Applying quality improvement principles to achieve healthy work organizations

BACKGROUND: Health care has used total quality management (TQM)/quality improvement (QI) methods to improve quality of care and patient safety. Research on healthy work organizations (HWOs) shows that some of the same work organization factors that affect employee outcomes such as quality of life and safety can also affect organizational outcomes such as profits and performance. An HWO is an organization that has both financial success and a healthy workforce. For a health care organization to have financial success it must provide high-quality care with efficient use of scarce resources. To have a healthy workforce, the workplace must be safe, provide good ergonomic design, and provide working conditions that help to mitigate the stress of health care work. INTEGRATING TQM/QI INTO THE HWO PARADIGM: If properly implemented and institutionalized, TQM/QI can serve as the mechanism by which to transform a health care organization into an HWO. To guide future research, a framework is proposed that links research on QI with research on HWOs in the belief that QI methods and interventions might be an effective means by which to create an HWO. Specific areas of research should focus on identifying the work organization, cultural, technological, and environmental factors that affect care processes; affect patient health, safety, and satisfaction; and indirectly affect patient health, safety, and satisfaction through their effects on staff and care process variables. SUMMARY: Integrating QI techniques within the paradigm of the HWO paradigm will make it possible to achieve greater improvements in the health of health care organizations and the populations they serve.     

The organizational costs of preventable medical errors

BACKGROUND: Preventable medical errors are associated with additional costs that tend to be borne by patients, but little is known about organizational costs associated with such errors. Two composite case studies (a fall and a delay in diagnosis) were used to identify the organizational costs of preventable medical errors. ANALYSIS: Legal, marketing, and organizational costs--direct, indirect, and long term--were associated with each of the preventable medical errors. A model was generated to examine the theoretical relationship between the costs and four determinants of corporate performance--price, wages, cost of capital, and efficiency. DISCUSSION: Organizations may also have a financial incentive to improve patient safety, for beyond patient and societal costs, preventable medical errors appear to account for significant legal, marketing, and operational costs for the organizations that deliver health care. Some of these costs are not so much the cost of the error but the costs of organizational responses to the error. Three broad areas of inquiry could be used to test the model and improve our understanding of the organizational costs of errors: market response to patient safety interventions, before/after studies of interventions, and case-control studies. SUMMARY AND CONCLUSION: Health care leaders have a moral imperative to implement systems that reduce medical errors and improve patient safety. An understanding of the costs associated with medical errors may help leaders understand the importance of patient safety from a financial perspective, develop measures to evaluate the impact of patient safety initiatives, and efficiently allocate resources to address this important health concern.     

Working in light vehicles--a review and conceptual model for occupational health and safety

Occupational light vehicle (OLV) use is the leading cause of work related traumatic deaths in Westernised countries. Previous research has focused primarily on narrow contexts of OLV-use such as corporate fleet vehicles. We have proposed a comprehensive systems model for OLV-use to provide a framework for identifying research needs and proposing policy and practice interventions. This model presents the worker as the locus of injury at the centre of work- and road-related determinants of injury. Using this model, we reviewed existing knowledge and found most studies focused only on company car drivers, neglecting OLV-users in non-traditional employment arrangements and those using other vehicle types. Environmental exposures, work design factors and risk and protective factors for the wider OLV-user population are inadequately researched. Neither road- nor work-related policy appropriately addresses OLV-use, and population surveillance relies largely on inadequate workers compensation insurance data. This review demonstrates that there are significant gaps in understanding the problem of OLV-use and a need for further research integrating public health, insurance and road safety responses. The model provides a framework for understanding the theory of OLV-use OHS and guidance for urgently needed intervention research, policy and practice.     

