Improving Patient Safety through Organizational Transformation


August 28, 2019

In our mission to transform the U.S. healthcare system, Cognosante has become known for our support of enterprise health IT systems, technology solutions, and business process outsourcing. Though less well known, improving patient safety is also an area in which we are helping our valued client make meaningful strides forward. Here’s how: 

The Journey to High Reliability 

Many healthcare systems, both private and government-run, are pursuing highreliability transformation to ensure patients receive excellent care, every time. This approachwhich has been successfully executed in high-risk industries such as aviation and nuclear energyoffers a framework for organizations that have a high risk of catastrophic failure, yet are virtually error-free.  

Research shows that highreliability organizations experience fewer accidents despite being high-risk environments in which small errors can produce catastrophic results. In the healthcare context, these organizations are committed to pursuing an environment of zero preventable harm.  

Over the past several years, Cognosante has supported the objective of zero preventable harm in several ways.  

  • We have helped organizations identify areas in which health IT can improve patient safetyas well as areas in which it can compromise that safety 
  • We have supported safety simulation exercises, creating an assessment process specifically tailored to individual facility resources. 
  • We have led organizational transformation initiatives to improve employee engagement, patient safety, and quality in government healthcare facilities. 

Organizational Transformation  

For the past four years, Cognosante has supported a large healthcare system in developing a proven organizational transformation methodology rooted in Intentional Change Theory. We began work at a pilot site that was chosen due to its poor employee engagement scores and other safety-related metrics. 

At all levels, our team empowered employees who were in positions to recognize improvement opportunities and implement the right changes using a simple yet structured performance improvement methodology. Our team collaborated in the executive team’s Lean Transformational Plan of Care (TPOC), focusing on the system’s Quality and Safety Strategic Pillars. Purpose rounding (Gemba walks) were initiated and enhanced. Cascading huddles were implemented at all layers of the organization. Mess Boards provided a communication and support vehicle up, down, and across the organization. 

We also successfully deployed a program to address front-line staff members’ pain points, including those involving safety and quality concerns. These staff members were empowered to identify and lead sprint teams focused on quality changes and improvement initiatives that could be successfully implemented within 8 to 12 weeks. 

Tangible Results 

These efforts produced results. Participation in the next employee survey increased, as did overall satisfaction and engagement ratings. These improvements in front-line engagement and employee satisfaction correlate directly to improvements in patient safety. We have replicated this success at several other sites, all of which have shown similar improvements.