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Safety Across the Board,

September 22, 2014

Life has the capacity to end in so many different ways. But for those who have lost a love one to a medical error or experienced medical harm, there is a lasting sense of hurt that lingers long past the event. Any random act of violence, acute illness, disease or accident can result in the need for a hospital stay. To that same point every hospital stay incurred today has the ability to result in a number of preventable harms that might also cause death.

A major sense of urgency came upon me after losing my father to a preventable medical error. Although, trained in health care operations and having worked in the field professionally for many years before, it wasn’t until after his death that I embarrassingly learned of the vastly inconsistent ways in which health providers monitor and manage the risk of medical harm. It wasn’t until his death that I learned first-hand about the extreme lack of transparency, inadequate communications and forfeited learning moments that happen all too often when harm occurs. Through my reflection of this still indescribable tragedy my passion grew stronger for the needs of everyday consumers. Today, I find that while there has been some progress this issue still remains very political and insufficiently prioritized at the local level. Mobilizing Patient and Family Advisory Councils (PFACs) on the front lines in local hospitals is a key strategy for moving this agenda forward.

The most astonishing discovery was the lack of consistency in the design of patient safety programs and the lack of proactive surveillance systems used to identify, measure and monitor all forms of preventable harms. As I began to do my research, hospital by hospital, every system was different. And in most cases harms were indeed dealt with like projects; on a case-by-case basis. I became completely broken hearted. Not only for my own situation, but for the millions of lives lost from preventable harm.

Daddy died in 2009, but it wasn’t until 2013 I discovered a methodology that could be a major game changer in health care. As originally introduced through the work of the Partnership for Patients Hospital Engagement Networks, Safety Across the Board (SAB) embraces what patients see as important. Safety Across the Board activates a systematic approach toward eliminating harm. To embed the consumer focus, patient and family engagement and health equity are central parallels to the work of Safety Across the Board. Rather than a project-by-project approach, hospital leaders operationalizing Safety Across the Board are requiring that their safety programs focus on reducing all harms occurring in the hospital setting through the systematic development of composite scores and reporting systems. There are several foundational components to achieving Safety Across the Board:

• Adoption of a culture of safety; where safety is a strategic imperative and is interwoven into the fabric of all organizational priorities
• Composite scoring and reporting that includes all known forms of harm
• Inclusion of patient and family engagement throughout the health services continuum and of inclusion and diversity as core principles or Patient and Family Partnership Councils development
• Health equity as a performance strategy. Hospitals operationalize strategies that identify and eliminate disparities in safety outcomes

The mechanism of composite scoring adds transparency to the decreases and increases in all preventable harms. Instead of having a bunch of different reports that look at various harms, hospitals use an aggregated report (composite scoring) to show all presentable harms in one grid. This provides a way of tracking opportunities by making obvious the lives harmed as well as the areas of improvements by counting the lives saved and harms prevented. Composite scoring exposes harm in a logical way. It calculates lives lost and lives saved in a very practical way that even people with non-clinical backgrounds easily understand. Similar to the way the airline industry provides directions for landing in case of an emergency, simple is what safety should be. Easy to interpret and communicate, so that more lives are saved.

The Safety Across the Board model is an epic change in the patient safety movement that puts into action a full complement of stakeholders working together on multiple levels to eliminate all forms of avoidable harm. Through patient and family engagement as well as the way in which reporting is structured, SAB moves the safety discussion from percentages and figures to the sharing of faces and real people who have been impacted by preventable harms within hospitals and health systems. Safety Across the Board provides both patients and providers a roadmap to improving safety in a meaningful way.

I gasp when I think that few hospitals have yet to integrate their work in health disparities with their quality programs. I gasp when I think about the few facilities that are looking at all known forms of preventable harm and making that information transparent to consumers. I gasp when I think of the fact that while many would agree hospitals shouldn’t compete on the issue of safety, there still is a sense of entitlement in that field that separates the concerns of real people and medicine. I gasp when I go into rooms where patient voices are filtered by corporate perspectives and overshadowed by pre-planned agendas. Safety Across the Board provides a practical framework for creating more robust and patient-centric safety systems.

As a patient advocate, I simply want to know that my loved ones and I are being protected against every possible harm at all times by every health care provider we engage. It’s just that simple. I challenge all consumers to spread and share Safety Across the Board.

SAB Conceptual Model_v10_wLEAPT (2) (1)-page-0

by Knitasha Washington, DHA, FACHEDr Knitasha Washington (2)
After many of years of commitment to advocating for the elimination of health disparities, her perspective on the U.S. Health System changed dramatically after losing her father to a medical error in 2009. “What I found out first hand was the bias that is embedded in the fabric of our health systems”, shares Dr. Washington. Today, Knitasha serves in multiple roles driving change and innovation nationally. As an advisor to the National Partnership for Patients Campaign, Dr. Washington has been commended for her work to improve equality of health outcomes within the quality domain. Knitasha is credited for being the thought-leader that forged a pathway to consider health disparities among vulnerable populations a strategic imperative in the nations fight to achieve improvement in quality and patient safety.

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One Comment
  1. Great blog Knitasha. My experience is with the Canadian medical system with chronic heart and now cancer problems. Given I live in a small isolated town the multiple conditions along with inconsistent medical access and garbled communications mean I need to be very proactive. Systems, even ones claiming to be caring institutions dislike “outsiders” who meddle with rationally constructed procedures and seek only cooperation.

    My cynical opinion is that my local mechanical shop is way more competent at “treating” my car than the local hospital is at people care. The excuse that people are more complex than machines simply ignores the fact that mechanics monitor their own performance and can’t blame the car for being uncooperative while doctors are all over being right without proof and experts at shedding blame.

    The obvious counter to my cynicism is that people like your Dad die which is an injustice to the care we all owe each other–not a policy, not a procedure but respect.

    Thank You for this tip on Safety Across the Board. It sounds like something my oncologist and cardiologist need to consider.

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