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Establishing a Patient Safety Culture, Part One

Start with Juran’s trilogy and follow a four-phased plan

Published: Monday, June 11, 2012 - 10:36

Ensuring patient safety is one of the most vital and challenging roles in health care. Public reporting of preventable medical errors has forced hospitals to report their medical error numbers accurately and to improve the quality of care. Organizations such as the Institute of Medicine recommend that all health care professionals strive to create a culture of safety and report medical errors, without fear of retribution or blame.

The Joint Commission continuously strives to improve the safety and quality of care provided to patients by providing health care accreditation and related services that support performance improvement. It demonstrates its commitment to this effort through patient safety standards, national patient safety goals, the Sentinel Event Policy, and patient safety research.

Despite this emphasis, errors continue to occur. Human errors are often the result of an untimely combination of high-risk actions and high-risk conditions. By reducing human errors and process failures, health care organizations have achieved improvements in patient safety outcomes. The variation in results seen among these organizations depends heavily on the current state of their patient safety culture. An organization’s culture can be defined by its mission, vision, values, and leadership as well as physician commitment, accountability, and behaviors. The culture of the organization is described by the behaviors its members exhibit when no one is watching. Do caregivers truly place patient safety ahead of everything else, despite the current climate in health care?

The Juran Model for Patient Safety is based on the Juran Trilogy, a management approach that includes quality planning, quality control, and quality improvement. Originally developed by Dr. Joseph M. Juran for business management, it is now used as a scientific approach for patient safety. The health care model focuses on the three managerial processes of patient safety: planning, improvement, and control. The patient safety model is designed to help organizations create a strong safety culture by reducing human variation and performance, thereby reducing medical errors and serious safety events.

The Juran Model for Patient Safety can be implemented with a simple, four-phased patient safety road map. This provides the details necessary to assess, plan, improve, and control a comprehensive patient safety program. The approach begins by partnering with the organization’s patient safety officer and coaching him through each phase of the road map. The following questions should be asked and answered prior to launching or refining a patient safety program.

What are the patient safety program’s goals?

These should include improving the organization’s culture and process-improvement capabilities to provide reliable care and eliminate safety events. In contrast to quality improvement, where the goal is to provide the right care 100 percent of the time, the goals of a patient safety program are to achieve a target of zero on outcome measures such as avoidable sentinel events.

What are the program’s major components?

These can be described using the Juran Patient Safety road map and are divided into four phases: assessment, planning, improvement, and control.
Assessment. This includes a patient safety culture assessment, behavior-based observations, executive and staff interviews, and an incident-reporting system analysis.
Planning. This focuses on creating the optimal patient safety infrastructure, patient safety officer training, error prevention training, root cause and special cause analysis training, and basics of performance improvement.
Improvement. This includes implementing the error prevention techniques, red rules (critical rules for patient safety), event management, and performance improvement activities.
Control. This includes the safety coach program, the accountability “just culture” model, data management, team leader continuing education, and ongoing program evaluation.

What is the optimal infrastructure to support the initiative?

The optimal infrastructure to support the Juran Model for Patient Safety must consider committee structure, resources, event management process, policies and procedures, and data-reporting structure. The committee structure includes a high-level patient safety steering committee responsible for the strategic and patient safety plans. The midlevel quality committee is responsible for implementing the patient safety plan at the operations level. Organizations that have successfully followed the Juran Patient Safety road map have dedicated resources to ensure the progression of the program and the penetration of the initiatives to the frontline staff. The number and type of resources needed depends on the organization’s size and complexity.

The event management process describes how events are reported, the description of the event (e.g., sentinel event, serious safety event, or near miss), what investigation tools to use, and what follow-up and reporting are needed. The policies and procedures must describe the processes above and in most cases will need to be revised. Training should include techniques for error prevention and simulation through role playing.

The optimal infrastructure also includes governance and chain-of-command procedures in physician and nursing ranks to ensure professional development and learning across the organization.

How should patient safety performance measures be selected and targets established?

Measures describe the dimension, quality, or capacity of a process overall at a specific point in the process, at a specific point in time, or over a period of time. Improvement baselines and targets are created through measures and provide a common language and focus for the organization. Good measures take into account what outcomes are desired by process customers. Ask yourself and your customers what everyone is most concerned about, and translate the voice of the customer into critical-to-quality measures. The ideal unit of measure satisfies the following requirements:
Understandable. Vagueness becomes a natural source of divisiveness. Those who lack understanding of the unit of measure become suspicious of those who possess the understanding.
Provides an agreed basis for decision making. The greater the validity of the measurement, the greater the likelihood of buy-in and decision making.
Applies broadly. Measures of safety are widely used for comparative analysis. You will need to answer questions such as: Is our patient safety getting better or worse? Are we competitive with others? Which one of our operations is keeping our patients safer? How can we improve patient safety to the level of the best performer?
Is conducive to uniform interpretation. The unit of measure must be defined with adequate precision, also known as an operational definition.
Is economical to apply. A balance must be achieved between the cost of measurement and the value of having measures. The most basic question is whether it is worthwhile to measure at all. If so, the next question relates to the accuracy of the measurement. What level of accuracy is needed to make valid decisions?
Is compatible with existing sensors. Measurement of safety is simple if there are existing instruments that you can plug data into and read the result. However, you are often faced with creating new units of measure and new recording instruments.

