Patient Safety Is A Team Sport: How Care Collaboration Can Reduce Errors and Improve Patient Experience

Patient Safety Awareness Week (March 11-17, 2018), which the Institute for Health Improvement (which merged with the National Patient Safety Foundation last year) has been coordinating for the last fifteen years. The IHI cites studies which suggest that medical error and preventable harm remain major sources of injury and death among patients.

A recent national survey conducted by the IHI/NPSF Lucian Leap Institute and NORC at the University of Chicago found that 1 in 5 people reportedly experienced a medical error in their own care, and one-third reported an error in the care of a close relative or friend. Of those who experienced errors, 73 percent said the error had a long-term or permanent impact on the patient’s

physical health, emotional health, financial well-being, or family relationships

Pt Safety

“Making sure patients and families feel that it’s okay to speak up and ask questions is really a critical element in patient safety,” said Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, IHI. “Even health professionals sometimes fear speaking up, and that’s directly tied to the culture of the organization in which they work. In order to improve, health care organizations need to see flaws or gaps in safety, encourage people to report problems when they see them, and take action to correct them.”

Patient Safety is a Team Sport 

When care teams, across different disciplines, work more collaboratively together, mistakes can be reduced, and patient satisfaction and the experience of their friends and families can be dramatically improved. The experience of medical teams and staff is also improved when doctors, nurses, certified nurse assistants, technicians, anesthesiologists, physician assistants, are able to communicate more systematically and easily.

Better communications is possible now with better technologies, artificial intelligence (AI), the implementation of electronic medical records, but we have found in completing projects at many large hospitals that culture may play the most important role.

The best hospitals in the US and around the world pay close attention to culture and communications, particularly in the most intense areas (emergency rooms, intensive care units, operating rooms) and the most delicate situations (cancer diagnosis, chemotherapy, radiation – for adults and children).

Cohesive teamwork is all about improving communication around the circle of care, reduces errors, improves patient outcomes, reduces costs through decreased length of stay, and results in greater satisfaction scores across the board (patients, families, staff).

The most enlightened and successful hospital administrators are those who see their role as “Chief Experience Officers” whether they are CEOs, Presidents, Department Chairs or other key leaders.

More and more care “teams” are being assigned to shifts together, rather than random scheduling, as these teams learn to work better and better as a unified “organism” able to understand and appreciate each other’s skills and approaches, and building respect, rapport and pride over months and years together.

Teaming Up for the Greater Good

We’ve seen improvements through our work in many areas, including:

Emergency Care, where clear and steady team communications can make a difference in minutes or even seconds and crisis resource management principles pay off in better patient outcomes

  • Intensive Care, particularly when teams are managing acute trauma patients with severe injuries and where long shifts are sometimes unavoidable and team members backing each other up makes life easier for all those in the business of saving live
  • Respitory Care, including improvements in ventilated patient care and faster reduction in the reliance of mechanical ventilation
  • Psychiatric Care, including stress response to surgery and greater preparation for discharging into a positive home or long-term care environment
  • Neuroscientific Care, including hospital stays following neurosurgery, where compassion is one of the most highly valued traits by patient’s friends and family

Patient Safety Awareness flows together with Patient Experience, and when hospitals put collaboration and communications together with culture, everybody benefits. These are conscious choices, and this week while we all get together to shine the light on patient safety, we look to the leaders and visionaries running some of our largest and most successful hospitals, hospital systems, medical centers and medical universities to set the examples, and create the models for more efficient and more effective healing.



Patient Experience in the 21st Century

To fully envision what defines a great patient experience in this new century, it’s important to understand how human beings are now living, what their expectations are, how their behaviors are influenced by media, technology and changing economics, and communications is woven throughout health journeys which are becoming increasingly individualized.


Patient Experience

To fully envision what defines a great patient experience in this new century, it’s important to understand how human beings are now living, what their expectations are, how their behaviors are influenced by media, technology and changing economics, and communications is woven throughout health journeys which are becoming increasingly individualized.

Consider precision medicine, for example. Today, patients now ask their doctors if their cancer or other illnesses are related to their genetic makeup. They ask if their condition could have been predicted and prevented. They ask if there are new treatments for diseases thought to be impossible to cure.

More frequently, patients are asking about alternative medicine, naturopathy, homeopathy, meditation, physical therapy prior to taking a risk on surgery.

