5 Steps to Establish a Patient Safety Culture

How healthcare providers can continually improve their quality management programs by ensuring patient safety


Events such as additional hospitalization, litigation costs, infections acquired in hospitals, lost income and disability can be a big drain on the economy. But apart from the financial implications, they clearly reiterate the fact that patient safety is one of the most urgent quality problems facing healthcare organizations worldwide.

According to the Agency for Healthcare Research and Quality Patient Safety Network, patient safety can be defined as the "freedom from accidental injury due to medical care or from medical error." 1 However, the concept of patient safety has evolved over time, with different criteria shaping its definition.

Patient safety is a key component of quality and encompasses the prevention of harm to patients which can occur through errors of commission and omission.2 It also involves providing care with the best outcome, providing the right care to the right patient at the right time, and fostering honest communication, transparency and early disclosure of events of harm.

The ultimate goal of patient safety is to prevent avoidable harm by proactively identifying and mitigating risk events, conducting investigation and root cause analyses to prevent the recurrence of such events, and redesigning systems and processes accordingly. Sharing lessons learned with competitors and the public is also absolutely essential to strengthen quality improvement programs.

How to build a patient safety culture
Any effort to establish a patient safety culture in an organization is ideally led by the following proven practices:

 

  • Simplify and standardize workplace, equipment, supplies and processes.
  • Establish constraints that encourage and drive medical professionals to do the right thing.(e.g. provide an electronic medical record chart that provides visual cues to accurately chart a patient's information).
  • Reduce reliance on memory and other weak aspects of cognition.
  • Foster robust communication between stakeholders to encourage a comprehensive understanding of the problems associated with patient safety. Communication failures often contribute to preventable patient harm events.
  • Conduct training for medical professionals so that they are well-equipped to perform their responsibilities.
  • Plan interdisciplinary team training programs and collaboration on areas such as patient care simulation.
  • Ensure that managers and leaders in the organization continually contribute to the process of improving quality.
  • Build an organizational culture that strikes a balance between fairness and accountability and is conducive to ongoing quality improvement.
  • Collate patient safety data, monitor and evaluate errors, and implement methods to reduce them.


The process of imbuing quality into patient safety programs
§ 482.21 of the Code of Federal Regulations outline the Condition of Participation in the Medicare program: Quality Assessment and Performance Improvement Program.3 It mandates that organizations must measure, analyze and track quality indicators, including adverse patient events and medical errors. The causes of these events must be analyzed, and preventive action implemented.

The organization's governing body, medical staff and administrative officials are responsible for ensuring that safety is firmly institutionalized and hard-wired into the operations and the practices of the enterprise.

To further improve quality in patient safety programs, here are five basic steps:

1. Identify loopholes in the overall quality program
It is imperative that healthcare organizations have a systematic process for identifying and managing medical errors and adverse events. They must also continually assess whether or not their staff are diligently identifying and reporting medical errors.

Event reporting provides extensive insights into safety and quality which can be meaningfully used to mitigate risks. Trend reports and results from individual units should be shared throughout the enterprise to elevate mere data into useful insights.

Healthcare organizations can also utilize various tools to enhance their quality program. AHRQ  provides quality indicators related to inpatient quality, patient safety, pediatric quality, and prevention quality. These indicators enable organizations to proactively identify areas of improvement.

The Institute for Healthcare Improvement global trigger tool5 is another effective method for measuring the overall level of harm to patients. It uses triggers or clues to identify adverse events.

Proactive risk assessment also helps drive change by helping organizations forecast potential failure, and enable better loss control.6

2. Perform event investigations to identify patient safety failure points
When an adverse event occurs, healthcare organizations must conduct a retrospective analysis to investigate the event and analyze the root cause. This will help identify the failure that occurred, and prevent its recurrence. 

Features of an event investigation 7

•    Plan meticulously
•    Investigate purposefully
•    Factor in crisis management and the organization’s risk appetite
•    Operate within authority
•    Be guided by the organizational philosophy and policy
•    Function within an established framework
•    Produce valid findings
•    Disseminate findings responsibly and on time
•    Adhere to state laws governing protection of information

A key step in investigation and analysis is to preserve evidence. Organizations should maintain an inventory of risks, which will come in handy in fighting lawsuits. They also need to secure medical records and other documentation necessary for investigation.

Another vital investigation procedure is to establish the sequence of events to gain more clarity on the "how, why, when and where" of the event. Sufficient resources and time must be invested to objectively analyze data, and document and disseminate these findings to key stakeholders.

The next steps involve implementing a corrective action plan, managing and sustaining the change that an adverse event results in, sharing the lessons learned and sending out safety alerts.

