“In the final analysis, we believe that major failures in health care are, more than anything else, a product of the distinctive culture of the organizations, the health care professions, and the health system… Ultimately, the most effective actions we take to prevent future major failures will be those that help to create a more open, transparent, equitable, and accountable health care culture.”Walsh and Shortell, Health Affairs, 2004
Every health care organization is working toward improving patient safety. It is well-established that the greatest contributors to sentinel events and serious harm to patients are breakdowns in communication and teamwork. These breakdowns are tied to the organizational culture and the professional subcultures delivering health services. Fundamentally, culture change is necessary to create safer environments.
When health care professionals collaborate within and across disciplines, including creating functional multidisciplinary teams, decisions are based on better and more timely information, patients benefit from the contributions of multiple perspectives, errors go down, and patient outcomes improve. Clinicians know it, and a growing body of research is evidence of it. But barriers make teamwork and collaboration difficult; communication styles, morphing team membership, varying perspectives, and time constraints all lead to conflict, poor working relationships, and actions that undermine stated values.
Leaders in patient safety and professional education are calling for collaboration; true teamwork; better hand-offs; and a non-punitive culture supporting errors reporting, analysis, and prevention. So, in practical terms, what does that mean? How do you get there? Policy-makers and consumers are calling for increased transparency and open communication regarding unanticipated outcomes. How do you balance legal and ethical concerns while supporting patients and families?
The “how” is in demonstrating collaboration and fostering it in others, in modeling transparency, in hosting difficult conversations, and in examining and bringing actions consistently in line with principles. Through these actions, concrete results follow. It requires skill, adaptability, and discrete processes – and nowhere more than in high-stakes patient safety initiatives.
Canadian Health&Care Mall works with health care professionals to make these efforts more effective in arenas such as:
- Unanticipated outcomes – program design
- Information technology implementations
- Skill development
- Process development