BIBLIOGRAFÍA INICIAL

the value of Patient Safety

It has long been recognized in patient safety literature that leadership support is needed to implement patient safety processes and changes in hospitals and other health service organizations. Committed leaders are able to drive culture and change; they are needed to envision, design, implement and promote a culture of safety. Leadership is also required to support the efforts of program directors and champions to design and deliver safety curricula and to evaluate its implementation.

Executive walkabouts and other strategies have become increasingly common aspects of organizational quality and patient safety programs.100,101 _{Similarly, the authors of} the Unmet Needs report argue that leadership support — “primarily medical school deans, teaching hospital CEOs, department chairs, and residency program directors”102 — is needed to alter the culture of medical education such that both the explicit and hidden curricula support a just culture of patient safety.

There are a number of ways that leadership can actively promote patient safety: making patient safety a priority, formally recognizing patient safety and advancing patient safety through organizational practices.

Making patient safety a priority

First, patient safety can be actively made a priority. As the Unmet Needs report highlights, patient safety extends beyond going through the motions of completing a checklist or following mandated protocols. The culture of practice must embrace the concepts of the provision of

safe and effective care and that every available reasonable step must be taken to reduce medical error. Without leadership support, culture will be slow to change. Similarly, program directors and medical educators will not likely have the resources and tools needed to truly effect change.103-105

Those institutions that have made patient safety a priority will most likely have articulated organizational quality and safety aims that are aligned with PGME training. They will also likely have the following characteristics: leaders (including CEOs, deans, department chairs and clinical chiefs) who understand the value of quality and safety training for residents and who insist on linking this training to institutional quality and safety goals; appropriately trained faculty who have the time and resources to teach quality and safety and who have ample career opportunities to pursue research and teaching in quality and safety; residents who incorporate quality and safety into their daily clinical work and who are rewarded and recognized for their efforts; and PGME programs that continually facilitate and support quality and safety learning opportunities and that provide trainees with opportunities to explore fulfilling careers in quality and safety beyond clinical training.17

Formally recognizing patient safety

Second, leadership in academic departments and institutions can formally recognize patient safety by including patient safety and QI in their academic mission. These leaders are uniquely positioned to develop, promote and institute patient safety and QI strategies, programs, initiatives and interventions at the local level. Moreover, academic departments and institutions can facilitate faculty capacity to lead scholarly patient safety and QI programs and to collaborate, undertake research, disseminate and recognize participation through academic promotion.106 Creation of a dedicated section on patient safety and QI within an academic department would allow a more co- ordinated patient safety and QI strategy. Moreover, such an initiative would be a powerful statement of a department’s

commitment to patient safety and QI and would help to establish a clearly articulated culture of patient safety.107

Advancing patient safety through organizational practices

Third, leadership can set the tone and change the culture of patient safety within the working and learning environments by altering traditional structures, such as M&M rounds. In a culture of blame, these rounds are not treated as a learning opportunity. Leadership needs to view M&M rounds and other patient-centred structures as vehicles to reinforce and embody the content of the patient safety curriculum and patient care management.33 M&M rounds, or other structures such as patient safety grand rounds, chart audits or personal learning projects (PLPs), should include learning objectives for students, residents and faculty. These existing structures also need to be viewed as an important venue for lifelong learning. There should be recognition that these compelling educational experiences can drive change. For example, residents’ involvement in experiential QI projects, such as chart audits — as part of a formal quality/safety curriculum — frequently leads to significant improvements in processes of care.22,108-110

When harm from the delivery of health care has occurred, the focus of immediate efforts should be centred on meeting the clinical, emotional and information needs of patients and making improvements to limit similar harm to other patients in the future. However, in many institutions and organizations, when harm has occurred, there is often little or no emotional support provided to the involved health professionals, including physicians and trainees. Support should be offered to those involved111 _{so that all} health professionals develop appropriate and healthy coping mechanisms and that the organization actively cultivates a just culture. Moreover, the response to an adverse event should include taking part in exercises in QI and root cause analysis to inform all providers, including residents, of how to improve the quality and safety of care in their practices and foster a generative patient safety culture.112

Certainly, training should include disclosure of adverse events to patients and the role of apology in often difficult circumstances, including legislative requirements.113-115 These existing structures provide an excellent opportunity for educators and practitioners to shift the focus from blame and shame to a fair and just culture approach that emphasizes system issues in the understanding of adverse events and close calls, and also concurrently, takes into account individual responsibility for professional behaviour.

PotentIAL BeneFItS