In the event of an adverse incident, healthcare professionals have to remember that the patient always comes first. Their top priority is to stabilize the patient and continue providing care. They also must apologize and disclose information about what happened to the patient, as well as provide emotional and, if possible, financial support. A sound mechanism must be in place to support the caregivers of the patient too. 

3. Focus on proactive approaches that reduce the risk of future patient harm
To detect harm before it occurs, a prospective analysis and proactive risk assessment is invaluable. External agencies can also be involved in this process. For instance, The Joint Commission, a U.S.-based nonprofit healthcare accrediting body, disseminates alerts identifying specific sentinel events, their underlying causes and steps to prevent recurrence. 

As part of proactive risk assessment, organizations need to identify high risk processes by coalescing all data sources, incident reports, loss claims data, workers' compensation reports and event alerts, into one coherent view.

4. Prioritize patient safety initiatives
Organizations can establish a strong and efficient patient safety plan by aligning the QAPI plan and patient safety initiatives with regulatory and accreditation requirements, such as quality measures. The safety plan should also be aligned with patient safety data, which includes an exhaustive list of high-risk processes, patients, medications and procedures, as well as patient complaints, mortality and morbidity reviews, claims and lawsuits.

5. Leverage technology to augment patient safety initiatives:
The challenging task of improving quality by improving patient safety can be simplified, streamlined and strengthened with the help of technology. Health Information Technology including electronic health record systems , computerized physician order entry and bar-coding at medication dispensing, serve as key tools in enhancing the quality, safety and efficiency of the health delivery system.
Technology can be leveraged to manage the entire lifecycle of patient safety risk management by enabling healthcare organizations to identify, assess, quantify, monitor and holistically manage the risks associated with patient safety.

A centralized technology framework can bring together varied risk management related data — including risks and their corresponding controls and assessments, results from individual adverse event investigations, key patient safety indicators, events such as losses and near-misses, and issues and remediation plans — into a single system. This integrated approach facilitates greater collaboration, information-sharing, and patient safety tracking.

Summary

Adverse events and errors in healthcare organizations are often the result of faulty processes, lack of coherent information, and outdated systems. Hence, patient safety has to be designed and built through a systematic and holistic approach that focuses on the underlying causes that can lead to poor quality, and establishes mechanisms to minimize risks. Technology with advanced capabilities can support and strengthen this exercise. The outcome is enhanced patient safety that ultimately results in more effective and proactive quality management.

Krishna Lynch is cofounder and a healthcare consultant at Crack the Marble Ceiling. She is an expert in healthcare operations, human performance training and development, and nursing. She has a bachelors of science degree in nursing and a master of jurisprudence in health law.

Timothy Schmutzler is regional vice president for GRC solutions at Metric Stream, with a broad background including governance, risk and compliance, IT audit, risk and controls assessment, information systems design and implementation. Prior to joining MetricStream, he was a partner with KPMG LLP in the Risk Advisory Practice focused on GRC, risk assessment and systems implementation. During his 20 years with KPMG, he held a number of roles including national and regional lead for GRC services, and IT advisory services lead for New England.

1 Glossary. (n.d.). AHRQ PSNet Patient Safety Network online site. Retrieved from: http://psnet.ahrq.gov/glossary.aspx?indexLetter=P
2 Committee on the Quality of Health Care in America, Institute of Medicine. (2007). Preventing Medication Errors.  Retrieved from: http://www.nap.edu/openbook.php?record_id=11623&page=26
3 Code of Federal Regulations Title 42 – Public Health. (2006). Vol. 4, Section 482.21- Condition of participation: Quality assessment and performance improvement program. Retrieved from http://www.gpo.gov/fdsys/pkg/CFR-2006-title42-vol4/xml/CFR-2006-title42-vol4-sec482-21.xml
4 http://www.qualityindicators.ahrq.gov/
5 IHI Global Trigger Tool for Measuring Adverse Events. (Last modified: 2013, August 8 ). Retrieved from: http://www.ihi.org/knowledge/Pages/Tools/IHIGlobalTriggerToolforMeasuringAEs.aspx
6 American Society for Healthcare Risk Management. (2002, July) Strategies and Tips for Maximizing Failure Mode Effect Analysis in Your Organization. Retrieved from:  http://www.ashrm.org/ashrm/education/development/monographs/FMEAwhitepaper.pdf
7 Hoppes, Michelle; Mitchell, Jacque L.; Venditti, Ellen Grady; Bunting, Robert F. (2012). Serious Safety Events: Getting to ZeroTM. American Society for Healthcare Risk Management – White Paper Series. Retrieved from: http://www.ashrm.org/ashrm/resources/SSEs/

How healthcare providers can continually improve their quality management programs by ensuring patient safety

 

Events such as additional hospitalization, litigation costs, infections acquired in hospitals, lost income and disability can be a big drain on the economy. But apart from the financial implications, they clearly reiterate the fact that patient safety is one of the most urgent quality problems facing healthcare organizations worldwide.

