As the pressure to improve patient safety has grown, healthcare organizations, particularly hospitals but also larger healthcare systems, have struggled to create effective structures for their safety efforts. Although there are few studies comparing various organizational models, best practices for promoting organizational safety have begun to emerge.1–6 This chapter will explore some of these issues. The organization of safety programs in ambulatory care is discussed in Chapter 12, and, of course, myriad issues relevant to organizing an effective safety program are addressed throughout this book.
Before the year 2000, few organizations had patient safety committees or officers. If there was any institutional focus on safety (in most institutions, there wasn’t), it generally lived under the organization’s top physician (sometimes a Vice President for Medical Affairs or Chief Medical Officer [CMO], or perhaps the elected Chief of the Medical Staff) or nurse (Chief Nursing Officer). In academic medical centers, safety issues were usually handled through the academic departmental structure (e.g., chair of the department of medicine or surgery), promoting a fragmented, siloed approach. When an institutional nonphysician leader did become involved in safety issues, it was usually a hospital risk manager, whose primary role was to protect the institution from liability.7 Although many risk managers considered preventing future errors to be part of their role, they rarely had the institutional clout or resources to make durable changes in processes, information technology, or culture. Larger institutions with quality committees or quality officers sometimes subsumed patient safety under these individuals or groups.
The latter structure is still common in small institutions that lack the resources to have independent safety operations, but many larger organizations have recognized the value of a separate structure and staff to focus on safety. The responsibilities of safety personnel include: monitoring and responding to the incident reporting system, educating providers and others about new safety practices (driven by the experience of others and the literature), measuring safety outcomes and developing programs to improve them, and supervising the approach to serious events (e.g., organizing root cause analyses [RCAs]) and to preventing future errors (e.g., implementing action plans after RCAs, performing failure mode and effects analyses [FMEA]) (Chapter 14).8 In addition, such personnel must work collaboratively with other departments and personnel, such as those in information technology, quality, compliance, and risk management.
An organization interested in improving the quality of care (as opposed to patient safety) might not spend a huge amount of time and effort promoting reporting by caregivers to central administration. Why? To the extent that the quality issues of interest can be ascertained through outcome (e.g., mortality rates in patients with acute myocardial infarction, postoperative infection rates, readmission rates for patients with pneumonia) or process measures (did every patient with myocardial infarction for whom it was indicated receive a beta-blocker and aspirin?) (Chapter 3), performance assessment does not depend on the direct involvement of nurses and ...