Governance Insights

Mitigating Safety Risks Post COVID-19

Effective board oversight is needed in unprecedented situations.

By Topic: Governance Board Roles and Responsibilities Risk Management


A key governance challenge the COVID-19 pandemic presents is the effective oversight of unprecedented safety risks in completely novel situations. For example, when elective surgery resumed, whole teams returned to work to practice procedures they had not performed for up to eight weeks or more. 

The first day back at work after time off is well-known by safety experts to be an error trap: a circumstance that significantly raises safety risks both for the worker (in this case, a surgeon, nurse or other staff member) and for the patient. This increased risk can be partially mitigated by being aware of it and having other members of the team double-check the work of the member who is just returning. But, what about when whole teams have been off work for an extended period? What if the whole team is rusty, both in technique and in execution of protocols and procedures? What are the safety risks of this unprecedented situation? What role should the board play in mitigating this risk? And, what can healthcare leaders do to prepare to demonstrate to the board that safety has been considered? 

One of the overarching roles of a board is to ask challenging questions, especially when presented with completely new situations.

Developing a Safety Case
Advanced safety organizations anticipate, and prepare for, future safety risks, according to a 2013 white paper from The Health Foundation about a framework for safety measurement and monitoring (this report is still in widespread use and is considered to be the best and most current reference on this topic). In this instance, the role of the board is to raise the issue with executives and clinical leaders for prospective safety plans to address the risk of restarting procedures. Specifically, this brings into focus one of the most powerful safety roles of the board: When the organization is starting something new or facing a completely unprecedented situation, the board must insist that the executive team develop a safety case with just as much rigor as the business case. 

The safety risks of restarting elective procedures during the COVID-19 pandemic go beyond the single error trap of the first day back. Surgical teams might be wearing new masks and other personal protective equipment, which could impair communication. Disruptions in the supply chain might require the use of substitute medications or unfamiliar equipment. Furloughs and layoffs could possibly have changed the team’s composition. There will undoubtedly be pressure on the schedule to make up for lost time and revenue. And, everyone in the room might be a bit anxious and potentially distracted by the fear of getting COVID-19 or bringing it home to family. All of these factors—unfamiliar equipment, time pressure, new team members, emotional stress—are known error traps. Coupled with the first-day-back problem, these issues add up to a perfect storm of safety risks.

So, what might a safety case for this situation look like? At the very least, it would include a plan for widespread communication and awareness that this is not business as usual. Even better, it would call for an upgrade of the organization’s safety practices in two specific arenas:

Anticipation and preparedness. Prior to restarting procedures, clinical teams would be made aware of and required to discuss these various error traps. Teams would have the opportunity to simulate procedures under the new conditions and devise strategies to mitigate any new risks noted. For each case, the pre-procedural timeout and checklist would be modified to include a brief conversation about specific error traps likely to be encountered and any mitigation strategies.

Learning and integration. All teams are supposed to debrief after each procedure, but this process is often done superficially. The safety case would require a thorough debrief about any new or unusual staff or patient-safety risks noted during the procedure. Furthermore, it would ask staff for suggestions for prevention and mitigation of those risks in future cases and create an action loop through which management promptly implements those suggestions systemwide.

One of the overarching roles of a board is to ask challenging questions, especially when presented with completely new situations. In this circumstance, the question the board must ask—and the CEO and his or her executive team should be prepared to answer—is “Yes, but can we restart procedures safely?” If the answer is “Sure, it’s just like riding a bike, we’ll get back on it and go,” be prepared for the board to push for a better answer. This is not a normal day in the office. This is, in safety-speak, an “upset condition” and requires a thoroughly thought-through plan. The good news is that when it is done prospectively, no injuries or serious safety events have occurred (yet!), and thus there can be no punitive or recriminatory undertones to the process. The board simply asks “what if” questions of the executive team. Leaders should be prepared to answer these questions by presenting evidence that the situation has been considered and that plans have been developed to anticipate and prevent novel upset conditions from manifesting into actual injuries to patients and staff. 

Many hospitals developed business cases for board review regarding how they would recover from the COVID-19 revenue slump, but they should consider developing safety cases, too. Moving forward, a good best practice for a board will be: If the situation warrants a prospective business case, then it is worthy of a prospective safety case as well. 

James E. Orlikoff is president, Orlikoff & Associates Inc., Chicago, and an ACHE faculty member ( James L. Reinertsen, MD, is president, The Reinertsen Group, Alta, Wyo. (