 

According to the Agency for Healthcare Research and Quality Patient Safety Network,, patient safety can be defined as the "freedom from accidental injury due to medical care or from medical error."[1] However, the concept of patient safety has evolved over time, with different criteria shaping its definition.

 

Patient safety is a key component of quality and encompasses the prevention of harm to patients which can occur through errors of commission and omission.[2] It also involves providing care with the best outcome, providing the right care to the right patient at the right time, and fostering honest communication, transparency and early disclosure of events of harm.

 

The ultimate goal of patient safety is to prevent avoidable harm by proactively identifying and mitigating risk events, conducting investigation and root cause analyses to prevent the recurrence of such events, and redesigning systems and processes accordingly. Sharing lessons learned with competitors and the public is also absolutely essential to strengthen quality improvement programs.

 

How to build a patient safety culture

Any effort to establish a patient safety culture in an organization is ideally led by the following proven practices:

 

·         Simplify and standardize workplace, equipment, supplies and processes.

·         Establish constraints that encourage and drive medical professionals to do the right thing.(e.g. provide an electronic medical record chart that provides visual cues to accurately chart a patient's information).

·         Reduce reliance on memory and other weak aspects of cognition.

·         Foster robust communication between stakeholders to encourage a comprehensive understanding of the problems associated with patient safety. Communication failures often contribute to preventable patient harm events.

·         Conduct training for medical professionals so that they are well-equipped to perform their responsibilities.

·         Plan interdisciplinary team training programs and collaboration on areas such as patient care simulation.

·         Ensure that managers and leaders in the organization continually contribute to the process of improving quality.

·         Build an organizational culture that strikes a balance between fairness and accountability and is conducive to ongoing quality improvement.

·         Collate patient safety data, monitor and evaluate errors, and implement methods to reduce them.

 

The process of imbuing quality into patient safety programs

 § 482.21 of the Code of Federal Regulations outline the Condition of Participation in the Medicare program: Quality Assessment and Performance Improvement Program.[3] It mandates that organizations must measure, analyze and track quality indicators, including adverse patient events and medical errors. The causes of these events must be analyzed, and preventive action implemented.

 

The organization's governing body, medical staff and administrative officials are responsible for ensuring that safety is firmly institutionalized and hard-wired into the operations and the practices of the enterprise.

 

To further improve quality in patient safety programs, here are five basic steps:

 

1.       Identify loopholes in the overall quality program

 

It is imperative that healthcare organizations have a systematic process for identifying and managing medical errors and adverse events. They must also continually assess whether or not their staff are diligently identifying and reporting medical errors.

 

Event reporting provides extensive insights into safety and quality which can be meaningfully used to mitigate risks. Trend reports and results from individual units should be shared throughout the enterprise to elevate mere data into useful insights.

 

Healthcare organizations can also utilize various tools to enhance their quality program. AHRQ[4] provides quality indicators related to inpatient quality, patient safety, pediatric quality, and prevention quality. These indicators enable organizations to proactively identify areas of improvement.

 

The Institute for Healthcare Improvement global trigger tool [5] is another effective method for measuring the overall level of harm to patients. It uses triggers or clues to identify adverse events.

 

Proactive risk assessment also helps drive change by helping organizations forecast potential failure, and enable better loss control.[6] 

 

2.       Perform event investigations to identify patient safety failure points

 

When an adverse event occurs, healthcare organizations must conduct a retrospective analysis to investigate the event and analyze the root cause. This will help identify the failure that occurred, and prevent its recurrence. 

 

Features Of An Event Investigation[7]

 

·         Plan meticulously

·         Investigate purposefully

·         Factor in crisis management and the organization’s risk appetite

·         Operate within authority

·         Be guided by the organizational philosophy and policy

·         Function within an established framework

·         Produce valid findings

·         Disseminate findings responsibly and on time

·         Adhere to state laws governing protection of information

 

A key step in investigation and analysis is to preserve evidence. Organizations should maintain an inventory of risks, which will come in handy in fighting lawsuits. They also need to secure medical records and other documentation necessary for investigation.

 

Another vital investigation procedure is to establish the sequence of events to gain more clarity on the "how, why, when and where" of the event. Sufficient resources and time must be invested to objectively analyze data, and document and disseminate these findings to key stakeholders.

 

The next steps involve implementing a corrective action plan, managing and sustaining the change that an adverse event results in, sharing the lessons learned and sending out safety alerts.

 

In the event of an adverse incident, healthcare professionals have to remember that the patient always comes first. Their top priority is to stabilize the patient and continue providing care. They also must apologize and disclose information about what happened to the patient, as well as provide emotional and, if possible, financial support. A sound mechanism must be in place to support the caregivers of the patient too. 

