Despite the tremendous efforts and advances in practices and technologies, medical errors remain a pervasive and persistent problem in the United States. In terms of patient safety and risk, in some respects, we have failed to eliminate the system failures that arise from the lack of evidence-based practices that measure the effectiveness and efficiency of risk strategies. The cure is to pursue innovation in risk management, develop evidence-based practices, and merge them with effective solutions, according to Douglas Hubbard, author of The Failure of Risk Management: Why It’s Broken and How to Fix It.
Innovation is a process that needs a social structure and a safety culture to foster it. Here are three categories of personality attributes described in the Rogers Innovation Adoption Curve that need to be considered for innovation to thrive:
There must be structures in place to test new innovations with data and evidence as well as processes to develop, evaluate, apply, and monitor the successes and failures of new ideas that need to be implemented.
"Design thinking" is one example of a useful process. In healthcare, systems often emerge in response to the availability of resources rather than the needs of the end user. Design thinking creates systems based on the patient's and provider's specific needs. By developing an understanding with the end user, testing and fine-tuning new solutions, and tracking their progress, design thinking can assist healthcare risk managers to find solutions that are predictive rather than responsive. Another example is the Garfield Innovation Center at Kaiser Permanente where teams apply their field experience to explore new care solutions through hands-on-simulations, quick prototyping, and technology testing.
To achieve ultimate success, innovation has to involve all partners. There needs to be a clear message to stakeholders of what value the innovation would bring to their specific needs. Understanding the opportunities and costs for all players will enable lasting collaboration.
By building relationships, testing promising ideas, and creating buy-in for these efforts, we can improve risk management and safety practices in healthcare.
The American Society for Healthcare Risk Management (ASHRM) has recognized the need to develop evidence-based healthcare risk management (EBHRM) and treat it as the key to unlocking the potential of risk management to improve patient safety. EBHRM is defined as "the conscientious use of current best evidence in making decisions to manage risk in the design and delivery of healthcare systems and services." There is some evidence that risk managers contribute to patient safety, but if this contribution is not improving overall, our approaches clearly need to change.
The success of almost any risk management program depends on the support of many stakeholders. To be successful, this support must come in the form of budgetary resources, frontline staff engagement, management support, and effective safety culture. EBHRM would bolster the support for the successful practices and interventions they recommend.
Healthcare risk managers play an integral role in helping their organizations achieve the goal of "Getting to Zero" serious safety events. By ensuring that practitioners have the tools they need to identify, implement, and sustain proven risk management interventions, EBHRM will improve the effectiveness of risk management practices to reach the goal of patient safety improvement. We can develop transformative, evidence-based solutions that not only improve the quality of care and reduce costs but also save lives.
Authored by Cindy Ebner, MSN, RN, CPHRM, FASHRM
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