Developing a culture of accountability

By Kim Rose

“You cannot change what you do not acknowledge.”

Straight-shooter “Dr. Phil” McGraw popularized this phrase as a self-help guru, but it certainly applies to health care process improvement.

In each Q Report, we will highlight how we’re taking action from “Lessons Learned” as a result of adverse events. We’re not alone. The news media reminds everyone that hospitals nationwide must tackle preventable adverse events that could or have resulted in harm to patients.

As health care transparency increases, and multimedia tools make information plentiful, consumers are more savvy and informed. Patients fear hospital-acquired infections, surgical errors, falls, medication errors, and medical personnel who might get distracted and fail to respond to monitoring equipment or alarms, or accidentally overlook symptoms. We encourage patients to actively participate in their care, but they should be able to rely on us.

We have had such incidents. Again, we are not alone. Throughout the industry, we are acknowledging and addressing what leads to human error.

“We need to think from our patients’ perspective, to give patients our full attention when they are in our care,” said Randy Harmatz, UF&Shands chief quality officer. “We are responsible to look after and protect

each patient as if they are our mother, father, grandparent, child, spouse and so on.”

Believing and acting from a sense of accountability and responsibility comes from feeling empowered, Harmatz said.

If you are empowered to protect your patients, you will speak up, ask questions, call on a co-worker for support, find someone who can help, catch a potential error, problem-solve, respond on the spot and report an issue.

Without hesitation or fear because it’s the right thing to do.

“You are accountable to your patient, yourself, your entire team and your fellow clinicians,” Harmatz said. “You support each other and feel like every patient is in your care.

“In health care, too often we feel frustrated and overwhelmed. We are tempted to say, ‘It’s not my patient, it’s not my job.’ But it is your job. When we put our patients first, then patient care, safety and quality is our job every time.”