By PETER PRONOVOST, MD

When you are a patient at a hospital, you want to know that the executives who run that facility put the safety and quality of care above all other concerns. Encouragingly, more of them are saying that safety is indeed their number-one priority—a fitting answer given that preventable patient harm may claim more than 400,000 lives a year in the United States.

Yet when you look at the way that most hospitals and corporate health systems are organized, weak infrastructure exists to support that priority. True, some hospital boards of trustees have made safety and quality their first order of business. At meetings, they might hear directly from a patient who suffered a medical error, sit through a case study of a unit that reduced complications, or get an overview of various efforts to boost the patient experience and improve outcomes.

Stories can inspire culture change. Sustained improvements, however, require health care organizations to institute top-to-bottom accountability for performance.

What would it look like if safety and quality truly were addressed this way? It might be something like how most hospitals’ finances are managed, from the board level to the smallest unit.

With amazing precision, the finance department in Johns Hopkins Medicine can track virtually every dollar that comes in and goes out. These data can be segmented, sifted and filtered into well-established reports, showing us how our clinics, departments and entire hospitals are performing.

This financial data is used across our organization, all the way up to our board, which reviews consolidated financial statements. If a clinical service line falls short of its financial goals, there is a robust management structure in place—from the hospital to unit and clinic level–to ensure that we investigate and seek solutions.

Quality and safety lack a parallel infrastructure.  A health system typically has a chief quality officer, and so does a hospital. Yet the internal capacity within departments and clinics to contribute to improvement work is woefully deficient.

We assume that board and leader goals for quality and safety magically filter to frontline staff, and that they have the time and training to improve. In general, they do not. In our patient safety collaborations with more than 1,000 hospitals, a scarcity of dedicated time for improvement work and a lack of skills were identified as major barriers to advancing safety. If finance were treated like quality is typically handled, we would ask a nurse manager who lacks training in accounting or budgets to be CFO, even if she has scant time outside her nursing duties for that role.

To truly elevate the importance of ending preventable harm and improving patient outcomes, we need to bring the same discipline, rigor and infrastructure to that work as our financial counterparts. We need to select meaningful measures that cascade through the entire organization, with clear understandings of who is accountable for meeting goals on them. Just as financial specialists understand the goals for the area where they work, local teams need patient safety specialists who know what is expected of them and have the skills and resources needed to get the job done.

At the board level, trustees should be able to look at one consolidated safety and quality statement—much like a quarterly financial statement—that provides them with a detailed, meaningful understanding of whether we are meeting our targets, and where we need to focus our improvement efforts.

At Johns Hopkins Medicine, we have been fine-tuning such reports, seeking feedback from our leaders and trustees about what is most helpful to them. It’s an evolving process, and we have much to learn.

Several factors make it a huge challenge. For one, we don’t have the luxury of boiling everything down to dollars and cents. Instead, we have to sift through 270 different safety and quality measures, maintained by different stakeholders across our organization, and decide which are most important. Simply gathering this information is a massive undertaking.

Hospital leaders get criticized for focusing too heavily on their budgets—sometimes rightly so. But in a way, it’s hard to blame them for favoring hard numbers over anecdotes and isolated success stories. If they have as much access to patient safety information as they do to financial data, they will be more likely to make preventing harm a priority in action, not just words.

Peter Pronovost, MD is the Director of the Center for Innovation in Quality Care at Johns Hopkins.