Back to the Basics: 6 Core Concepts for Patient Safety & Quality Control

To construct a truly outstanding patient-safety and quality control program, hospitals must first have a strong quality foundation. Many hospitals attempt to launch sophisticated initiatives and find they are unable to build upon their poor structural foundation and are surprised when their initiative fails; instead, these hospitals should go back to the basics and focus on the core elements of quality and process improvement, says Joseph Cappiello, chief operating officer of Healthcare Facilities Accreditation Program.

"You don't have to be big hospital with significant resources to do a really good job with quality and patient safety initiatives," he says. "There are so many small critical access and community-based medical centers that are doing outstanding work in the quality setting. What you really need is committed leadership supporting staff that are confident in that leadership and fully engaged in the program. Top level patient safety and quality programs are not exclusive to large university-based medical centers. Amazing things are being done by smaller and remote centers every day."

Here, Mr. Cappiello discusses the core concepts that serve as a basis for strong patient safety programs.

1. Keep physician credentials updated.
Credentialing and privileging are the fundamental building blocks of quality. While the vast majority of hospitals have been vigilant on these issues, some situations continue to be troublesome. Hospitals often work with surgeons who don't perform many cases at their facility. If this is the case, you want to make sure their credentials are up to date and their privileges reflect their current competency when they do bring cases into your hospital, says Mr. Cappiello.

"There is a growing trend of the use of contract physicians — especially anesthesiologists and emergency medicine physicians," says Mr. Cappiello. "Make sure that new physicians who come to practice at the facility are adequately credentialed and privileged. Sometimes with the odd hours and emergency shift work, these physicians may slip under the radar and not be updated with their credentials and privileges."

In addition, make sure you stay aware of the performance of aging physicians, and be prepared to discuss with them when might be the right time to "hang up the shingle."

"You need to collect data to ensure older physicians still have an adequate skill set for the privileges they are being granted," says Mr. Cappiello. "That can be a very politically and emotionally sensitive issue to discuss with physicians who have been engaged in your medical center and great supporters for many years. Medical centers have to keep a keen eye on this because with age frequently comes the erosion of skills."

2. Hire and maintain competent staff members.
Maintaining staff competency goes hand in glove with updating credentialing and privileging. When there is an explosion of new equipment, techniques, drugs and disease protocol — as we see in healthcare today — it's important to keep staff training up-to-date on these changes.

"Unfortunately, when hospitals have to make cutbacks because of declining reimbursements or other budgetary issues, the first of these casualties is often education and training," says Mr. Cappiello. "You have to be cautious of eliminating education programs because it raises the issue of staff competency."

When staff members aren't comfortable or knowledgeable in new processes or protocols, the level of patient care suffers. Training staff members appropriately gives them the confidence to administer drugs or follow protocols that maximizes patient safety.

3. Give clinicians the appropriate tools.
Hospital leaders must understand what staff members need to be engaged and focused in their work. Actively engaged staff members are focused on the goal of improving patient safety and delivering the best possible patient care.

"One of the challenges of leadership is to understand what it takes to support staff members so they can stay focused on the patients they serve and interact with each day," says Mr. Cappiello. "There must be a trust and faith in the leadership that they understand that challenges that staff face each day and that they will do the right thing, by their actions, to support staff. Staff must be adequately trained and be provided adequate mentoring and supervision. Both must understand the complexities of providing high quality safe care and both must strive to create the most optimal settings and environment to complete their job safely and effectively."

For example, the nurse who is preparing medications should have a designated quiet space to focus on preparing each patient's dose. If an extra space isn't available, the nurses could be given a vest or some other means to signify they shouldn't be disturbed until they are finished. This is but one strategy or example that shows how leadership and staff come together to address issues that have a direct impact on safety and quality of care.

4. Hospital leaders should keep a critical eye on themselves.
Hospital leaders oftentimes walk a fine line between being encouraging and critical when they become involved in quality or clinical improvement programs, says Mr. Cappiello. Leaders must set the tone and model the behavior they expect from staff when issues arise.

"Everyone looks to see what leadership does and how they respond to issues — that behavior sets the tone," says Mr. Cappiello. "Leadership behavior is the surest way for staff to understand the priorities of the organization and how they themselves should act.  What we need more of in healthcare are leaders who are unafraid to be critical of themselves and the organization they lead. Leaders with the courage to be critical, send a clear message to staff that they should be doing the same — looking for opportunities to improve and having the courage to bring those ideas forward."

Leaders must have an early warning and recognition system for issues of risk and respond quickly and appropriately to mitigate that risk wherever possible. They must also ensure there are fail-safe systems in place so the right patient is treated at the right time in the right setting. "I think all of this leads to the real business of improving  the healthcare delivery systems," he says.

5. Tighten the processes for delivering patient care.
The route medication takes from the physician writing the order to the administration by the nurse could be tightened in most institutions to reduce the possibility of errors. Our systems of care delivery are many, varied and usually very complex. Medication ordering, administration and delivery systems are but one example. Despite the attention given to this system, the multiple checks and balances, the electronic innovations, medication errors still occur and sometimes with tragic consequences.

"We now have electronic medical records, electronic ordering, and checks and balances done electronically," says Mr. Cappiello. "But there is also a human element in all of our delivery systems. As we think about how to improve care delivery, we have to look at both the electronic or automated systems as well as the human factors and how they interface. We have to look at them separately, how they come together as a system and how they constantly interface."

We continue to have clinicians and staff in denial. They believe that their own careful attention to detail and the fact that they haven't made an error in the past will somehow ensure that will not commit an error in the future. These clinicians do what they can to avoid the protocols advised by their colleagues or outside quality groups or simply go through the motions with the belief that these activities are an intrusion and an imposition.

"That's a bad attitude to take," says Mr. Cappiello. "You're first mistake can be your next patient. What we are trying to do is provide both risk assessment and risk prevention to minimize the setting and opportunities for those errors to occur."

6. Engage patients in safety initiatives.
Healthcare providers engage patients in their care for a variety of reasons, including the desire to improve HCAHP scores and create a patient-centeredness in the facility. "Beyond that, I believe that knowledgeable patients make care safer," says Mr. Cappiello. "If they understand what is being done and why it's being done, they have the opportunity to be invested in their own care. The more engaged the patient and family members are, the better their experience will be but more importantly, the safe their care will be."

Patients should be encouraged to ask questions about their medications and treatments, what to expect from those medications and why they are undergoing those treatments. "An environment that encourages patient involvement and allows a patient to actively participate in their own care, increases their knowledge to where they become care partners not just patients, The end result of that, I strongly believe, are patients and family members who help the staff create a safe and supportive environment," says Mr. Cappiello. "

More Articles on Patient Safety:

4 Strategies to Keep Infection Prevention Specialists Ahead of the Curve

Horizontal vs. Vertical Strategies to Reduce HAIs: Q&A With Kathryn Bowsher of PurThread Technologies

Kansas hospitals Reduce Bloodstream Infections by 38%

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