When the State of New York Department of Health recently commissioned three quality improvement projects the topics seemed, at first sight, to be like many other quality projects before them. Each clinical topic is aimed at preventing recognised complications of interventions and each has an evidence base: perioperative use of beta blockers in non-cardiac surgery, prevention of thromboembolism, and surgical antimicrobial prophylaxis. Each group of hospitals that won the competition to run the projects has developed an evidence-based standard of care. Implementation of each clinical standard might be thought to run the risk that taking the evidence into practice may suffer from the usual barriers.¹ This all seems routine, so what is new?

The differences, and the enhanced opportunities for success, lie in the context of the projects which are part of an initiative that aims to change practice and improve outcomes and, hence, improve safety. Each of the topics represents a type of adverse event regularly reported in the New York State Patient Occurrence Reporting and Tracking System (NYPORTS).² Topic related pre-implementation adverse event data are already available on the NYPORTS system for each participating hospital, and post-implementation data will be used to assess the effectiveness of the implementation package. These post-intervention data relate to important short term outcomes such as intraoperative or postoperative myocardial infarction, deep venous thrombosis or embolic events, and wound infections, together with associated mortality, morbidity, and costs.

Something else is different. Senior hospital executives are required to be part of the project team, which means that they—as well as the clinical team members—have explicit responsibility for delivering better and therefore safer care. All this raises intriguing questions about the accountability role of boards and management in delivering safe care. In the post Enron and WorldCom age, where boards are increasingly being encouraged to ask tough questions of the companies they govern, should healthcare boards be held accountable for clinical practice at the institutions they govern? Should boards be leading the charge to improve the safety and quality of patient care?

The involvement of chief executives, finance directors, and board members may be where patient safety programmes have the edge over “traditional” quality improvement programmes, for safety looks at quality from the other end of the telescope. Of course, every safety project should recognise the hard work of clinical teams who improve care by increments (sometimes over many years). But the safety perspective challenges the whole organisation. The safety approach says that those people who are not receiving evidence-based care represent a safety challenge. The people who are not receiving thromboembolism prophylaxis or who have had a myocardial infarction and been discharged from hospital without aspirin are at risk. Some will suffer an adverse event as a result of not receiving necessary advice or intervention.

“Safety looks at quality from the other end of the telescope”

Gaining the attention of hospital and primary care organisation chief executives and boards, sometimes for the first time, brings with it a recognition that quality of care is as much their responsibility as it is that of clinical teams.³ Leape⁴ has referred to this as “reciprocal responsibility”. Clinical teams take care to provide professional care under the circumstances in which they work. In turn, employers, managers and health service funding bodies have a responsibility to provide the circumstances, skills, people and equipment with which safe care can be delivered. This includes attention to the safety climate of the organisation, perhaps through what Weick and colleagues⁵ have characterised as the “process of mindful organising”, in which there is a preoccupation with the likelihood of failure and a reluctance to simplify interpretations. This constant sense of unease might help to explain how some organizations are able to sustain high risk repeated encounters without suffering adverse events.

Safety brings with it a further dimension, one that many clinical teams have long struggled with. Safety is a systems issue. As knowledge advances and new technologies are deployed in the workplace, many undesired and unanticipated risks and consequences result. Although, disappointingly, some of the literature still refers to “medical error” and “human error”, deep questioning related to adverse events will usually identify underlying systemic causes.^6,7 Healthcare organisations are complex and are almost always under pressure, so the chance of failing to provide an element of care, or providing the wrong one, is always there if human activity is left unsupported by systems which can take up routine tasks, provide information, support decisions, and force safer functions.

Do support systems work? Evidence on guideline implementation suggests that there are no easy fixes when it comes to effecting change in clinical behaviour.⁷ But case studies on safety and system re-engineering from the Institute of Healthcare Improvement in the United States⁹ and from the National Health Service modernisation programme¹⁰ have demonstrated real gains by engaging managers and by using systems approaches to quality and safety. Additionally, much of the research on improving the quality and safety of prescribing suggests that systematising the process can lead to substantial improvements.¹¹

Quality used to be considered the preserve of clinical teams. Sometimes this was because of defensiveness and a wish to remain separate from management, sometimes because management was uninterested, more often because each side did not recognise each other’s role. However, moving towards a culture of safety is at the heart of the ethical imperative of changing health care.

This places new requirements on healthcare organisations for even the introduction of clinical governance meant that healthcare organisations were more concerned with risk management than the more positive and encompassing concept of safety. Furthermore, every healthcare organisation faces significant safety and quality challenges that cannot all be fixed at once. Clinical and managerial partnership is required to set priorities and to support a culture of safe and effective practice.

The concept of safety as part of quality improvement enlarges the “quality envelope”. Engaging senior management, funding agencies, and healthcare professionals with the safety agenda through a growing recognition of reciprocal responsibility and a focus on systems as well as people is the new dimension. It just might work.