The effects of error management climate and safety communication on safety: A multi-level study

Work in the construction industry is considered inherently dangerous, despite the technological improvements regarding the safety of work conditions and equipment. To address the urgent need to identify organizational predictors of safety performance and outcomes among construction workers, the present study examined multi-level effects of two important indicators of safety climate, namely contractor error management climate and worker safety communication, on safety behavior, injury, and pain among union construction workers. Data were collected from 235 union construction workers employed by 15 contractors in Midwest and Northwest regions of the United States. Results revealed significant main effects for safety communication and error management climate on safety behaviors and pain, but not on injuries. Our findings suggest that positive safety communication and error management climate are important contributors to improving workplace safety. Specific implications of these results for organizational safety research and practice are discussed.     

Promoting patient safety: is technology the solution?

BACKGROUND: On April 30, 2001, the Cleveland Clinic Foundation and Cleveland Clinic Health System Quality Institute sponsored a 1-day conference focused on technology in patient safety. PATIENT SAFETY-A CALL TO ACTION: Kenneth W. Kizer focused on ten high-priority patient safety strategies identified by the National Quality Forum-including implementing recognized "safe practices", recognizing and dealing with professional misconduct, and supporting efforts to create a nonpunitive environment for health care error reporting. CULTURAL IMPLICATIONS OF INTRODUCING NEW TECHNOLOGY: Randolph A. Miller described a computerized clinician order-entry system used to provide decision support, reduce excess test ordering, introduce cost savings, and meet regulations for inpatient radiology and cardiology tests. USING BAR CODES TO ELIMINATE MEDICATION ERRORS: Jeff Ramirez reported on the Veterans Health Administration's use of bar coding technology for point-of-care validation of medication administration, which has resulted in improvements in response time; the efficiency of the dispensing, delivery, and administration process; and patient care. HOW TO MAKE COMPUTERS TEAM PLAYERS: The knowledge base exists to design computers as team players that expand human expertise and help health care practitioners better create safety. Yet David D. Woods challenged the audience to anticipate the changing shape of iatrogenic risk as a result of increasing dependence on automation in health care. TECHNOLOGY AND MEDICATION SYSTEMS: Mark Neuenschwander spoke about automating various steps within the medication use system, through computerized prescriber order entry and bedside scanning. FUTURE TECHNOLOGICAL POSSIBILITIES: Charles Denham suggested how technology may aid health care professionals in their care of patients, such as in using predictive modeling to identify the risks of therapeutic intervention.     

Federal efforts to improve quality of care: the Quality Interagency Coordination Task Force (QuIC)

FORMATION OF THE QUIC: The Quality Interagency Coordination Task Force (QuIC) was established in 1998 to enable the participating federal agencies to coordinate their activities to study, measure, and improve the quality of care delivered by federal health programs; provide people with information to help them in making more informed choices about their care; and develop the research base and infrastructure needed to improve the health care system, including knowledgeable and empowered workers, well-designed systems of care, and useful information systems. STUDY, MEASURE, AND IMPROVE CARE: The QuIC's initial efforts to improve the care delivered in federal health care programs have focused on diabetes, depression, and the effect of working conditions on quality of care. More recently, patient safety efforts are under way to establish a coordinating center that will enable those who are testing methods of reducing errors to share information across their projects and with experts in error reduction. DEVELOP A RESEARCH BASE AND INFRASTRUCTURE: The QuIC has coordinated efforts in credentialing, information on measures of quality, a taxonomy of quality improvement methods, and errors data collection. PROVIDE INFORMATION TO AMERICANS ABOUT HEALTH CARE QUALITY: The QuIC agencies are developing products that will enhance their ability to communicate with the American people about their health care choices: improved gateways for consumer information available from federal agencies, a glossary of commonly used terms, and guidance for producing report cards on quality of care. MOVING THE QUALITY IMPROVEMENT AGENDA FORWARD: Federal efforts to improve quality of care are moving forward in a more integrated fashion on a wide number of fronts.     