They and their families are concerned about the costs of care, the complexities of insurance programs, the costs of in-patient vs. out-patient care, and so much more.

And now that we have crossed the chasm into the general availability of Electronic Medical Records, including immediate access to their blood tests, scans, visit reports, scrips, the 21st Century patient is increasingly participating digitally, whether from their desktop computers or their smartphones, and while this can be extremely empowering, it can also be daunting.

Daunting as well is the ocean of information on the web – some of it accurate, some of it inaccurate – which patients and their loved ones often become immersed in, particularly when they are diagnosed with an unusual disease or rare form of a family of diseases.

What does all this mean for doctors, nurses, specialists, caregivers and administrators?

It means that the bar is being raised higher – which is good for society and the healthcare profession, but which can be difficult for institutions to keep up with, particularly as budgets are strained, and pressure is on to remain competitive, highly ranked, safe and less prone to malpractice and other legal actions.

While there are many exciting new technologies coming out that can help automate routine tasks, analyze data quickly, provide better self-service for patients and more – freeing up professionals to spend more time with patients – based on my many years of consulting to hospitals and medical schools and medical centers – a positive experience for patients and their families always comes down to the human experience.

What we used to call “bedside manner” is now a 360-degree view of good manners from the moment a patient realizes they have a new pain and contacts their general practitioner all the way through to leaving a hospital experience and returning to home and future health.

The patient journey, particularly because patients have so much more access to information and process, can become far less mysterious, frustrating and scary, but only when they are guided by caring human beings who chose their profession because they genuinely wish to help, heal and comfort people.

Over the last few decades, the market’s recognition and acknowledgement of patient experience has been significant. We’ve witnessed tremendous growth and serious investment by organizations committed to becoming better and more competitive through excelling at experience. I have had the honor to develop and manage many programs and have seen the impact patient experience initiatives have not only for the patient, but for the entire care collaboration team who very often desire to provide a better experience, but are held back by cultural issues, negative behaviors, lack of funding and tools, and environments where they are often overworked and underpaid.

The Beryl Institute, a global membership community of over  55,000  members engaging in efforts to improve the experience for all in healthcare has established a deep store of a community-validated and developed body of knowledge; the expansion of research represented in the submissions to and readership of Patient Experience Journal (with articles now downloaded 10,000 times per month in over 190 countries and territories); and launched an independent entity, the Patient Experience Institute.

In 2017, they graduated approximately 500 individuals as Certified Patient Experience Professional (CPXP) – a small number relative to the need, but a great start.

They also launched the Patient Experience Policy Forum (PXPF) to begin efforts at advocacy and action that support findings from a study released last year.

A few highlights:

  • In their patient experience movement and in the data that frame its efforts, they are seeing fundamental shifts in behavior, practice and perspective
  • They call out the shift in the habits of people and organizations in healthcare
  • They are witnessing an exciting alignment around the idea that patient experience matters


After interviewing nearly thousands of professionals, across all segments, 26% of respondents identified themselves as having “well established” experience efforts, while just 1% offered they had “not yet started.”

The majority of respondents, 56%, replied they had an established effort that was “making some progress,” while the remaining 18% said they were just getting underway.

“These numbers reveal that organizations are no longer thinking about efforts to address experience but are downstream in considering what they need to do to address it,” the report says. “The questions, as a result, will now be less about how to get started in setting up experience efforts to what priorities and practices lead to sustained success. This distribution reveals a new and significant dynamic for patient experience efforts to consider in both how they maintain focus and commitment as well as reinforce relevance and show impact.”

The full report, sponsored in part by Philips Corporation, is available for download here.

We applaud the efforts of the Beryl Institute and others who are studying the global landscape and doing important work in building a sustainable community around our opportunity to improve patient experience while, in parallel, we improve the entire medical and wellness system.

What is very clear is that when new models are built, those which succeed will be those which focus on the patient’s physical, mental and emotional journeys – while also “caring for the caregivers” – creating vibrant, efficient, humanized hospitals and other medical settings.


In future posts, I will share insights and ideas on how we can, together as an industry and as individuals and institutions, reinvent healthcare delivery with the patient at the center – how technology can help, how cultural investment can help, how training and certification can help, and how all of this can be done with brilliant economic outcomes, and most important – brilliant health outcomes.