Background

Most health care organizations are still striving to attain high reliability—the ability to minimize adverse events while consistently providing high-quality care in the context of a rapidly changing environment. Workers at the sharp end are best positioned to identify hazardous situations and address system flaws. Although the concept of leadership has traditionally been used to refer to the top rungs of an organization, frontline workers and their immediate supervisors play a crucial leadership role in acting as change agents and promoting patient-centered care. As the safety field has evolved, there is a growing recognition of the role that organizational leadership plays in prioritizing safety, through actions such as establishing a culture of safety, responding to patient and staff concerns, supporting efforts to improve safety, and monitoring progress. Research using a variety of methodologies has defined the relationship between leadership actions and patient safety and has begun to elucidate key organizational behaviors and structures that can promote (and hinder) safety efforts.

This Patient Safety Primer will discuss the role of organizational leadership in improving patient safety. The crucial roles that frontline and mid-level providers play in improving safety are discussed in the related Safety Culture and High Reliability Patient Safety Primers.

The Historical Role of Hospital Leadership in Quality and Safety Activities

All hospitals are overseen by a board of directors, whose responsibilities include (but are not limited to) formulating the organizational mission and key goals, ensuring financial viability, monitoring and evaluating the performance of high-level hospital executives, making sure the organization meets the needs of the community it serves, and ensuring the quality and safety of care provided by the organization. However, hospital boards have traditionally had relatively little direct engagement in evaluating and improving quality and safety. As a 2010 review article explains, board members historically have been community leaders with little to no health care experience, often lacking the knowledge to interpret complex data on the quality and safety of care. Boards also had limited ability to address quality issues that lived within the domain of practicing physicians, given that most physicians are not directly employed by the hospital.

Surprising as it may seem, despite being accountable for the quality and safety of care being provided in their organizations, until recently board, executive, and medical staff leadership at most hospitals in the United States placed relatively little emphasis on identifying and addressing safety issues. A 2010 survey of more than 700 hospital board chairs found that only a minority considered improving the quality of care to be one of the board's top two priorities, and very few board chairs had any direct training in quality or safety. This situation is changing, driven by data on the influence of leadership engagement, as well as greater emphasis on quality and safety in general. Today, we are seeing a shift toward more direct oversight of quality and safety at the organizational level.

How Leadership Can Influence Patient Safety

An emerging body of data now demonstrates a clear association between board activities and hospital performance on quality and safety metrics. A 2013 review found that high-performing hospitals—defined as those ranking highly on objective measures of quality and safety—tended to have board members who were more skilled in quality and safety issues and who devoted more time to discussion of quality and safety during board meetings. Insight into how boards can positively influence quality was provided by a recent study of hospitals in the US and England, which found that boards of high-quality hospitals used more effective management practices to monitor and improve quality. These practices include structured use of data to enhance care, both by setting specific quality goals and regularly monitoring performance dashboards. They also included explicitly using quality and safety performance in the evaluation of high-level executives and focusing on improving hospital operations. Examples of organizations that have transformed their practices and organizational culture to emphasize patient safety include the Dana-Farber Cancer Institute, which responded to a serious and widely publicized preventable death by ingraining patient safety into the responsibilities of clinical and organizational leadership and emphasizing transparency with patients and families, and PeaceHealth, which created a governance board overseeing all safety and quality activities across the system and tied executive compensation to specific quality and safety goals.

Hospital boards influence quality and safety largely through strategic initiatives, but data also shows that executives and management can improve safety through more direct interactions with frontline workers. Leadership walkrounds—visits by management to clinical units in order to engage in frank discussion around safety concerns—can positively impact safety culture. Although walkrounds are widely used and recommended as a safety intervention, recent research indicates that relatively small differences in the way walkrounds are conducted can markedly enhance or limit their effectiveness. For example, issues raised by frontline staff during walkrounds must be promptly addressed, lest staff view the rounds as simply a visibility exercise for leadership. Similarly, voluntary error reporting systems often lack credibility among frontline staff due to insufficient follow up after an error is reported. By engaging with those who take the time to report errors and devoting time and resources to structured follow through, hospital leadership can both address specific safety issues and tangibly illustrate the importance of patient safety as an organizational priority.

An important area in which hospital leadership can directly address safety concerns is through managing disruptive and unprofessional behavior by clinicians. As boards have oversight over the medical staff, they have the ability to ensure unprofessional or incompetent clinicians do not put patients at risk. Although there is limited evidence regarding specific strategies leadership can use to prevent disruptive behavior, some organizations have developed a structured approach that emphasizes early intervention by hospital leadership for clinicians who display recurrent unprofessional behavior or are the subject of multiple patient complaints.

Current Context

The Joint Commission issued a 2009 sentinel event alert highlighting the importance of leadership engagement in improving patient safety. The alert called for organizational leaders to take specific actions to enhance safety within their institutions, including improving the culture of safety and establishing a just culture for addressing errors. The Joint Commission also strongly recommended strengthening hospital boards and patient engagement in safety efforts and making safety performance an explicit part of how leadership is evaluated. The Joint Commission evaluates adherence to the recommendations in sentinel event alerts during the accreditation process.