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Leadership Sentinel Event Advisory

Patient Safety Quality Monthly, September 24, 2009

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Last month, The Joint Commission issued a Sentinel Event Alert titled "Leadership Commitment to Safety." You all know how important the commitment of your leadership team is, and you've probably been fighting to develop it for as long as you have been in the safety and quality area. Some of you may be winning the battle—we are starting to see some strong dedication in some facilities—but the need for all the leadership teams to get committed is strongly stressed in this advisory. So how should you use this advisory to help move your organization?

First, make sure people know about it. This is a more general advisory. It is focusing on a deep underlying cause, not a specific set of events. This makes it a little more difficult to get it into play, but if no one reads it, it is not going to help your organization!

Second, plan a strategy. The advisory lists 14 suggested actions. Although these 14 items are a great place to start building your strategy, they are still a bit general.

Below are some specific suggestions for how you can try to get the broader suggestions into play. Each of these suggestions is coded to the 14 suggested actions.

1. Make sure you have a clear safety goal that is endorsed by the board and leadership. Test this by asking, "Would I like that on the banner over the front entrance?"
2. Make sure all key leaders know how many significant events happen in your facility. If you ask the board, senior leadership, directors, managers, and frontline staff members, "How many significant events have happened here in the past two years?" and you get radically different answers, you know you may not have good transparency.
3. Develop your performance algorithm. Make sure it includes both reporting and harm. Strive for an increase in number of reports with a decreasing severity.
4. Refocus your cause analysis and prevention from regulatory response tools to business tools. Cause analysis should be just a normal part of the business.
5. Set simple expectations for safe behaviors. Everyone should know them by heart. Yes—everyone, clinical, nonclinical, leadership, and physicians.
6. Set some simple expectations for your data and trends. Make sure you can answer the four simple questions: magnitude, direction, variability, and rate of change. Aggregate, aggregate, aggregate!
7. Get your risk and event data out to the trenches. Let the front lines and the management ask questions about the events and trends—don't just push the graphs and data out to them.
8. Prioritize through a master list. If you don't have all your quality and performance improvement projects on a master list, leadership can't and won't get involved. One master list means projects will get looked at and prioritized—even those we don't want looked at. But if we want leadership commitment, they have to know where we are spending our efforts.
9. Get physicians involved. Make sure they see the benefits to their patients and practice. Don"t assume they will unless you work with them to identify the benefits to THEM.
10. Encourage the voice of the patient. I was at a hospital as a patient last week, and there was plenty to see and talk about with the staff members who were helping me. Make sure you have a process to really listen.
11. Quality management stresses the front lines—get them involved in mapping your processes so you see the real "as is" way you are doing things.
12. Use the results of your culture of safety survey. It can tell you a lot about your culture. Set some goals for change. Compare the leadership responses to the front lines—bet they don't look the same.
13. Notice and comment! If no one notices, nothing will change!
14. Notice and comment! If no one notices, nothing will change!

Ken Rohde 09/24/09

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