The problem of mixing productivity with patient safety

The fundamental challenge in any high-risk industry is balancing “productivity” versus “safety.” The term “protection” is frequently used within the scientific literature to express the role of safety departments within an organization. Described this way, it might sound as if the safety experts are framing the debate to suggest “the evil factory bosses are continually speeding up the assembly line, while the righteous safety-folks are yelling ‘slow down!’” This essential misunderstanding must be cleared up.

In healthcare, protection would appear to refer to “protecting the patient,” yet that is clearly not the case. By optimizing safety, what we are ultimately protecting is the financial health of our healthcare system. Productivity and protection are not at odds with one another: they are both vital to the success of any healthcare organization.

As an industry, healthcare spends more on bad outcomes than good outcomes. By one estimate, nearly 30% of our $2.5 trillion annual healthcare budget is spent without improving health of the nation, via unnecessary, inappropriate, and administrative costs. But the days of passing these costs on to the “consumer” are rapidly coming to an end. And the healthcare organizations which rapidly figure out how to simultaneously improve productivity and safety will be the ones to thrive and prosper.

Yet is now the “right time” to fix safety? If “protection” is viewed as anti-productive, and a hospital’s survival depends upon squeezing every last dollar, will “doing the right thing” be enough justification for healthcare leaders to reduce productivity even more? And how do we filter the demands of both productivity and safety – seemingly contradictory concepts – to the frontline workers? Further complicating this picture is the severe imbalance in timeframes: financial pressures and metrics are real-time issues affecting the hospital today. But “patient safety” is a poorly understood concept, with indistinct future rewards and uncertain immediate benefits. Incorporating safety into a long-term strategy is overshadowed by the more pressing concerns of higher priority issues which are more compelling right now. Safety can wait another day.

The essence of our dilemma is this: Productivity is visible, continuous, readily-understood and directly measured: a daily metric. On the other hand, safety is invisible, boring, discontinuous, indirect, and its success is measured by the ABSENCE of negative outcomes: a long-term goal. Safety, exclaimed as a “priority” after an accident, soon fades after a short period.

In the real world, long-term pleasant-sounding “visions” are readily embraced by all rational people. Statements such as “Patient safety is a core principal at our hospital” are commonplace. The problem, however, is turning that vision into action: it is in the daily operations – those details – where safety must start. How do we start?

The challenge of safety management lies in translating and subdividing the vision into daily effort. In the absence of a vigorous commitment to safety, operational demands always win. A short cut today brings no harm, so tomorrow safety margins reduced, day-by-day, until the next accident. This is precisely why safety – protection – needs to be managed independently, by experts in safety, and from a high level, within any organization.

As a healthcare CEO, imagine the power of knowing exactly how our fragmented, non-standard, undocumented care delivery processes are contributing to patient risk and harm at your hospital? With a robust safety information infrastructure, you would have those answers readily available. Having this powerful decision-making data at your fingertips would optimize your ability to make daily judgments about how to manage both risk and productivity. Proper safety management takes the guesswork out of this essential question: how can we reduce cost, reduce risk, and increase productivity… all at the same time?

And could we, today, catalog all of our industry-wide “patient safety” initiatives to determine which ones are successful and worthy of expansion, and which ones could be eliminated without impacting actual safety? Does a comprehensive database currently exist? Consider the power of being able to manage safety in the same way as finance: estimate the impact in advance, make educated decisions, and receive real-time feedback.

Ultimately, when it comes to managing “productivity vs. safety,” these questions must be answered: 1) “Who is the person or department in a hospital that serves as the focal point to receive or collect all safety data, including adverse events, incidents, known near misses and mistakes, safety reports or suggestions, findings from safety or compliance related audits, and relevant patient or patient advocate input?” 2) “How, and at what interval, is this information communicated to the CEO?”  And finally, 3) “Who is responsible for corrective action?” The answers typically reveal an ill-defined, poorly-organized, and unaccountable system … even at hospitals with lofty-sounding patient safety “visions.”

