Organized Accountability for Quality Care

Aug 01, 2002


David Shulkin, MD
David Shulkin, MD, compares hospitals' current adoption of patient safety officers (PSO) to ten years ago, when healthcare systems began naming chief medical officers (CMO). As the first CMO of the University of Pennsylvania health system and the first appointed CMO of any academic medical center, Shulkin remembers the "slow and painful process" he and his colleagues experienced when undertaking new roles and how difficult it was to create everything-from job descriptions to definitions of success-from scratch.

"It was déja vu when I saw what was happening with the institution of the patient safety officer," recounts Shulkin. "There really is a more effective way to transition professionals into these new positions successfully."

Born of that sentiment is the Patient Safety Officer Society, a nonprofit, Phila-delphia-based organization dedicated to offering resources, such as newsletters, educational materials, and access to technology to accomplish systematic improvements in patient safety and reduce medical errors. Officially launched in June 2002, the organization has 250 members, none of whom pay fees.

However, spurred by the November 1999 Institute of Medicine report, the public and media focus on patient safety that resulted in new regulatory guidelines for reporting medical errors and new standards for patient safety is forcing many hospitals to create PSO positions almost daily. As executives join those ranks, membership is expected to swell.

"In addition to regulatory and accreditation bodies and the media, payers have an interest in patient safety because it is clear that medical errors and substandard care cost a fair amount of money," says Shulkin. "So, employer groups in particular are focusing on what hospitals are doing and creating accountability for healthcare."

Although recent patient safety initiatives have focused on bar-coding technology (See "From Grocery to Pharmacy," PE, November 2001), that technology is expensive and often takes years to implement. PSOs can instead focus on changing institutions' culture so that staff can talk about errors instead of hiding them, then focus on preventing further problems and improving the system.