Published 5/1/2010
Barry C. Dorn, MD, MHCM

Patient safety and risk management

Kim, aged 3 years, lays asleep, waiting for a miracle. Outside her room, the nurses on the night shift pad softly through the half-lighted corridors, stopping to count breaths, take pulses, or check the intravenous pumps. In the morning, Kim will have her heart fixed. …

Kim will be fine if the decision to operate on her was correct; if the surgeon is competent; if that competent surgeon happens to be trained to deal with the particular anatomic wrinkle that is hidden inside Kim’s heart; if the blood bank cross-matched her blood accurately and delivered it to the right place; if the blood gas analysis machine works properly and on time; if the suture does not snap; if the plastic tubing of the heart-lung machine does not suddenly spring loose; if the recovery room nurses know that she is allergic to penicillin; if the “oxygen” and “nitrogen” lines in the anesthesia machine have not been reversed by mistake; if the sterilizer temperature gauge is calibrated so that the instruments are in fact sterile; if the pharmacy does not mix up two labels; and if when the surgeon says urgently, “Clamp, right now,” there is a clamp on the tray. If all goes well, if ten thousand “ifs” go well, then Kim may sing her grandchildren to sleep some day. If not, she will be dead by noon tomorrow.

Donald M. Berwick, MD, MPP, wrote these words 18 years ago, but they could just as easily have been written yesterday. That fact underscores how little progress has been made in addressing risk management and patient safety.

In managing risk, system design is critical. For all too long, healthcare delivery has not been seen as a system. Often, when there is a failure or injury to the patient, the hospital looks one step back and fixes that problem or fires that nurse. What hospitals should be doing is looking at the entire system and putting in checks and balances, which would provide systematic warnings of impending errors.

Today, the growth of the Electronic Health Record (EHR) gives healthcare providers the opportunity to correct some of the design failures. If physicians can be convinced to make the commitment of time and money, system reform will move one step closer to reality. If independent health records—from physicians, hospitals, and other providers—are linked, a system that will serve to eliminate many of the daily missteps that occur every day in every hospital will be another step closer to reality.

The capability is there, but as John Halamka, chief information officer for Boston’s Caregroup, has often said, “This is not about computers but rather about the people using the computers correctly.” Although physicians will be given federal money to implement EHRs, how many will take advantage of this program and how all the varied systems will be linked is unknown. By making reporting of certain parameters to the Centers for Medicare & Medicaid Services and by linking appropriate claims data reported to insurance companies, development of system linkages can begin. There is pressure for better outcomes and lower costs; a system-based, physician-led approach is critical to achieve those goals.

The meta-leadership model
To make this happen will require real leadership. We at the Harvard School of Public Health have developed a model of leadership known as meta-leadership. We have used it extensively in dealing with complex, multidimensional issues. Meta-leadership is a systems-based approach to leadership. Using its five dimensions as lenses and guides can help physicians lead more effectively and make a positive contribution.

Healthcare leadership to advance patient safety—given current changes in organization, reimbursement, technology, and demographics—requires a heightened capacity for effective cross-disciplinary, cross-departmental coordinated efforts. This objective is hindered by the tendency of practitioners to advocate the specific interests and purposes of their narrow silo of activity.

Meta-leaders think and perform differently. They recognize that optimizing patient safety performance demands a spirit of cooperation combined with tangible inter-departmental mechanisms that promote collaboration.

By intentionally linking and leveraging the efforts of many departments, disciplines, professions, and specialists, meta-leaders galvanize a valuable connectivity of effort to advance patient safety.

The functions and dimensions of meta-leadership
Meta-leadership reframes the process and practice of healthcare leaders. It has the following three functions:

  • A comprehensive organizing reference to understand and integrate the many facets of leadership
  • A strategy to engage collaborative activity
  • A cause and purpose to improve healthcare functioning and safety

The learning and practice of meta-leadership has the following five dimensions, which begin with the individual and expand to the relationships between and among the various components of a healthcare system (Fig. 1).

  1. The person of the meta-leader refers to emotional intelligence, self-awareness, and self-regulation. When we (humans) are stressed or face difficult situations, we automatically revert to our hind-brain, that portion of the brain we share with lower animals, where the triple “F” response of freeze, flight, or fight lives. This emotional basement is the worst place for decision making. Meta-leaders recognize this and use appropriate tools to raise the level of decision making to the midbrain, where policies, procedures, drills, and previous experiences are stored. This enables them to make rational decisions and also to pull those around them up to this level.
  2. Situational awareness refers to the ability of a meta-leader to create a broad frame of reference, often with incomplete information, that can be used in problem diagnosis and solution building, to chart and lead a course of action, recruit wide health service engagement, and engender support for patient safety. Getting the “Big Picture” and being willing to take in and assess conflicting information is important.
  3. Leading your silo is a phrase that reflects the meta-leader’s ability to trigger and model confidence, inspiring others to excellence. The meta-leader drives the learning curve to elevate quality and performance, encouraging strong, effective subordinates who further galvanize cross-silo connectivity. Leadership should be built into every level of the silo; the farther down it can be pushed, the more successfully will the silo function.
  4. Leading up describes how the meta-leader effectively “manages the boss,” validating the power-command equation. Truth to power, effective communication, and being a great subordinate are critical, especially when people with different expertise and responsibility work together on patient safety priorities. Because many people are in leadership positions, information and change management must be pushed to the highest levels of the organization. Knowing your bosses’ backgrounds and priorities is very helpful in this “education” process.
  5. Leading cross-agency connectivity is the way that meta-leaders strategically and intentionally devise cross-silo linkages to leverage knowledge, experience, resources, and information across the spectrum of health system components, integrating and thereby optimizing performance and quality. Because so many silos exist, the chance for error in information transmission is heightened. These relationships and connections must be studied and made relatively foolproof.

A case of “wrong side” surgery shows how this could occur. For example, if the surgeon is using multiple operating rooms and a resident is setting up the case, the surgeon could easily walk to the wrong side if the operating table was turned 180 degrees from the usual. If, during the preparation, the doctor or nurse forgot to mark the side, no indicator would show that the surgeon is on the wrong side. And, if the patient had already been anesthetized, there would be no patient input. It may sound unlikely, yet it still happens.

Bad leadership is a public health hazard
As can be seen, avoiding wrong-site surgery requires multiple decisions made by many different individuals. If effective leadership fails to look at all these possibilities, failure can easily occur.

I think this shows how bad leadership is truly a public health hazard.

Look at your hospital or clinic and evaluate the areas where effective leadership is critical to appropriate function. Find the cracks or holes in the system that can exist if effective leadership is not employed.

Asking physicians to lead without giving them the proper tools would be akin to asking a surgeon to operate with kitchen tools. It can be done, but the results would not be pretty.

Barry C. Dorn, MD, MHCM, is associate director of the Program on Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health. He prepared this article at the request of the AAOS Medical Liability Committee.

Editor’s Note: Articles labeled Orthopaedic Risk Manager are presented by the Medical Liability Committee under the direction of contributing editor S. Jay Jayasankar, MD.

Articles are provided for general information and are not legal advice; for legal advice, consult a qualified professional.

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