Safety climate and self-reported injury: assessing the mediating role of employee safety control

To further reduce injuries in the workplace, companies have begun focusing on organizational factors which may contribute to workplace safety. Safety climate is an organizational factor commonly cited as a predictor of injury occurrence. Characterized by the shared perceptions of employees, safety climate can be viewed as a snapshot of the prevailing state of safety in the organization at a discrete point in time. However, few studies have elaborated plausible mechanisms through which safety climate likely influences injury occurrence. A mediating model is proposed to link safety climate (i.e., management commitment to safety, return-to-work policies, post-injury administration, and safety training) with self-reported injury through employees' perceived control on safety. Factorial evidence substantiated that management commitment to safety, return-to-work policies, post-injury administration, and safety training are important dimensions of safety climate. In addition, the data support that safety climate is a critical factor predicting the history of a self-reported occupational injury, and that employee safety control mediates the relationship between safety climate and occupational injury. These findings highlight the importance of incorporating organizational factors and workers' characteristics in efforts to improve organizational safety performance.     

John M. Eisenberg Patient Safety Awards. Individual lifetime achievement: Julianne M. Morath,RN, MS

BACKGROUND: This article provides a brief biography of Julianne M. Morath, describes the scope and impact of her patient safety initiatives at Children's Hospitals and Clinics in Minneapolis and St Paul, and includes an interview in which Morath responds to questions about challenges to patient safety and medical accident reduction. BIOGRAPHY IN BRIEF: With a 25-year career spanning the spectrum of health care, Morath has served in leadership positions in health care organizations in Minnesota, Rhode Island, Ohio, and Georgia. LEADERSHIP AT THE FRONT LINE: Morath joined Children's Hospitals and Clinics in 1999 and launched a major patient safety initiative that put Children's on the map. Elements of the initiative included a culture of learning, patient safety action teams, open discussion of medical accidents and error, blameless reporting, and a full accident disclosure policy. AN INTERVIEW WITH JULIE MORATH: As the greatest challenge to leadership ownership of the patient safety initiative, Morath cites the need to confront the myths of the medical system and to develop the awareness of the issues of patient safety. She believes that clinicians on the front lines will be convinced that patient safety isn't "just another fad of the month" when leadership action is disciplined and aligns with what is being espoused. She advises other leaders of health care organizations interested in establishing a culture of safety to start with a personal and passionate belief that harm-free care is possible, to commit to informed action, and to identify and develop champions throughout the organization and medical staff.     

Error analysis leading technology development

The aim of the research was to provide a valid theoretical frame consisting of both task and error analyses methods to analyse elder patients’ clinical pathway within a healthcare system. The research study consisted of (a) utilizing a task analysis method to identify the process workflow affiliated with elder patients transitioning through different continuums of care to receive medical treatment; (b) utilizing an error analysis method to identify opportunities for improvement in the workflow that enhances both patient safety and healthcare worker efficiency and; (c) developing an ideal process workflow that incorporates the recommendations for improvement. The study findings contribute towards a larger research effort being proposed consisting of the development and implementation of a shared web-based patient community information system enabling hospitals and nursing homes to share patient information resulting in increased knowledge of a patient's medical history, decreased errors and enhanced patient safety.     

Developing a systemwide approach to patient safety: the first year

BACKGROUND: Health care organizations face an imperative to ensure that care is provided to patients in the safest manner possible. In 2000 INTEGRIS Health, an Oklahoma City-based health system including ten acute care organizations, developed a patient safety framework that was built on the foundation of a culture of patient safety and began implementation in January 2001. IMPORTANCE OF LEADERSHIP IN PATIENT SAFETY: The first step in establishing a culture of safety was to ensure that leadership and the entire organization understand the rationale for a focus on patient safety. The traditional blaming approach will not prevent human error; staff need to speak freely, to talk about errors that happen and those that almost happen, and to identify where mistakes are likely and where systems allow mistakes to get through. Systems and processes should make it difficult for staff to make mistakes and easy for them to do things correctly. EXPERIENCE TO DATE: Since our efforts began, staff have helped identify multiple accidents waiting to happen. For example, an anesthesiologist, the service chief at one of our large hospitals, prepared a list of safety issues immediately after hearing a presentation to the Medical Executive Committee. Many system flaws have been identified as a result of our discussions; some of the solutions are easy and some much more complex. CHALLENGES: Challenges include keeping patient safety highly visible and demonstrating progress in our implementation, developing effective mechanisms for communicating safety solutions and ensuring that they are implemented in all the facilities, and figuring out how to measure success in a meaningful way.     

