Greater openness among clinicians is needed to drive improvement in patient safety

Patient Safety Monitor Insider

January 6, 2016

By Tejal K. Gandhi, MD, MPH, CPPS

Earlier this year, the National Patient Safety Foundation?s Lucian Leape Institute released a report calling for greater transparency in healthcare as a means of improving patient safety. Defining transparency as ?the free, uninhibited flow of information available to the scrutiny of others,? the report argues for transparency across all areas of healthcare: between clinicians and patients; among clinicians; between organizations; and with the public (NPSF Lucian Leape Institute, 2015).

Yet weaving transparency into the fabric of everyday practice is easier said than done. Throughout the year, Institute members have expanded upon this theme in articles, webcasts, and meetings as we address how to do the hard work of implementing practices that can help us achieve greater transparency.

At the Institute?s fall meeting in Boston, leaders, researchers, and frontline clinicians discussed the practical challenges to transparency. One bit of consensus from the groups was that getting providers and provider organizations to share data and information is essential for improving patient safety, but it is also one of the most difficult areas in which to make progress.

Greater openness between providers has the potential to help us better understand safety risks, spread best practices among peers, and perhaps most important, begin to reduce the shame felt by clinicians when an error occurs, which can then help normalize the reporting of errors and adverse events (NPSF Lucian Leape Institute, 2015). Sharing of data among clinicians?including outcomes and safety data?has largely been limited to peer review sessions or committee meetings within organizations. Some organizations begin board meetings with storytelling of safety lapses, and others publish newsletters to share safety information among the staff (Kowalczyk, 2013).

Unfortunately, one of the greatest barriers to transparency among clinicians lies in the very culture of the organizations in which they work. So many years into the patient safety movement, we still hear stories of blame or fear of punishment in regard to reporting safety issues.

(Editor?s note: This article was written by Tejal Gandhi, president and CEO of the National Patient Safety Organization, and originally appeared in the November/December issue of PSQH. Read the full article here.)