Enabling Practice Leaders to Reduce Patient Harm through “System-Base Practice and Practice-Based Learning and Improvement”

Background: Healthcare organizations regularly face new challenges. Their leaders must be adaptive through systematic approaches. These approaches must meet three basic needs: 1) facilitation of workflow/process/task assessment and improvement; 2) creation of high reliability organization; and 3) respect of each practice as a special part of the total healthcare system. The US Institute of Medicine has called for higher quality at lower cost through “leadership that fosters continuous learning”. Retrospective methods are currently the most commonly used. These reveal only the tip of the iceberg of the total harm. The US Inspector General takes the view that the “current methods of detection of adverse events are inadequate”. Recommended Approach: An innovative prospective process is put forward. It fosters empowerment and ownership, eventually leading to high reliability practices. Conclusion: This approach is shown to be effective in measuring safety state in a practice and reducing patient harm. Could this be the “better way” that the Inspector General is seeking? Our experience with this approach in the domains of medication safety, falls safety, postoperative pain, and assessment of effects of HIT introduction has demonstrated that it also promotes core competencies of “system-based practice and practice-based learning and improvement” in staff.