 

 

3.       Focus On proactive approaches that reduce the risk of future patient harm

 

To detect harm before it occurs, a prospective analysis and proactive risk assessment is invaluable. External agencies can also be involved in this process. For instance, The Joint Commission, a U.S.-based nonprofit healthcare accrediting body, disseminates alerts identifying specific sentinel events, their underlying causes and steps to prevent recurrence. 

 

As part of proactive risk assessment, organizations need to identify high risk processes by coalescing all data sources, incident reports, loss claims data, workers' compensation reports and event alerts, into one coherent view.

 

4.       Prioritize patient safety initiatives

 

Organizations can establish a strong and efficient patient safety plan by aligning the QAPI plan and patient safety initiatives with regulatory and accreditation requirements, such as quality measures. The safety plan should also be aligned with patient safety data, which includes an exhaustive list of high-risk processes, patients, medications and procedures, as well as patient complaints, mortality and morbidity reviews, claims and lawsuits.

 

5.       Leverage technology to augment patient safety initiatives:

 

The challenging task of improving quality by improving patient safety can be simplified, streamlined and strengthened with the help of technology. Health Information Technology including electronic health record systems , computerized physician order entry and bar-coding at medication dispensing, serve as key tools in enhancing the quality, safety and efficiency of the health delivery system.

Technology can be leveraged to manage the entire lifecycle of patient safety risk management by enabling healthcare organizations to identify, assess, quantify, monitor and holistically manage the risks associated with patient safety.

A centralized technology framework can bring together varied risk management related data — including risks and their corresponding controls and assessments, results from individual adverse event investigations, key patient safety indicators, events such as losses and near-misses, and issues and remediation plans — into a single system. This integrated approach facilitates greater collaboration, information-sharing, and patient safety tracking.

Summary

Adverse events and errors in healthcare organizations are often the result of faulty processes, lack of coherent information, and outdated systems. Hence, patient safety has to be designed and built through a systematic and holistic approach that focuses on the underlying causes that can lead to poor quality, and establishes mechanisms to minimize risks. Technology with advanced capabilities can support and strengthen this exercise. The outcome is enhanced patient safety that ultimately results in more effective and proactive quality management.

 

Authors:

Krishna Lynch – Cofounder and Healthcare Consultant at Crack the Marble Ceiling, LLC

Krishna Lynch is an expert in healthcare operations, human performance training & development, and nursing.  She is also an author; professional coach, mentor, and speaker. Ms. Lynch is currently a health care consultant at Crack the Marble Ceiling, LLC, which she cofounded. She has a Bachelors of Science in Nursing and a Master of Jurisprudence in Health Law.

 

Timothy Schmutzler — Regional VP of GRC Solutions, MetricStream

Timothy Schmutzler is Regional VP for GRC solutions with a broad background including governance, risk and compliance (GRC), IT audit, risk and controls assessment, information systems design and implementation. Prior to joining MetricStream he was a Partner with KPMG LLP in the Risk Advisory Practice focused on GRC, risk assessment and systems implementation. During his 20 years with KPMG, he held a number of roles including national and regional lead for GRC services, and IT advisory services lead for New England.

 



[1] Glossary. (n.d.). AHRQ PSNet Patient Safety Network online site. Retrieved from: http://psnet.ahrq.gov/glossary.aspx?indexLetter=P

[2] Committee on the Quality of Health Care in America, Institute of Medicine. (2007). Preventing Medication Errors.  Retrieved from:

http://www.nap.edu/openbook.php?record_id=11623&page=26

 

[3] Code of Federal Regulations Title 42 – Public Health. (2006). Vol. 4, Section 482.21- Condition of participation: Quality assessment and performance improvement program. Retrieved from http://www.gpo.gov/fdsys/pkg/CFR-2006-title42-vol4/xml/CFR-2006-title42-vol4-sec482-21.xml

[5] IHI Global Trigger Tool for Measuring Adverse Events. (Last modified: 2013, August 8 ). Retrieved from: http://www.ihi.org/knowledge/Pages/Tools/IHIGlobalTriggerToolforMeasuringAEs.aspx

[6] American Society for Healthcare Risk Management. (2002, July) Strategies and Tips for Maximizing Failure Mode Effect Analysis in Your Organization. Retrieved from:  http://www.ashrm.org/ashrm/education/development/monographs/FMEAwhitepaper.pdf

July 2002.

[7] Hoppes, Michelle; Mitchell, Jacque L.; Venditti, Ellen Grady; Bunting, Robert F. (2012). Serious Safety Events: Getting to ZeroTM. American Society for Healthcare Risk Management – White Paper Series. Retrieved from:

http://www.ashrm.org/ashrm/resources/SSEs/

 

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