Five Disciplines for Zero Patient Harm: How High Reliability Happens

  • 6h 19m
  • Charles A. Mowll
  • Health Administration Press
  • 2019

Safe care for every patient, in every setting, every time. Is this really an achievable goal for all healthcare organizations?

Yes, it is. The vast majority of occurrences of harm to patients during their care are preventable. But simply aiming for improvement won’t do; healthcare organizations must reset their patient safety goal to zero patient harm.

Five Disciplines for Zero Patient Harm: How High Reliability Happens offers real-world, how-to guidance for driving fundamental change that consistently achieves safe patient care. Drawing on best practices from high-hazard industries such as aviation, nuclear power, and air traffic control, this book details the safety habits and disciplines that are ingrained in such organizations’ cultures and behaviors. Specifically, five disciplines of performance excellence, when consistently applied to healthcare organizations, can save lives and protect patients from harm:

  1. Prepare for excellent performance through simulation, deliberate practice, and training.
  2. Apply proven offensive strategies that exhibit consistent, excellent individual and team performance.
  3. Minimize both individual and team errors through immediate feedback and coach interventions.
  4. Employ strong defensive strategies that effectively block the potential negative effects of errors, latent hazards, and emerging threats.
  5. Coach individuals and teams to achieve consistent, excellent performance in the first four disciplines.

Zero preventable patient harm can be the norm, not the stretch goal, when the practices and action steps in this comprehensive resource are implemented. Five Disciplines for Zero Patient Harm provides an evidence-based guide for hospitals and healthcare systems to transform unsafe behaviors into safe behaviors and safe behaviors into safe habits. That’s how high reliability happens.

About the Author

Charles A. Mowll, LFACHE, served as executive vice president of The Joint Commission for more than 20 years, acquiring expertise in patient safety, high reliability, and Lean Six Sigma. In this role, Mr. Mowll had the opportunity to interact with and learn from some of the world’s leading experts in these fields. He also understands the financial constraints that healthcare organizations face—he spent the first half of his career as a healthcare financial management executive. Following his retirement from The Joint Commission in 2015, Mr. Mowll formed the Patient Safety Coaches Academy, which focuses on helping hospitals develop patient safety coaching programs, enhance the competence of their patient safety coaches, and spread the consistent use of safe care practices. He earned his master’s degree in public health from the Robert Wood Johnson Medical School at Rutgers University. Mr. Mowll is a Life Fellow of the American College of Healthcare Executives and previously was a fellow of the Healthcare Financial Management Association and an American Society for Quality–certified Six Sigma Black Belt.

In this Book

  • Introduction—The Patient Safety Challenge and Setting the Zero Patient Harm Goal
  • Accelerating Change and Changing Behaviors
  • Enhancing Individual Competence, Behavior, and Performance
  • Training Individuals to Effectively Participate on Teams
  • Preparing Through Deliberate Practice and Simulation
  • Preventing Harm Through Safe Care Practices
  • Cultivating Resilience and Adaptability
  • Using Technology to Improve Patient Safety
  • Understanding the Specific Causes of Serious Safety Events
  • Influencing Human Performance and System Performance
  • Influencing the Human Factors That Impact Human Performance and System Performance
  • Strengthening Defenses to Prevent Harm
  • Designing Safer Systems
  • Developing Effective Patient Safety Coaching Skills
  • Coaching Teams to Consistently Demonstrate Safe Behaviors
  • Leading the Cultural Transformation to Harm-Free Healthcare
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