Issue link: https://beckershealthcare.uberflip.com/i/824946
11 PATIENT SAFETY Joint Commission: Healthcare Leaders' Failure to Create Safety Culture Can Lead to Adverse Events By Brian Zimmerman T he Joint Commission issued a Sentinel Event Alert March 1 calling on health- care leadership to make forming an effective safety culture a top organizational priority. A safety culture is the cumulative effort of an organization to keep patients safe from avoidable errors. e failure of healthcare leaders to create sustainable and effective safety cultures within their respective organi- zations is contributing to adverse events like wrong-site surgeries and treatment delays, according to the alert. "A strong safety culture begins with leader- ship; their behaviors and actions set the bar," said Ana Pujols McKee, MD, executive vice president and CMO of e Joint Commis- sion, in an email release. "I urge all healthcare leaders to make safety culture a top priority at their healthcare organization. Establishing and improving safety culture is just as critical as the time and resources devoted to revenue and financial stability, system integration and productivity — because a lack of safety cul- ture can have serious consequences for pa- tients, staff and other stakeholders." Here are 11 tenets outlined by e Joint Commission to aid healthcare leaders in es- tablishing a safety culture. 1. Encourage provider reporting and com- munication around errors by establishing a non-punitive, educational approach to ad- dressing avoidable medical errors. 2. Develop processes to properly distinguish between human errors and errors indicative of systemic shortcomings. 3. Make efforts to eradicate intimidating be- haviors in the workplace in regards to errors. Appropriate behaviors should be modeled from top executives down. 4. Communicate and properly enforce estab- lished policies designed to eliminate errors. 5. Recognize care team members who iden- tify errors and offer suggestions to improve protocols. 6. Establish an organizational baseline mea- sure to assess safety performance. 7. Disseminate safety culture surveys through- out the organization and analyze them properly to identify improvement opportunities. 8. Use safety assessments to develop unit- based quality and safety improvement initia- tives. 9. Embed team training for improved safety into the safety culture. 10. Assess the strength and vulnerabilities of system tools like the EHR and prioritize im- provements for these tools. 11. Conduct an organizational assessment of safety culture every 18 to 24 months to track progress and ensure the sustainability of the culture. n To Shorten Hospital Stays and Save Money, Train Patients Before Surgery By Brian Zimmerman R esearchers with Michigan Medicine in Ann Arbor have developed a pre-surgical training program for patients, which may concurrently reduce the length of hospital stays and costs associated with inpatient ad- mission. The third study assessing the program — dubbed the Michigan Surgical Home and Optimization Program — was published in the journal Surgery in February. For the study, researchers asked patients walk every day and self-mon- itor physical activity. Most patients were asked to log 12 miles of walking per week. They were given pedometers to monitor the distance they traveled. A total of 641 patients who underwent major elective gen- eral and thoracic surgery between June 2014 and Decem- ber 2015 enrolled in the study. Approximately 82 percent reported active engagement in the program. An analysis of care outcomes found active participation in MSHOP to be associated with a 31 percent reduction in the duration of hospital stay and a 28 percent overall reduction in costs. "We do a lot in medicine to get people ready for sur- gery, but they're primarily administrative tasks — check- ing off boxes that don't necessarily make a patient bet- ter," said Michael Englesbe, MD, transplant surgeon with Michigan Medicine who has studied and championed the philosophy behind the MSHOP program for close to 10 years. "The more you can do to manage your status preop- eratively, the quicker you'll be able to bounce back." Since the program was established five years ago, it has been implemented at more than 20 hospitals and 30 prac- tices across Michigan. n