By William A. Hyman, ScD
Healthcare sometimes looks to other industries to identify safety practices that are applicable to the mission of reducing adverse events and enhancing patient safety. Aviation has been popular in this regard. Far less often mentioned is the construction industry, which shares with healthcare the operation of a relatively dangerous enterprise. While construction usually does not have on-site customers, each person’s activities can present ample risk to others. Fellow workers are in a situation analogous to patients in that they rely on other people to keep them safe. Despite this, I had not given construction much thought from the healthcare safety perspective (falling cranes in New York City not withstanding) until I was recently in Brooklyn and saw a sign at the entrance to a construction site that read “Have you done your pre-task plan today?”
The prime contractor on this site and author of the sign was Skanska, an international construction, engineering and development company (http://www.skanska.com/). Intrigued by the sign, I looked at Skanska’s website and discovered that they have a strongly expressed commitment to safety that involves a number of activities that could be adopted, with perhaps some modifications, by hospitals and healthcare.*
Skanska describes the pre-task plan process as “a specific time set aside before work begins each morning. Each work crew identifies the day’s tasks, the risks associated with those tasks, and the steps each worker needs to take to avoid those risks. The discussion of daily work plans is vital in order to keep all members of management and craft workers aware and alert to constantly changing site conditions and possible hazards.” This sounds much like a pre-surgical timeout, although the discussion is stated far more broadly and involves all workers at the start of their day. This might be applied to other areas of the hospital at shift changes, and it has elements of effective hand-off communications imbedded in it. As with many safety dictates, the effectiveness of such a meeting, assuming it actually occurs, is whether or not it is taken seriously from a safety perspective, or is it just something to get through before we can get to work
Culture of Safety
Skanska describes itself as being committed to an injury-free environment. This, we are told is more than safety, it is “care and concern for people, which encourages everybody to accept responsibility for their own and their colleagues’ well-being”—to which we would add patients. This is nicely personalized in the statement:, “We look out for one another to ensure that everyone returns home from work safely to their family and friends.” For Skanska, this involves a “mindset intolerant of any incident or injury, not compromised by cost or schedule.” The latter might be a direct response to an objection to surgical time outs, for example, which is that they are time consuming. Associated training “is compulsory for our employees and subcontractors, with regular refresher training to refocus on our commitment.” The inclusion of subcontractors has a parallel to contractors in hospitals. How many hospital safety programs directly reach contractor personnel or even their physicians?
Skanska also mandates that every meeting, regardless of subject matter, begin with a discussion of safety. Although one can see eyes rolling at this, it can be a good reminder that safety is an over-riding imperative.
Skanska defines five areas that, in healthcare, we might call “never events”:
• Zero Accidents
• Zero Ethical Breaches
• Zero Environmental Incidents
• Zero Losing Projects
• Zero Defects
While only some of these are directly adaptable to hospitals, we could easily find five things to focus on in healthcare, especially since CMS defines many more than five never events. Of course, CMS never events are by definition things they won’t pay for, which might not be the only reason to never let some things happen. There is a broader list of never events from the National Quality Forum, which defines them as “serious reportable events.” Perhaps we could also have a rotating set of “Zeros of the Month” which might help bring more focus on particular things rather than a long list.
If negativity doesn’t always seem appropriate, a complimentary approach is a list of “Always” such as proper patient identification, surgical time outs, appropriate handoffs, etc.
Reporting and Sharing
Skanska describes their incident reporting program and the associated sharing that occurs after reports are received and analyzed. This is counter to many hospital reporting schemes in which reports go in and nothing ever comes back, even to the reporter.
A more adventurous idea from Skanska for hospitals to consider is daily group Stretch and Flex exercises. These are “conducted to reduce injuries on the jobsite but equally important is the camaraderie it promotes,” and “ultimately, is a daily reminder to put safety first.”
I contacted Skanska with respect to my intent to adopt some of their ideas in this article. They replied by saying that Skanska doesn’t see its approach to safety as apply only to construction. Skanska’s chief environment, health & safety officer, Hendrik van Brenk, wrote that safety is more than a set of protocols. “It is a state of mind,…We see similar thinking in place in manufacturing and industrial settings. Planning to be safe even applies in each of our homes, where millions of serious injuries take place every year.”
Making safety a real priority as opposed to a lip-service activity can be a challenge. One way to address this challenge is to create active rather than passive undertakings, and to give them the management commitment that they need to succeed. This includes supporting the time that some of these activities take. In this regard, pre-task planning has the elements of thoughtfulness that are a hallmark of actively achieving safety as opposed to thinking that safety simply occurs by itself. Skanska seems to be doing this, or at least has put programs in place that reflect such a commitment. I have no measure of their success, but that doesn’t mean we can’t learn from what they say they do.
*Conflict of Interest Statement: I have no personal, professional or financial association with Skanska.
William Hyman is professor emeritus of biomedical engineering at Texas A&M University. He lives in New York City, where he is adjunct professor of biomedical engineering at The Cooper Union. Hyman may be contacted at email@example.com.
Editor’s Note: See a related story, Construction Updates and Safety Alerts —There’s an App for That