To further complicate the process, measures can be classified as either lagging or leading. Lagging measures are reported infrequently, often too late to prevent a problem. Examples of organizational lagging measures include patient satisfaction, mortality, and medication errors. If lagging measures are selected, then break them down into dimensional measures, i.e., by division, department, and unit. This will allow one to discover where a problem exists.

More robust measures are leading measures, also referred to as process measures. Leading measures identify what drives a lagging measure, e.g., arrival time to seen by a provider in the emergency department. Leading measures explain why a problem exists.

Performance targets can be established from critical-to-quality customer requirements, benchmarks, historical trends, management objectives, or what management thinks it can control. The key is to reach agreement on the measures and communicate them down to the lowest level in the organization.

The patient safety officer is responsible for identifying safety performance measures. When selecting a measure, be sure it can actually be measured, that it drives the right behaviors, and that it is not picked just because it has always been measured. Keep measures to a vital few, assign a process owner to the measure, and decide who should have access to measurement data. Structured tree diagrams and flowcharts are helpful tools in identifying leading and lagging measures.

What is the board members’ responsibility in ensuring patient safety? What the patient safety officer’s role with the board?

Board members must fully embrace and endorse the transformational patient safety strategy because they bear ultimate responsibility for all services provided and outcomes achieved. In doing so, board members must own the duty to oversee patient safety with the same level of vigilance they have for strategic planning and hospital finances; otherwise, patient safety will not be positioned as a strategic imperative in the organization.

The patient safety officer must have complete access to the board at all times, and together they can shape a culture that promotes patient safety behaviors and improves patient safety outcomes. Only when patient safety receives the highest level of attention will the organization know it is a top priority.

Are there key strategies for engaging physicians?

The Juran Patient Safety road map requires not only physician support and engagement but also active physician participation during the assessing, planning, improving, and controlling phases. One key strategy is to identify physician champions in both leadership and nonleadership roles. It is also important that physician champions are respected by their peers, are in an administrative role, and have some authority over decisions that drive physician practice and accountability. Because physicians are scientists and have taken the oath of “do no harm,” sharing patient safety stories and providing sound data are key strategies to providing the burning platform for change.

If possible, encourage physician champions to be trainers for all physician groups. Physician compensation correlates directly with the time spent providing care, so when patient safety initiatives require time, a good strategy is to provide compensation or continuing medical education (CME) credits for project team, committee, or training meetings.

How are patient safety standards delivered systemwide?

The Juran Patient Safety road map can be used by small organizations and large, multihospital systems to achieve the same positive results. For large systems, it is important that each systemwide initiative is standardized and implemented consistently by each individual facility. In addition to providing the necessary resources at each facility, such as a patient safety officer, each facility must have a role in the planning process. This can be easily accomplished by making sure that all facilities have membership on the high-level patient safety steering committee and have a leadership role on the facility or midlevel quality committee. Committee structure, accountability, and standardized initiatives provide the optimal road map to systemwide improvement.

What do we do if performance lags or moves in the wrong direction?

According to Juran, there are two types of phenomenon that keep organizations from hitting their performance targets: chronic problems (common cause) and sporadic problems, or spikes (special cause). When processes in control trend or when control limits shift in the wrong direction (common cause), process improvement tools such as root cause analysis should be used for small or medium gains, and lean and Six Sigma tools should be used for significant breakthrough improvement. When a spike occurs in a process (e.g., sentinel event, special cause), then root cause analysis should be used for sentinel events and/or complex failures, and special cause analysis should be used for serious safety events and near misses. Using the right tools for the right type of problem in conjunction with the event management process ensures a proactive approach to problem solving.

How will safety information and performance results be communicated?

One important strategy in patient safety is partnering with patients, families, and the community. The key themes for this are awareness, education, and participation. Health care organizations should always provide multimedia education outlining why certain practices are performed in the hospital (e.g., site-marking, positive patient identification, hand hygiene, the five rights).

The Juran Patient Safety Model encourages patient and family participation by asking them to remind caregivers to perform the basic patient safety practices, such as hand hygiene and positive patient identification, as a form of peer accountability. Being transparent about patient safety data is vital to improving the organization’s safety culture. It also helps organizations learn from mistakes.

In conclusion, the patient safety officer, along with the leadership team and board, are responsible for creating the organizational culture of patient safety. This requires that patient safety be a critical component of the organization’s strategy and operational plan. The patient safety officer must provide support at every level of delivery and reinforce the behavioral expectations to promote the safety of patients, families, staff, and all customer groups. The ultimate goal is to create a culture where all members of the organization always place patient safety as the highest priority in their hearts, minds, and actions because our patients will always be worth it.


About The Authors

Mary Beth Edmond’s picture

Mary Beth Edmond

Mary Beth Edmond is an executive vice president and senior nurse executive with Juran Healthcare, as well as a lean Six Sigma Black Belt. She assists clients in designing and implementing enterprisewide quality assurance systems, quality improvement deployment strategies and plans, business process management, enterprisewide patient safety programs, lean Six Sigma coaching and project support, and organizational performance assessments.  Edmond has 40 years of healthcare experience in nursing and consulting for community hospitals, academic medical centers, and ambulatory surgical centers.


Jonathan Flanders’s picture

Jonathan Flanders

Jonathan Flanders is a vice president and patient safety executive with Juran Institute specializing in the implementation of business transformation management, patient safety, and Lean and Six Sigma. His specific areas of knowledge and expertise include emergency departments, laboratory, revenue cycle, medication management, surgical services, outpatient clinics, inpatient throughput and flow, and core measure performance.