Case management and patient safety☆

Elements of a culture of blame 

A cursory review of the literature shows that patient injuries from medical errors are a huge problem in health care, particularly those resulting from medication errors. The Institute of Medicine report “To Err is Human” cites 2 separate studies in concluding that perhaps 44,000 to as many as 98,000 patients die annually because of medical errors—more than from highway accidents, breast cancer, and acquired immunodeficiency disease syndrome combined. Even if we accept the lower estimate, medical error deaths still exceed the number attributable to the eighth leading physiologic cause of death. Even though the data are subject to manipulation, we cannot dispute the fact of patient injuries and deaths from medical errors. Whatever the actual rate, the injury rate in health care compares unfavorably with other industries.

We can agree on the traditional institutional response to patient safety. Authors on the subject almost uniformly have concluded that the health care industry has failed to design systems for patient safety, relying instead on individual “error-free” performance enforced by punishment. There is an entrenched belief in the effectiveness of blame and punishment for error prevention—a conviction reinforced by highly punitive legal and regulatory systems and the public media. The health care industry relies almost exclusively on the threat of legal, financial, or disciplinary penalties to ensure patient safety and operates on the assumption that most patient injuries result from poor practitioner behavior (eg, incompetence, negligence, or corporate greed). In short, a culture of blame pervades health care.

Experience in other industries confirms that this approach produces the exact opposite outcome from the intention. Blame and punishment provide strong incentives for people to hide their mistakes, which prevents the recognition, analysis, and correction of underlying causes. Rather than improving patient safety, blame and punishment make reducing errors much more difficult.

Toward a patient safety culture 

When the health care industry attempts to change the personal attitudes of its professionals without addressing either their job-related behaviors or systems management, the industry fails in its efforts to address patient safety issues. Or when the industry disregards the job-related behaviors and personal attitudes of professionals, it fails in its efforts to change the management of systems. Each dimension of the personal, the behavioral, and the systemic is essential to create a safety culture.

Thus, the promotion of a safety culture hinges on the development of the dimensions of safety climate, behavior, and management. A patient safety climate, for example, depends on the personal commitment of health care professionals and staff to patient safety, their personal involvement in decisions about patient safety, their patient safety knowledge, and their personal commitment to their institutions. Patient safety behavior, on the other hand, depends on teamwork, task strategies and complexity, and work environment. Finally, patient safety management depends on management commitment and actions, communications, resource allocation, strategic planning, policy development, standards, feedback, and monitoring. In short, a patient safety culture must encompass subjective internal, psychologic factors, observable day-to-day patient-safety behaviors, and objective systems and subsystems oriented to patient safety.

Case manager contributions 

How can CMs help transform the health care industry from a culture of blame to a culture of safety? A brief analysis of the organizational actions that help create or enhance a safety culture will help us derive some ideas about how CMs can promote these characteristics throughout the industry. These actions include the following:

CMs have multidisciplinary resources at their disposal that could help make a significant contribution to the development of each of these characteristics throughout health care. CMs intermittently perform 3 functions and roles—education, case consultation, and monitoring and auditing—that they could use to promote a patient safety culture. For example, CMs could use their educational function and role to influence a patient safety climate that depends on shared beliefs, values, and attitudes regarding patient safety. Through education, CMs can help shape a self-sustaining image of patient safety among administrators, practitioners, staff, employers, and patients themselves. Shared beliefs, values, and attitudes about the importance of patient safety then foster a commitment in the industry to the patient safety culture.

As we have seen, when the industry focuses entirely on the attitudes of practitioners, it actually undermines patient safety climate. Health organizations have relied primarily on discipline to change people's attitudes and behaviors. But discipline is an inefficient means by which to manage change in values, beliefs, and attitudes or unsafe behavior. The literature on safety culture suggests that the best way to change safety attitudes and unsafe behavior is to focus on safety behavior. This focus entails adopting a collaborative, problem-solving approach involving administrators, professionals, and staff to identify critical sets of safe and unsafe behavior. CMs could use their case consultation function to help develop “safety inventories” that administrators, professionals, and staff use to monitor patient safety behavior. CMs thereby would encourage cooperation, involvement, and better communication to improve patient safety climate and behavior.

Safety management systems 

A patient safety climate ultimately depends on the perceptions and beliefs of health care professionals and staff about the industry's patient safety management practices. Organizations ought to adopt a holistic approach to developing the safety management dimension of safety culture. A safety management system depends on many activities with diffuse responsibility and therefore requires an integrated approach for managing safety risks, ongoing safety performance, and compliance.

First, an organization should develop its safety management practices based on management commitment and action, communications, strategic planning, policy development, and procedures that provide internal consistency and harmonized functions. Second, an organization should audit the system to ensure the reliability, efficiency, and effectiveness of its planning, policy development, implementation, and monitoring of safety performance. Finally, an organization ought to perceive the development of a safety management system as a way to generate awareness, understanding, motivation, and commitment on the part of all personnel.

CMs could use both their education and particularly their monitoring and auditing roles to influence the development, implementation, and monitoring of patient safety management systems. Through education, CMs could influence management commitment and actions, communications, resource allocation, and strategic planning. Through monitoring and auditing, CMs can influence the development of patient safety standards. By helping to develop such standards, CMs can help the industry monitor and review interrelated safety activities.

Conclusion 

As the safety literature shows, the creation and maintenance of a safety culture is multidimensional and depends on dynamic reciprocal relationships among multiple stakeholders premised on mutual trust. Organizations with an interest in safety must attend to each safety dimension—climate, behavior, and management. Experience in other industries demonstrates that failure is probable if health service organizations try simply to change attitudes about safety, mandate only organizational systems changes, or seek changes only in the behavior of health care professionals and staff. Each dimension is integral to the creation of a culture of safety.

CMs ought to be at the epicenter of the industry's transformation from a culture of blame to a patient safety culture. CMs have multidisciplinary resources at their disposal that may be used to help the industry address not only the subjective internal, psychologic factors of patient safety but also the observable day-to-day behaviors related to patient safety and the objective patient safety-oriented systems and subsystems. The case management functions and roles of education, consultation, and monitoring and auditing lend themselves perfectly to the development of those organizational characteristics that support the creation and maintenance of patient safety culture throughout health care.