Building a Culture of Transparency in Health Care

Executive Summary

In health care today, the conversation around transparency centers on the consumer. The consumer is empowered to ask for treatment options and costs, potential treatment risks, realistic outcomes, and much more. Health care providers must respond with as much information as possible to ensure appropriate care is delivered, quality and safety are top of mind, and patients and their care team can make thoughtful care decisions. It is impossible to have complete transparency with patients without first developing a strong culture of internal transparency — among all team members, at all levels, on all issues — throughout the health care organization itself. When team members are open and honest with each other, without fear, it leads to mutual trust, collaboration, and sharing of best practices across disciplines. Patients are the ultimate beneficiaries.

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In health care today, the conversation around transparency centers on the consumer. The consumer is empowered to ask for treatment options and costs, potential treatment risks, realistic outcomes, and much more. Health care providers must respond with as much information as possible to ensure appropriate care is delivered, quality and safety are top of mind, and patients and their care team can make thoughtful care decisions.

I believe it is impossible to have complete transparency with patients without first developing a strong culture of internal transparency — among all team members, at all levels, on all issues — throughout the health care organization itself.

When team members are open and honest with each other, without fear, it leads to mutual trust, collaboration, and sharing of best practices across disciplines. Patients are the ultimate beneficiaries.

Insight Center

Shining a Light: Safer Health Care Through Transparency, a 2015 report by the National Patient Safety Foundation’s Lucian Leape Institute, states that “if transparency were a medication, it would be a blockbuster, with billions of dollars in sales and accolades the world over.” The report defines transparency as the free, uninhibited flow of information that is open to the scrutiny of others.

Barriers to internal transparency. A culture of internal transparency does not come about overnight. There can be many barriers, some of which can be quite complex. For example, employees may be reluctant to report safety issues or errors for fear of being reprimanded by their managers or shunned by their colleagues.

The Lucian Leape Institute report states that “from the quality and safety perspective, transparency is foundational for learning from mistakes and for creating a supportive environment for patients and health care workers.”

At Virginia Mason Medical Center in Seattle, for example, every employee is considered a safety inspector regardless of job or title. All our team members are expected and encouraged to file a patient safety alert whenever he or she sees anything that poses an immediate or potential safety risk. This level of internal transparency is necessary because leaders and team members cannot correct problems unless they know they exist.

Internal transparency is hindered when lessons learned aren’t shared freely across the enterprise. While many organizations have routine team huddles, it is critical to prioritize multidisciplinary huddles and encourage clinicians to break through silos by sharing information with their colleagues in other specialties and departments.

Providers are often hesitant to disclose mistakes to their patients even though a 2006 study in the Journal of General Internal Medicine concluded that full disclosure is associated with a lower likelihood of changing physicians, higher satisfaction, and greater trust.

Leaders must create a no-blame culture. The most effective way to build a culture of transparency begins with those in leadership positions. It is the responsibility of the leadership team to develop an atmosphere in which there is balanced accountability and continuous improvement and this is everyone’s shared duty. Leaders must lead by example.

A 2013 article in The Ochsner Journal, titled “Just Culture: A Foundation for Balanced Accountability and Patient Safety,” concluded that “a fair and just culture improves patient safety by empowering employees to proactively monitor the workplace and participate in safety efforts in the work environment.”

A new paradigm. When something isn’t working in health care, it can take a long time to change, but providers can reach their own unique breakthrough moment that serves as the catalyst for long-term transformation.

At Virginia Mason, we began nearly 20 years ago to create a culture in which our team members could believe zero-defect care is possible and have the tools to make this happen. We recognized that to achieve such a transformation, a paradigm shift was needed. Our management approach at the time was not nimble enough to keep up with the changing health care environment: We needed to eliminate wasteful elements from patient care, and we wanted to empower our employees to be stewards of patient safety, regardless of their job title.

To find an innovative way forward, we looked beyond our own industry because traditional approaches in health care management had not evolved much over the previous decades. In 2002, we implemented the Virginia Mason Production System (VMPS), a management method that employs basic principles of the Toyota Production System for eliminating waste (i.e., anything that lacks value from the patient’s perspective), improving quality and safety, and controlling cost.

This change did not happen easily. There were doubters and naysayers, as well as enthusiasts who were open-minded about exploring a new path. Some team members adopted a wait-and-see attitude. A few decided to leave our organization. There was a mix of optimism and a feeling of loss as it became clear that doing things as we’d always done them was no longer good enough.

By openly sharing information in employee forums and during one-on-one conversations over several months, we worked to help our team members understand that change was necessary for the future of the organization. We developed compacts with our physicians, board members, and leaders at all levels that clarified organizational expectations and what, in turn, they could expect from the organization. Our leaders — including department directors and managers — are required to practice VMPS methods and teach them to their teams. Completing a course in VMPS basics is an important part of the onboarding process for newly hired employees.  The result is a safer environment for patients and staff.

I believe all of us in health care have a moral imperative to make health care better and more affordable. Safety is the foundation of quality.

In 2004, one of our patients, Mary McClinton, died because of an avoidable error while she was in our care. That mistake shook us to our core as an organization. It also served as an inspiration to create an environment that is safe for every patient and team member, and to be open with our patients, staff, and the community about our work to continually improve safety. To honor Mrs. McClinton’s legacy, we created an annual award that recognizes a team that improves quality and safety through innovation. Their projects are shared broadly across the Virginia Mason organization so everyone understands how patients and care givers will benefit from the award-winning initiatives. Members of Mrs. McClinton’s family attend the award ceremony that is named for her.

In the United States, we have more information than ever about how to provide appropriate, high-quality care and keep patients safe. Transparency with internal and external stakeholders is essential for quality, safety, accountability, and informed decision making. As the Lucian Leape Institute report explains, transparency between clinicians and patients, among clinicians and health care organizations, and between health care organizations and the public produces safer care, better outcomes and more trust among all the involved parties.

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