A Web-based program for implementing evidence-based patient safety recommendations

BACKGROUND: In response to increasing national concerns about medical safety, product developers from a health services research and software group recently created a commercial Web-based program to address a wide variety of patient safety issues in the acute care setting. They also wanted to provide a program with credible, referenced, and up-to-date content, not just a technology infrastructure for reporting errors. SAFETY OPTIMIZER: This Web-based program, which has evolved over time, now features seven modules for assessing organizational risk and for implementing strategies to reduce risk. The Literature Module features detailed synopses that are graded and organized into summary statements to provide recommendations for improving patient safety. The Implementation/Tracking Module includes numerous risk-reduction strategies. The Incident Reporting Module enables the collection of data at the point of care on a variety of incidents, using either paper-based or on-line forms. Other modules offer opportunities to assess adherence to JCAHO patient safety standards, forecast the benefits of certain evidence-based guidelines, evaluate staff competency, and obtain information from a variety of key safety Web sites. EXPERIENCE TO DATE: The program is in use at more than 30 health care organization facilities and systems. It is still too early to provide quantitative data on the impact of this program on patient safety. CONCLUSIONS: It is hoped that vendor solutions such as the one described in this article will help organizations develop a practical and effective framework for addressing the wide range of issues in patient safety.     

The forgotten component of the quality triad: can we still learn something from "structure"?

BACKGROUND: Quality assessment was founded on structural measures, such as accreditation status of facilities, credentialing of providers, and type of provider. Recent efforts in measures development have focused on processes and outcomes because research has suggested that structural measures are not strong markers of the quality of care at the health plan or provider levels. Nevertheless, the literature on the quality of health care contains a number of examples illustrating the potential application of structural measures to the assessment of quality. The continued development of measures of structure-which would at least measure aspects of the physical environment, working conditions, organizational culture, and provider satisfaction--may be helpful because generalizing from studies of process and outcome requires specification of the conditions under which these linkages are found. A ROAD MAP FOR MEASURES DEVELOPMENT: The Leapfrog Group of large purchasers has promoted the application of three patient safety "leaps" that are, in essence, structural measures: the use of computerized physician order entry, the selective referral of patients to high-volume providers for certain procedures, and the availability of board-certified critical care specialists in intensive care units. Structural measures, like process and outcomes measures, face the same challenges of standardization, reliability, validity, and portability. Field testing of potential measures will be required to examine the feasibility and added value of these measures in real-world settings. CONCLUSION: Research to date suggests that a new cadre of structural measures of health care quality, which have largely been overlooked in the recent measures development boom, have the potential to fill in important gaps in our ability to assess quality.     

Does a healthy health care workplace produce higher-quality care?

BACKGROUND: The multiagency Quality Interagency Coordination Task Force (QuIC) coordinates activities and plans for quality measurement and improvement across all the U.S. federal agencies involved in health care. One of its working groups focuses on the health care workforce and ways to improve the quality of care that it provides. In October 1999 four government agencies, under the aegis of the QuIC, convened a conference to examine how health care workplace quality influences the quality of care. A healthy workplace is one in which workers will be able to deliver higher-quality care and in which worker health and patients' high-quality care are mutually supportive. In October 2000 a follow-up conference was held to focus on a specific aspect of health care quality-patient safety. WHAT WE STILL NEED TO KNOW: Although enough is known to justify some initiatives to improve the quality of the health care workplace, participants in both meetings agreed that the evidence to prove these associations is weak and that there has been too little research to evaluate the impact of interventions intended to improve quality through improvements in the health care workplace. New evidence-based information is needed to test the theory of the nature of the relationship between working conditions and care quality. CONCLUSION: The tradition of evidence-based decision making needs to be applied to health care management as it has in medicine and nursing, to show how staffing, environment, organization, and culture can each can affect the quality of care.     

