4 leaders on the patient safety issue they'd fix overnight

Healthcare leaders are bringing renewed attention to patient safety issues that have been overshadowed by another year of the COVID-19 pandemic. 

Becker's recently asked patient safety experts the following question: "If you could fix one patient safety issue overnight, what would it be and why?"

Here are their responses: 

Editor's note: Responses were lightly edited for clarity and length.

Cynthia Barnard, PhD. Vice President of Quality at Northwestern Memorial Healthcare (Chicago): 

Perhaps the most foundational need for patient safety is the right number of qualified people communicating effectively about and with the patient. To optimize patient safety and enhance satisfaction, it is essential that there are enough capable people with enough time working in well-designed systems with comprehensive communication.

At this time, the entire U.S. healthcare system is struggling with both capacity and communication. With the cumulative demands of an unprecedented worldwide pandemic that has exhausted and depleted our clinicians and support staff, we are all struggling to bring a sustainable complement of people to our patients. And even with the astounding growth of digital technology and devices, we still find ourselves with too much data and not enough information, accessed haphazardly by dedicated staff trying hard to understand the patient's journey and challenges, and typically communicating asynchronously among the clinical team and with the patient. The confluence of these challenges impacts both patient safety and caregiver well-being.

If I could fix one thing overnight, it would result in a team composed of the right group of qualified people in relevant disciplines, who have the time to talk with each other and with the patient, using optimally organized clinical information that includes the patient's concerns and preferences.

Patricia McGaffigan, RN. Vice President of Safety Programs at the Institute for Healthcare Improvement:

I would fix the cracks in our foundation that, if improved, would help address nearly every patient safety issue we struggle with today and better prepare us for the next crisis to rock our healthcare system. In this dream scenario, every healthcare leader would fortify the essential foundation for safe, person-centered, equitable care at their institution, using the National Action Plan for Patient Safety as a roadmap to reinvigorate the work. 

Using the plan, leaders would build on the gains we've made in safety to date, address recent setbacks and new challenges to safety, and strengthen the resilience of our systems across four interdependent, foundational areas. These areas include the role of leadership and governance in fostering safe and equitable cultures; co-production and evolution of safe and equitable care design and delivery that matters to and is informed by patients and families; ensuring measurable and equitable protection and support for the safety, well-being and engagement of the healthcare workforce; and implementation of reliable learning systems within and across organizations to foster continuous improvement and sustainable progress in safe, equitable care for all.

Ana Pujols McKee, MD. Executive Vice president and CMO and Chief Diversity, Equity and Inclusion Officer at The Joint Commission: 

If I could fix one patient safety issue overnight, I would eliminate the complacency regarding quality improvement and patient safety that currently exists in healthcare. Complacency is accepting patient harm as a byproduct of care. While understanding that certain serious events create a sudden sense of urgency and attention, typically complacency sets in over time. 

Complacency prevents leaders from committing to zero harm; complacency permeates through an organization when leadership accepts a slight percentage reduction of a healthcare-acquired condition as an acceptable annual goal; and complacency is perpetuated when a healthcare organization's board of directors is not educated in quality and safety and therefore is unable to drive its safety agenda.

I anticipate that some healthcare leaders may take offense to my use of the word "complacency," but I challenge them to offer honest justification to the problematic scenarios described.

Gary Stuck, DO. CMO at Advocate Aurora Health (Downers Grove, Ill., and Milwaukee): 

If I could change one thing, I would eliminate hospital-acquired sepsis cases. This is literally life-saving work, as patients across the country who develop sepsis during an inpatient stay often progress to septic shock, and mortality rates increase at 7.6 percent for each hour treatment is delayed. 

While we can't completely eradicate the problem, leveraging high reliability principles to create processes that ensure early diagnosis and prompt management can significantly improve short and long-term patient outcomes. Building on our EHR system, we've redesigned best practice advisories, checklists and tools to complement and support clinical workflows and critical thinking by clinicians. This is a team sport, where steps that streamline care delivery and reinforce a consistent strategy are certain to deliver a win for our patients.


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