An abridged patient safety guide for executives M atthew J. Lambert's Leading a Patient-Safe Organization is a personal education resource for health care executives -a concise overview of the plethora of publications on medical errors, leadership's role in reducing errors and strategies for creating a culture of safety in health care organizations.
This good read is organized around three topics: the basics of medical errors, leadership's role and safety culture. Beginning with a framework for understanding the human side of error and the contribution of poorly designed systems on error in health care, Chapter 1 sets the stage for an appreciation of error management tactics enhanced through improved communication in a high technology environment.
The second chapter is an overview of the role of leadership in changing health care organizations to patient-safe ones. The challenges to improvement are discussed including distorted views of error by health professionals, a lack of awareness by administrators of the details of patient care outcomes, and a narrow focus by executives on financial measures and performance.
Continuing with a discussion on the era of consumerism in health care, accountability for patient outcomes is considered. Current public reporting initiatives, such as the National Voluntary Hospital Reporting Initiative, are deliberated along with governmental initiatives in patient safety such as the Institute of Medicine's 20 priority areas for quality improvement, and those by private, not-for-profit organizations like the National Quality Forum.
Next, underlying reasons for a lackluster pursuit of quality and safety improvements in health care in spite of the overwhelming evidence of the need for change are presented. Executives will relate well to indiscriminate payment systems that reimburse for health care regardless of outcomes, thereby presenting an obstacle to investments in quality and safety improvements. However, recent efforts to overcome this obstacle, such as rewarding hospitals with a higher rate of payment for demonstrating evidence of quality outcomes, and safety improvements supported by business coalitions like the Leapfrog group which promotes certain practices proven to reduce errors but have been difficult to achieve, are reviewed.
Finally, although called for in this era of accountability, barriers to assessing physician competence are identified and the conflict that