Latent risk assessment tool for health care leaders

Lori A Paine; Christine G Holzmueller; Robert Elliott; Eileen Kasda; Peter J Pronovost; Sallie J Weaver; Kathleen M Sutcliffe; Simon C Mathews

doi:10.1002/jhrm.21316

Latent risk assessment tool for health care leaders

J Healthc Risk Manag. 2018 Oct;38(2):36-46. doi: 10.1002/jhrm.21316. Epub 2018 Apr 6.

Authors

Lori A Paine¹, Christine G Holzmueller², Robert Elliott¹, Eileen Kasda³, Peter J Pronovost⁴, Sallie J Weaver⁵, Kathleen M Sutcliffe⁶, Simon C Mathews⁷

Affiliations

¹ Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD.
² Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine (Baltimore, MD); Johns Hopkins University School of Medicine, Baltimore, MD.
³ Johns Hopkins Health System, Baltimore, MD.
⁴ Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine (Baltimore, MD); Johns Hopkins University, Baltimore, MD.
⁵ Health Systems and Interventions Research Branch (HSIRB) of the Healthcare Delivery Research Program at the National Cancer Institute; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD.
⁶ Johns Hopkins University Carey Business School (Baltimore, MD); Johns Hopkins University School of Medicine (Baltimore, MD); Johns Hopkins University School of Nursing (Baltimore, MD); Johns Hopkins Medicine (Baltimore, MD); Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD.
⁷ Division of Gastroenterology, Johns Hopkins University School of Medicine (Baltimore, MD); Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD.

PMID: 29631323
DOI: 10.1002/jhrm.21316

Abstract

Efforts to improve quality of care and patient safety have concentrated on provider practice and frontline care processes. Little attention has focused on understanding the role that leadership decisions play in creating risk within a health care system. The framework and tool described in this article builds on Reason's construct of latent organizational failure, by assessing the latent risks of leadership decisions, and identifying appropriate mitigation strategies before the implementation of a change. Stakeholders who will be involved in or impacted by the change are engaged in the assessment to more thoroughly explore both technical and cultural risks.

Keywords: latent error; leadership; patient safety; risk assessment.

MeSH terms

Adult
Attitude of Health Personnel*
Delivery of Health Care / organization & administration*
Female
Hospital Administrators / psychology*
Humans
Leadership*
Male
Middle Aged
Organizational Culture*
Patient Safety / standards*
Risk Assessment / standards*
United States