Ana Pujols-McKee, MD
Chair, Pennsylvania Patient Safety Authority
Board of Directors

The patient safety movement seems to generate themes as we continue to move forward. For 2008, the buzz phrase getting “boards on board” remains a prevailing theme generating much attention at national meetings. One can barely hear a presentation on patient safety without hearing the discussion of the importance of the board of trustees’ active commitment and fiduciary responsibility to quality and patient safety.

There is no debate on the need to increase the board of trustees’ involvement, but there is no real consensus on how to reach a meaningful level of engagement. Does it add value to educate trustees on probability coefficients? Are dashboards the best way to tell what is really going on? Throughout the year you will continue to hear many strategies and potential solutions, and Pennsylvania should be at the cutting edge and leading the nation in this initiative.  

Legislation enacted in 2002 created an opportunity for Pennsylvania hospitals to significantly advance and engage their governing bodies on their path to improving patient safety. Act 13 of 2002, the same law that authorized the Patient Safety Authority, required hospitals, ambulatory surgical facilities, and birthing centers in the Commonwealth to develop patient safety committees whose membership may include a member of the board of trustees. In addition, it required patient safety committees to provide quarterly reports to the organization’s administration and governing body. The Act also provides detail about the contents of these reports, which include the number of Serious Events and Incidents, but more importantly, the committee’s recommendations to eliminate future Serious Events and Incidents.

Admittedly, legislation is not always the most comfortable way to initiate change, but when these processes are properly implemented, they can afford an organization a tremendous opportunity to achieve the correct level of engagement, an appropriate level of sharing, and a significant return of value to the community served.

Moving forward in 2008, I invite each of you to look within your organizations and ask yourselves if you have made the most of this opportunity afforded by Act 13. 

For our part, the Patient Safety Authority is committed to increasing trustee awareness of patient safety through education regarding their role in governing an organization dedicated to quality.  The Authority’s Board of Directors included facility board education as one of its strategic initiatives, and the Authority has begun work to adopt an appropriate curriculum for Pennsylvania. More information will be provided as it becomes available.

Wishing all of you a great year in making it safer!

Information for Boards

Dr. Pujols-McKee and the rest of the Pennsylvania Patient Safety Authority Board of Directors call attention to the importance of board-level leadership for patients to have a safe medical experience. She has raised the issue of how boards can reach that objective. Clearly, the Authority believes that reporting is one of the tools. “You can’t improve what you don’t measure.” However, becoming aware of errors does not fix them. Improvement comes from redesigning systems, not making providers aware of their errors and the consequences.

Board committees may wish to consider the following recent articles among many that discuss patient safety from the perspective of the board:

Pronovost PJ, Berenholtz SM, Needham DM. A framework for health care organizations to develop and evaluate a safety scorecard. JAMA 2007 Nov 7;298(17):2063-5. Dr. Pronovost and colleagues recommend rate-based measures of outcomes and processes related to outcomes, plus other measures of the culture of safety in the organization. Because patient safety reporting systems are vulnerable to reporting bias and lack denominators, the authors recommend using them to identify, but not measure, errors.

Shortell SM, Singer SJ. Improving patient safety by taking systems seriously. JAMA 2008 Jan 30;299(4):445-7. The authors emphasize the importance of having systems for reliably delivering medical care, both within organizations and across organizations.

Clarke JR, Lerner JC, Marella W. The role for leaders of health care organizations in patient safety. Am J Med Qual 2007 Sep-Oct;22(5):311-8. Myself and others from ECRI Institute reviewed critical “patient safety literacy” for board members, including high reliability organizations, culture of safety, decreasing unjustified variability in care, at-risk behavior, an emphasis on system design rather than provider performance, and disclosure. Twenty actions are cited that are appropriate for board consideration, including reporting, monitoring, and benchmarking against past performance.

—John R. Clarke, MD, Editor