Preventing home health nursing assistant back and shoulder injuries

BACKGROUND: Franklin County Home Health Agency (St Albans, Vermont) undertook a performance improvement project in 1996 to reduce employee injuries. A review of recent injuries led to the prevention of licensed nursing assistants' (LNAs') back and shoulder injuries as the first priority. Root causes of injuries were agency communication, employee training, patient home environment, nursing assistant body mechanics, and failure to use safety measures. Given that injury causality is complex and multifactorial, a variety of improvement strategies were implemented over the following two to three years. IMPLEMENTATION OF POTENTIAL SOLUTIONS: Short-term (a few months), mid-term (six months), and long-term (one year) potential solutions to the LNA back and shoulder injury problem were charted. Safety and health training was the major focus of the team's short-term plan. Risk management forms were to be used to identify and follow up on hazardous situations. RESULTS: Project plans that were successfully implemented included revision of LNA plans of care, standardization of the return-to-work process after injury, development of guidelines for identifying unsafe patient lifts and transfers, improved follow-up of employee reports of injury-risk situations in patient homes, improved body mechanics screening of new employees, and a stronger injury-prevention training program for current employees. A less successful initiative was aimed at collecting more data about injuries and causal factors. Employee injuries were gradually reduced from 4-10 per quarter to 0-3 per quarter. CONCLUSIONS: Injury prevention requires commitment, persistence, and patience--but not expensive improvements. Multiple interventions increase the chances of success when there are many root causes and lack of evidence regarding the effectiveness of various approaches.     

When does lean hurt? – an exploration of lean practices and worker health and safety outcomes

This research takes a first step toward a more complete understanding of the effects of lean production on both operational and worker health and safety performance. Previous operations management literature considered only the operational performance implications of lean while previous safety literature considered only the worker health and safety implications of lean. This research considers both perspectives by providing empirical evidence on the impact of lean on operational and health and safety performance. Results from 10 case studies show that the adoption of lean practices and or an overall lean philosophy has a positive impact on operational and health and safety performance. However, there are some nuances in the role of individual practices associated with lean. The plants with the worst operational and health and safety performance in the sample were those that adopted just-in-time practices without human resource and prevention practices. The results show how both the social and technical components of lean are required for lean to have positive operational and health and safety impacts.     

From production systems to health care delivery systems: a retrospective look on similarities,difficulties and opportunities

Manufacturing systems have attracted substantial research attentions during the last 50 years. In recent years, there has been growing interest in health care systems research to improve efficiency, safety and care quality. The similarities identified between manufacturing systems and health care delivery systems heighten the importance of transferring the experience and knowledge in manufacturing to health care. In this paper, based on the lessons we learned and the experience we obtained during our journey from production systems research to health care delivery systems study, we discuss the similarities between production systems and health care delivery systems in system modelling, design, performance evaluation and continuous improvements and investigate the differences and difficulties that stem from variability, constraints, dynamics and human behaviour. Building upon these, the opportunities encompassing care operations, planning and scheduling, patient transitions, and safety and teamwork in health care delivery systems are discussed. Finally, the challenges and future directions are proposed. We expect this work to serve as a catalyst to stimulate more in-depth and comprehensive studies.     

Expanding a performance improvement initiative in critical care from hospital to system

