The Power of One Leader: Learning from Medical Mistakes

by Holly Hayes

The American Journal of Mediation Fifth Edition focuses on mediation in healthcare. Dale Hetzler, Deanne R. Messina and Kimberly J. Smith write about “Conflict Management in Hospital Systems: Not Just for Leadership”. They contend “communication skills and conflict skills will be primary predictors of the organizations ability to progress in both quality improvement and patient safety, and will therefore equip its caregivers and administrators with these skills. For those who do adopt this approach, they can expect lower turn-over, less burnout, increased patient loyalty and lower rates of medical errors.”

In keeping with this idea, The American Society for Healthcare Risk Management (ASHRM) has announced its annual conference October 7-10, 2012 in Washington DC. The theme will be ‘“Getting to Zero™: Eliminating Preventable Serious Safety Events”—a multi-faceted patient safety and healthcare risk management initiative that aims at driving down the incidence of preventable serious safety events in healthcare organizations’ to emphasize the role of a single leader in making positive change to reduce preventable safety errors.

The ECRI blog posted this comment about the ASHRM annual conference theme:

It’s a lofty goal, and an intimidating one: risk managers tend to shy away from absolute statements. Phrases like “never events” make risk managers cringe. Sure, we all want to eliminate, say, wrong-site surgery, but we can’t actually eliminate it, right? All the way to zero? None at all?

Evidence is starting to mount that yes, in fact, we can. Through implementation of evidence-based practices, some Pennsylvania hospitals seem to be winning the fight against wrong-site surgery, according to the Pennsylvania Patient Safety Authority. The Authority reported in 2010 on eight hospitals that had each gone at least 64 weeks without reporting a wrong-site surgery and the practices they put in place to accomplish this.

Elsewhere, Michigan’s MHA Keystone Center for Patient Safety& Quality has had similar results, most notably with reducing catheter-associated infections.

There are lots of reasons to be cautious in interpreting these results. The collaborative programs that yielded these results are time-and resource-intensive; they require sustained attention for the results to last. Sometimes what works in one hospital won’t work in another one. People, being people, are fallible and subject to back-sliding.

But the Pennsylvania, Michigan, and other groups give the lie to the idea that “zero” is unattainable. It’s hard, and it’s not easy, but it’s doable.

And that’s where “the power of one” part of the ASHRM slogan comes in. For programs like these to be implemented and sustained, someone in each participating organization must champion them. Part cheerleader, part advocate, part cajoler-in-chief, the champion invests in the success of the initiative and makes sure it never drops off the front burner.

Who better to be that champion than the risk manager? During Healthcare Risk Management Week, risk managers can highlight similar efforts in their organizations, and all that they do to improve patient safety and reduce the hospital’s liability. And what could be more valuable than that?

For more on our posts about conflict management in healthcare, see here.

Holly Hayes is a mediator at Karl Bayer, Dispute Resolution Expert where she focuses on mediation of health care disputes. Holly holds a B.A. from Southern Methodist University and a Masters in Health Administration from Duke University. She can be reached at holly@karlbayer.com.