The Lessons of Patient Safety Mindfulness

Some people say that attaining a high level of proficiency in the core standards of patient safety helps you develop a patient safety mindset. I like that idea, but I prefer to think of it as patient safety mindfulness.

Patient safety mindfulness means understanding that there is no quality without patient safety at its core. It means putting attention in the right places. Many health systems focus a lot of their energy on special programs they want to develop, centers they want to open, or new technologies they want to bring online.

Those things can be exciting. They get headlines in the newspaper. But, if we’re not careful, they can also be distractions.

We don’t have anything if we don’t have safety. None of those exciting things are doable without the safest care possible for our patients. Good, sound operations help us create the system that keeps people safe.

Seeing with Fresh Eyes

As a physician leader with an operations role, I found myself over the years frequently turning to IHI resources (such as A Framework for Safe, Reliable, and Effective Care) and bringing insights I gleaned from those resources to my team. Then, a mentor of mine who is a senior leader in another organization suggested I work toward the Certified Professional in Patient Safety^TM credential (CPPS). I have immense respect for him, so his endorsement spurred me to do it.

In some ways, studying the five patient safety domains (culture; leadership; risks and solutions; measuring and improving performance; and systems thinking and design/human factors) for the CPPS exam reinforced what I already knew. In other important ways, it made my understanding more robust. Looking back, I know that in the past, opportunities or threats to patient safety did not stand out to me as they do now.

In my work to continuously raise the quality of the radiation oncology services entrusted to my team, I’ve learned a few lessons about patient safety mindfulness that might be useful for others:

• Strive for unity of purpose. If you have a system of actors and goals, sometimes the only way to get anything done is to have a clear animating aim. Everybody who’s an actor in that system needs to know the aim and the aim should be meaningful to all. One example of this was when I led the creation of institutional standards for the management of spine metastases to eliminate unwarranted variation. No one is compelled to follow the institutional guidelines we created. However, I persuaded the various parties to “sign on” by putting the patient at the center. I emphasized that reducing unwarranted variation would improve the quality of the care we deliver, reduce the risk in the system, and achieve predictability of patient outcomes. Getting people to focus on building a quality program moves them more than the next quarter’s revenue projections or relative value unit (RVU) bonuses.
• Improve safety to increase value for patients and systems. I was charged with the operational redesign of a set of services in our cancer program. While generating the value process map of all the services the patient traverses, I noticed numerous substantial risks to patient safety which frequently resulted in emergency department visits and admissions. We rapidly tested innovations to reduce these risks and incorporated successful solutions into our standard work. The result was substantial improvement in safety and value both for the patient and for the health system by driving down the costs associated with repeat ER visits and costly readmissions.
• Engage those closest to the point of care in improvement. Patient safety rounds are part of my standard work as a leader. The most exciting change that I’ve seen over time is that our frontline team members now have a strong sense for risks to patient safety and they have become the best source of winning ideas to mitigate these risks.

We provide medical care in a world that is often chaotic and full of many potential defects. We risk harming patients. Processes don’t go as they should. Patients aren’t satisfied with their care experience. If you’re charged with running a department, a set of clinics, or an entire health system, patient safety mindfulness means preventing harm is at the forefront of everything you do.

Anthony Paravati, MD, MBA, CPPS, is Clinical Director, SRS/SBRT Services, Department of Radiation Oncology at Kettering Health Network.