Going to a hospital to get healthier should not be a life-threatening activity. Yet, various research accounts (The Institute of Medicine) state that around 100,000 Americans die annually from preventable hospital errors. Patient Safety America estimates the number of deaths to be between 210,000 and 440,000 a year. Whatever the real number may be, the fact is the cascading threats that create preventable hospital deaths are invisible, underestimated and can build up slowly and silently over time.
A Healthy Hospital Culture keep Patients Healthy
The health of any hospital system’s activities can be likened to a circulatory system in the human body (Figure 1). The level of patient safety can be assessed by diagnosing the circular cascade in a hospital that is triggered by leadership decisions that influence the culture, work processes, performance, responses to critical situations, and learning feedback loops. Studies have shown that the teamwork health of a surgery teams can dramatically impact the success of a surgical operation and the survival chances of the patient.
Assessing Patient Safety Threats
The health of any hospital team or sub-system correlates highly to patient safety. A Cascading SWOT Analysis (Figure 2) examines the Strengths, Weaknesses, Opportunities and Threats for each of the 6 elements in an organizational cascade. It can be a very powerful tool If broad, candid and honest inputs from all stakeholders are solicited and addressed. It can be effectively used to identify and address risky.
Hidden Threats in the Healthcare System
Over 100 key threats to patient safety can be assessed, which often link to form powerful forces that can create significant safety threats to patients. Just one of those 100 threats was highlighted in a 2012 study published in the Archives of Internal Medicine. It noted that 38 percent of the doctors surveyed had high emotional exhaustion scores and 30 percent had high depersonalization scores (viewing patients more like objects than human beings). This is bad for patient safety.
Hybrid and Gamified Safety Systems
Hospitals are in need of effective safety systems that integrate the best practices of several safety initiatives to create a highly effective safety culture (Figure 3).
This hybrid approach does not have to be more complicated than any one of its contributing elements. It can even be a gamified collection of the most effective aspects from each best safety practice. Individual safety methods have shortcomings. They don’t fully address all of the organizational barriers required to achieve breakthrough success. In contrast, a comprehensive, hybrid, cascading safety initiative seamlessly applies the best features of many complimentary safety methods to significantly enhance patient safety and to create positive organizational safety cascades, at all levels.
Gamification provides a framework for stakeholders to candidly identify and assess practices – even sensitive and unspoken topics. By soliciting and comparing risk and best practice perceptions at leadership, mid-management and non-management levels (Triangulation), we can develop a complete and accurate assessment of the health of an organization’s patient safety practices.
Gamification has many other benefits. It enhances employee engagement, builds ownership and overcomes resistance to change. It can transform a dull analysis into an exciting and stimulating activity. Gamification promotes high levels of team focus and innovation.
Stay tuned for more articles on how gamification and war gaming can be a powerful addition to your safety and risk management toolboxes.
Bio: David Patrishkoff is President of E3 – Extreme Enterprise Efficiency® and the Founder of The Institute for Cascade Effect Research®. He is a Lean Six Sigma Master Black Belt, Adjunct Professor for Kettering University Master’s Degree Programs and the inventor of a Cascading Risk Management Methodology. Prior to starting his consultancy in 2001, David held many worldwide senior executive positions in the automotive and trucking industry. Author email: david.patrishkoff@cascadeeffects.com.
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