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DALLAS, Texas (April 26, 2009) — As I continue my series of blogs on leadership, I read a story on the HealthLeaders.Com web site that once again brought into focus the important role a health system or hospital CEO plays in setting a leadership culture that ensures that his or her patients are safe.


Philip Betbeze, for HealthLeaders

“Nobody wants to harm patients, especially the CEO, but according to Rick May, M.D., an orthopedic surgeon (who)consults for HealthGrades, it’s likely your hospital has a culture of hiding mistakes. And it’s lurking, just waiting to bite you.

“According to a recent study by the healthcare ratings organization, a Medicare beneficiary experiences a patient safety event every 1.7 minutes. And the innocuous nature of the word “event” doesn’t effectively describe that it’s a synonym for mistake, sometimes one that ends a life prematurely. Some 913,215 patient safety events occurred during the scope of the study, which was conducted from 2005-2007. That means approximately 2.3% of the nearly 38 million Medicare hospitalizations resulted in an error.” (To read the entire article, visit the HealthLeaders site. It is a great resource for ideas and information.)

This story is disturbing but NOT surprising.

If you look at the number preventable mistakes that lead to death or complications, if you look at the number of deaths from failure to respond, it is clear that there are a multiple of barriers at hospitals across the country that limit our ability to improve the quality of care and patient safety.

A good leader must own the responsibility of creating a culture that breaks down these dangerous barriers – a culture that does not tolerate anything that might result in harm to a patient.

My days of hospital operations are over but I still have a responsibility for helping to improve my industry’s performance. At JohnMarch Partners, we have added an entire section to our already extensive candidate screening interview process that focuses on prior performance, attitudes concerning transparency, and experience in changing an organization’s patient care-safety culture. In short, we want to know, conclusively, whether they walk the talk.

CEOs cannot rely on quality of care /safety “programs” or “initiatives” to achieve sustainable results. A CEO who strives to be a great leader will invest emotionally and physically in this effort.

This is not a challenge that can be solved sitting behind a desk, out of sight to those taking care of patients. Everyone in the organization must clearly understand that quality and safety are THE two most important elements of the organization’s mission. They must understand that that there can be no excuses. They must understand that there are consequences for the dangerous organizational silos that exist in virtually hospital in the country. They must know that there are consequences for the silly turf wars that executives and managers sometimes engage in. They must believe that there are consequences for not paying attention to the details or following basic practices of delivery care. The list of things that can go wrong is long. Preventing mistakes is a complex process but there are consequences if we fail to reach our goal of defect-free care. A patient dies or suffers pain. Or, at best, incurs more expense.

These consequences are why it is important for the CEO – the leader – to own the results, to make quality care and patient safety more than a program or an initiative but a way of EVERY day life in their health system, hospital, nursing home, or healthcare delivery venue.

I have had a very personal experience with a preventable mistake — a never event — and I never want to experience that again. Sadly, I am joined by hundreds of thousands of people – from industry colleagues to people from coast to coast who trusted that the care they would receive would do no harm.

John G. Self is Chairman and Senior Client Advisor of JohnMarch Partners. He is a Co-Founder of the Firm. A former investigative reporter and crime writer with more than 30-years of leadership experience in public relations, national marketing, business development and as Chief Executive Officer of hospitals and consulting firms, Mr. Self is highly regarded for his keen insight into operations, business culture and consistently selecting the types of leaders who will succeed. You can contact Mr. Self at 214.220.1234 or Or you can follow him on Twitter at Self_JohnMarch.

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