April 28, 2010 | | Comments 0
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It’s not just reporting EC improvements, but tracking whether they truly made things better

When I conduct the EC interview session with clients, I always review their annual evaluations, and I almost always ask the question, “Looking back at the last 12 months, what improvements have been made in the organization’s ability to manage risk in the physical environment?”

I then wait a moment before translating into English, “What got better in the last 12 months?” which generally results in a trickle of response, but once folks get the hang of it, they can usually think of a fair amount of stuff.

Once we cover a few items, I will ask them, “Accepting that these are things that got better, the question then becomes, how do you know it got better?” which ultimately points you towards making the most use of the annual evaluation process.

You want to be able to identify improvements you’ve made, and you want to be able to articulate how those improvements have manifested themselves. But you also want to identify what didn’t go as well you expected, wanted, hoped, and dreamed.

We do not live in a perfect, risk-free world, and our evaluation of the risk management process should be reflective of that. Speak of the organization’s vulnerabilities and ways to reduce those vulnerabilities.

And yes, I understand that folks are frequently squeamish about “officially” dealing with failure modes because it could get them into trouble during a Joint Commission survey, and there are, no doubt, surveyors that do not understand how this whole process is supposed to work. But those vulnerabilities exist, whether you “officially” acknowledge them or not.

If I see performance indicators that are always perfectly coiffed, I know that there’s some digging to do, and I generally know where to dig from having seen a client’s building. Any surveyor can go into an organization and find deficiencies — this goes back to the “no perfect world” concept.

The key is to ascertain how the organization identifies those failure modes and develops strategies for making and sustaining improvements. That, I submit, is what you should be sharing with your governing board — what went well and why, and what didn’t go well and why, how we’re going to make it better, and here’s how board members can help us.

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Filed Under: Environment of care


Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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