Vogus and his co-authors from the University of Michigan lay out a comprehensive three-prong framework of how to create a safety culture in the complex health care environment.

“In health care, a safety culture encompasses the shared values, attitudes and behavioral norms that every member of the organization needs to focus on to minimize patient harm,” Vogus says.

Three ways to create a safety culture in health care

Vogus and his co-authors find that there are at least two ways in which health care leaders enable safer practices on the front line. First, by directing attention to safety through personal example and organizational practices, so subordinates actually see certain actions that lead to a safer environment.

Secondly, by creating an atmosphere where practitioners feel safe to speak up and report medical errors without fear of recrimination.

Enacting is directly connected to communication and repeating safety guidelines until they become meaningful practices. Missing or withheld information means that frontline caregivers lack the tools to detect and make sense of an emerging threat to safety and limits their ability to pursue an alternate course of action that could help a patient.

“Enacting a safety culture relies on the willingness of frontline employees to communicate about potential sources of error and unsafe conditions, to disclose errors and near misses, and to transmit their concerns upward in the organization,” Vogus says.

Once a safety culture has been enabled and enacted, it’s time for health care leaders to refine safety practices and expand the initial set of safety practices.

“When elaborating is focused on patient safety, two themes emerge: the centrality of reflection and the centrality of feedback,” Vogus says.

Why is it so hard to improve safety in hospitals overall?
Research by both Vogus and Ramanujam finds that medical culture tends to focus on the autonomy of individual departments and practitioners, instead of the hospital or health care facility as a whole. This makes it nearly impossible to make across-the-board changes at hospitals nationwide.

Ramanujam believes that the health care industry’s inability to embrace innovation prevents organizations from implementing key quality improvement measures. “The professional culture of medicine contributes to the incomplete, ineffective and piecemeal implementation of otherwise promising technological processes, such as electronic medical records or computerized physician order entry, resulting in a minimal impact on safety,” Ramanujam says.
Unlike other environments, in a health care setting the manager does not have final authority to implement a change -- the doctor or other medical professional ultimately decides whether or not to try a technical innovation.

“Since a medial professional’s strongest belief is to help a patient, or at least ‘do no harm,’ they are often reluctant to try something new,” Ramanujam says. “Avoidance is a natural response when a behavior like innovation implementation threatens deeply held norms. “

Published Jan 21, 2011 in Vanderbilt Business Intelligence
Copyright 2011 Vanderbilt Owen Graduate School of Management