Whether the in-house subject matter expert for patient safety is called a “Director of Patient Safety”, “VP of Patient Safety”, “Manager of Patient Safety”, or “Chief Patient Safety Officer”, they are there to serve as an internal consultant to advise senior leadership where within the walls of the hospital the risks are. Knowing what is safe, and what is not, will allow a Chief Executive Officer to decide where to best allocate a hospital’s precious resources. The vision and plan of modern safety management entails building and operating a robust safety information infrastructure that produces a real-time picture of risk. We all know that safety is commonly touted as a core tenet of every hospital. It is the sole mission of a patient safety leader to see to it that this core principle is reflected in the care we give every one of our patients, every day.

Michael Appel is an anesthesiologist, former airline pilot, and safety consultant. He is a speaker and frequent contributor to The Salus Network.

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  • Janice_Flahiff

    Thank you for the article.
    For anyone interested…
      About once a year the National Library of Medicine sponsors a free online seminar on Patient Safety
    The materials are freely available at
    The free online materials do a great job of meeting the seminar’s objectives (I took the seminar recently)
    *Describe definitions related to patient safety and detect systems of potential error within institutions
    *Identify patient safety issues and points of contact specific to individual institutions
    *Locate resources available for administrators, health professionals, and patients and families
    *Formulate methods for the library to effectively participate in improving patient safety

    Quite a few hospitals have a librarian on board as part of a patient safety committee
    Even if they are not on the committees (yet!), never underestimate what a hospital or health science librarian can contribute to the patient safety culture (including literature searches, “publicity” through the library’s social media)

  • jlcadiz

    Point well taken.  A systematic approach to patient safety is all well and good. But when the system fails, who is there to wield the safety net? I would argue that it still is–in most cases–the physician.  Unfortunately, the physician is still the last one at the bottom of the line–the last “fail safe”, the one ultimately held responsible in the court of law, and the one usually left holding the bag and trying to support the patient and family through the inevitable outcome.  This may work to a certain point, until the physician is exhausted and/or leaves practice because he/she needs a better job to meet the mortgage (and med school debt).

    • Michael Appel


      Thank you for your comments. Very insightful.You bring up a critical issue: the idea that any one entity (in your example, physicians) has mis-aligned interests is perhaps the best example of a broken “system.”The welfare of the patient MUST be the over-arching principle. Until it is, we will be left fighting amongst each other in a dysfunctional industry of silos: exactly the reason we are in our current predicament./Michael Appel

  • Robert Ley

    Your third paragraph conflates ‘unnecessary, inappropriate and administrative costs’ with productivity. If you’re not conflating the two, the two sentences don’t belong in the same paragraph. Most administrators would consider more ‘unnecessary, inappropriate’ procedures to be very productive as regards their bottom line. But I don’t think you meant it  that way. Measuring something changes it; the processes work toward improving the thing being measured while ignoring collateral damage. NOT productive, is it? For example, in the hospital can you really have both high ‘productivity’(as they measure it) and happy physicians? The word, and its ‘measurement’, needs to be downsized in the conversation and no longer ‘measured’. Processes are important. They are a component of what I would call ‘medical ecology’. Concentrating on ‘productivity’ interferes significantly with the ability to, and need to, see processes in our system. 

  • DrozdK

    Safety is directly R/T  RN/patient ratios in hospitals. There is no shortage of nurses, There are hospitals that refuse to hire (especially on a full time basis) the appropriate numbers with safety in mind.,

  • jamesp

    Dr. Appel,

    Intriguing questions- and you seem to have the background to pose them! Since you are/were a pilot, I can’t help but ask- Whenever someone compares safety in our field (I am a GP) to that in the airlines, I get the urge to say, You can’t compare the two- No pilot departs a runway expecting to crash, but ALL humans will die. Your thoughts???

    • Michael Appel

      jamesp: Thank you for your reply and for your kind words. Your question is excellent, and would require a book to properly address (one which I am in the process of writing). Why do humans die? Is it due to the inevitable course of life, including all known disease states? Or is it a result of poorly-managed risk while immersed in a process known as the healthcare system? We must accept risk as part of healthcare, just as we accept risk in commercial aviation; it can never be “ZERO.” But acceptance of risk should only come after ALL REASONABLE MEASURES are taken to minimize it. Is that what we do in healthcare?

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