A panel of patient safety experts recently found that a “systems approach” is necessary to ensure patient safety in hospitals and other health care organizations. An article published late last year in the industry newsletter FierceHealthcare summarized findings of a new report from the National Patient Safety Foundation (NPSF).
The December 2015 report, follow-up to the NPSF’s groundbreaking 1999 report “To Err is Human: Building a Safer Health System,” publishes findings of an expert panel on patient safety convened by NPSF early in 2015 and co-led by Dr. Donald Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement. The panel’s charge was reportedly to “assess the state of the patient safety field and set the stage for the next 15 years of work.”
Summarizing the findings, FierceHealthcare Executive Editor Ilene MacDonald writes that the new NPSF report finds necessary “a total system approach and a culture of safety” to combat medical errors and adverse events. A total system approach. Surely that resonates with those of you who are already adherents of the Baldrige Excellence Framework (which includes the Health Care Criteria for Performance Excellence). Systems perspective is the first of 11 core values and concepts described in the Baldrige Program’s 2015–2016 Health Care Criteria for Performance Excellence. Those core values and concepts serve as the “foundation for integrating key performance and operational requirements within a results-oriented framework that creates a basis for action, feedback, and ongoing success” (page 39).
The Baldrige framework’s other 11 foundational and interrelated core values and concepts are visionary leadership, patient-focused excellence, valuing people, organizational learning and agility, focus on success, managing for innovation, management by fact, societal responsibility and community health, ethics and transparency, and delivering value and results.
The Baldrige Performance Excellence Program, which produces the Baldrige Excellence Framework (health care version), defines systems perspective as “managing all the components of your organization as a unified whole to achieve your mission, ongoing success, and performance excellence.” According to the full definition in the booklet’s glossary, “Successfully managing overall organizational performance requires realization of your organization as a system with interdependent operations. Organization-specific synthesis, alignment, and integration make the system successful.”
As described further in the Baldrige framework booklet, when a health care organization takes a systems perspective, its senior leaders focus on strategic directions and on patients and other customers. They monitor, respond to, and manage performance based on the organization’s results. With a systems perspective in place, a health care organization uses its measures, indicators, core competencies, and organizational knowledge to build its key strategies, link these strategies with its work systems and key processes, and align its resources to improve the organization’s overall performance and its focus on patients, other customers, and stakeholders.
So health care organizations that have adopted the Baldrige Excellence Framework to manage their performance in and across all areas already have “a total system approach” in place. Baldrige organizations are thus in optimal position to achieve good and ever-improving patient safety results. How is your health care organization improving patient safety?