BACKGROUND: Concern about the expense and effects of intensive care prompted the development and implementation of a hospital-based performance improvement initiative in critical care at North Shore University Hospital, Manhasset, New York, a 730-bed acute care teaching hospital. THE HOSPITAL-BASED PERFORMANCE IMPROVEMENT INITIATIVE IN CRITICAL CARE: The initiative was intended to use a uniform set of measurements and guidelines to improve patient care and resource utilization in the intensive care units (ICUs), to establish and implement best practices (regarding admission and discharge criteria, nursing competency, unplanned extubations, and end-of-life care), and to improve performance in the other hospitals in the North Shore-Long Island Jewish Health System. In the medical ICU, the percentage of low-risk (low-acuity) patients was reduced from 42% to 22%. ICU length of stay was reduced from 4.6 days to 4.1 days. IMPLEMENTING THE CRITICAL CARE PROJECT SYSTEMWIDE: A system-level critical care committee was convened in 1996 and charged with replicating the initiative. By and large, system efforts to integrate and implement policies have been successful. The critical care initiative has provided important comparative data and information from which to gauge individual hospital performance. DISCUSSION: Changing the critical care delivered on multiple units at multiple hospitals required sensitivity to existing organizational cultures and leadership styles. Merging organizational cultures is most successful when senior leadership set clear expectations that support the need for change. The process of collecting, trending, and communicating quality data has been instrumental in improving care practices and fostering a culture of safety throughout the health care system.     

Lifecycle risk assessment of a technological system using dynamic Bayesian networks

Investigations of technological systems accidents reveal that technical, human, organizational, as well as environmental factors influence the occurrence of accidents. Despite these facts, most traditional risk assessment techniques focus on technical aspects of systems and have some limitations of incorporating efficient links between risk models and human and organizational factors. This paper presents a method for risk analysis of technological systems. Application of the presented framework makes it possible to analyze the influence of technical, human, organizational, and environmental risk factors on system safety. It encompasses system lifecycle from design to operational phase to give a comprehensive picture of system risks. The developed framework comprises the following main steps: (1) development of a conceptual risk analysis framework, (2) identifying risk influencing factors in different levels of technical, human, organizational, and environmental factors providing the possibility of analyzing interactions in a multi‐level system, (3) modeling system risk using dynamic Bayesian network (DBN), (4) assignment of probabilities and risk quantification in node probability tables (NPTs) based on industry records and experts extracted knowledge, (5) implementation of the model for wind turbines risk analysis combining use of V‐model, risk factors, and DBN in order to analyze the risk, and (6) analyzing different scenarios and the interactions in different levels. Finally, the various steps of the framework, the research objective fulfillment, and case study results are presented and discussed.     

Human and organizational biases affecting the management of safety

Management of safety is always based on underlying models or theories of organization, human behavior and system safety. The aim of the article is to review and describe a set of potential biases in these models and theories. We will outline human and organizational biases that have an effect on the management of safety in four thematic areas: beliefs about human behavior, beliefs about organizations, beliefs about information and safety models. At worst, biases in these areas can lead to an approach where people are treated as isolated and independent actors who make (bad) decisions in a social vacuum and who pose a threat to safety. Such an approach aims at building barriers and constraints to human behavior and neglects the measures aiming at providing prerequisites and organizational conditions for people to work effectively. This reductionist view of safety management can also lead to too drastic a strong separation of so-called human factors from technical issues, undermining the holistic view of system safety. Human behavior needs to be understood in the context of people attempting (together) to make sense of themselves and their environment, and act based on perpetually incomplete information while relying on social conventions, affordances provided by the environment and the available cognitive heuristics. In addition, a move toward a positive view of the human contribution to safety is needed. Systemic safety management requires an increased understanding of various normal organizational phenomena - in this paper discussed from the point of view of biases - coupled with a systemic safety culture that encourages and endorses a holistic view of the workings and challenges of the socio-technical system in question.     

Agile workforce evaluation: a framework for cross-training and coordination

This paper outlines approaches for assessing and classifying manufacturing and service operations in terms of their suitability for use of cross-trained (flexible) workers. We refer to our overall framework as agile workforce evaluation. The primary contributions of this paper are: (i) a strategic assessment framework that structures the key mechanisms by which cross-training can support organizational strategy; (ii) a tactical framework that identifies key factors to guide the selection of an architecture and worker coordination policy for implementing workforce agility; (iii) a classification of workforce agility architectures; (iv) a survey of a broad range of archetypical classes of worker coordination policies; (v) a survey of the literature with an operational perspective on workforce agility; and (vi) identification of opportunities for research and development of architectures for specific production environments.