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A Culture of Safety in Hospitals and the CEO’s Role

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I prepared a handout for a recent HCESoCal educational/networking event and I’m sharing it here, because I really believe it is important for truly effective healthcare leaders.  

I prepared a handout for a recent HCESoCal educational/networking event and I’m sharing it here, because I really believe it is important for truly effective healthcare leaders.  

Quality and safety do rise out of the culture of the organization and ownership for creating it is the responsibility of the leadership team.  But, the CEO’s desk is where the buck stops.  And, the governing body is reponsible for the oversight to ensure that the roles and responsiblities are carried out in accordance with their policy.

Core Organizational Infrastructure Components[i]

 A Culture of Safety

  • Plans for Managing Risks and Maintaining a Safe and Secure Environment of Care (Hazardous Materials/Waste, Fire, Medical Equipment, Medical Gases, Utility Systems, etc)
  • Collecting Information, Monitoring Conditions, Analyzing Issues and Improving the Environment of Care
  • Integrated Patient Safety Program (National Patient Safety Goals, Staff Competency, Infection Control, etc)
  • Emergency Management (Hazard Vulnerability Analysis, Emergency Operations Plan, Communications, Managing Resources/Security/Safety/Staff/Patients/ Volunteers/Utilities, &Testing/Exercises)
  • Life Safety
  • Communication (Between leaders and to those who need it, including staff, licensed independent practitioners, patients, families and external interested parties.)

The Healthcare Executive’s Role[ii]

Guide an organizational culture dedicated to improvement, focusing resources on the structures, processes and monitoring systems that will ensure patients receive the care they need without risk of harm.

Equip board with tools and information to provide appropriate oversight of the patient safety/quality strategy

  • Involve the entire executive leadership team in the patient safety/quality strategy
  • Engage the medical staff as meaningful partners in the development and implementation of the patient safety/quality strategy
  • Develop processes to hear the voices of patients and families and applying their input in the design and improvement of care processes.
  • Cascading a patient safety/quality orientation throughout the organization
  • Develop a culture of improvement that includes an organization-wide commitment to continuous learning.
  • Rigorously seek out and apply best practices.
  • Provide open communication and demonstrate a commitment to transparency
  • Adopt information systems that support the patient safety/quality strategy
  • Encourage organizational involvement in voluntary collaborative

 [i] Joint Commission 2011 Acute Care Standards, Revised December 2010.

 [ii] The Healthcare Executive’s Role in Ensuring Quality and Patient Safety, ACHE Policy Statement, November 2008.


Feel free to download the actual Healthcare Safety Program Handout

Also check out the article The Patient Safety Team: Healthcare Executives Embrace Their Role, which highlights the impact that transparency is having on moving safety to the front burner. 

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