Where do hospitals go from here on quality, safety? Key thoughts from 4 experts

Earlier this year, research suggested adverse events occur in about one-fourth of hospital admissions, prompting NEJM Catalyst to seek insight from leaders on how healthcare organizations can get more strategic around patient safety and quality improvement. 

Thomas Lee, MD, editor-in-chief and editorial board co-chair of the NEJM Catalyst Innovations in Care Delivery journal, reached out to 13 leaders in response to the study findings led by David Bates, MD, chief of general internal medicine at Boston-based Brigham and Women's, that indicate it is time to revamp patient safety and quality work. 

"The work ahead may seem daunting, but the leaders commenting here seem undaunted," Dr. Lee wrote. 

Several themes emerged across leaders' responses, including the need for more proactive approaches to mitigate risk, making use of real-time data as well as support from policymakers.

Here are excerpts from four leaders' responses:

Allen Kachalia, MD. Senior Vice President of Patient Safety and Quality at Baltimore-based Johns Hopkins Medicine, and Director of the Armstrong Institute for Patient Safety and Quality: Healthcare leaders and providers want their organizations to be the best when it comes to quality and safety. The underlying question is, how do we ensure that quality and safety receive the proper prioritization? For example, there is no question that other large problems exist in healthcare, such as maintaining financial solvency, staff turnover, and worker safety. But the point that is probably too often overlooked is that steps taken to address these important problems may generate unintended quality and safety risks. Perhaps the most obvious example is how, across the board, budget cuts can inadvertently impede or set back quality improvement efforts.

Nevertheless, there is cause for optimism. Over the last two decades, we have seen increasing investment and attention toward quality improvement. Most healthcare systems now have board committees and operational structures designed to elevate the organizational importance of patient outcomes. Healthcare organizations need to lean into these mechanisms to stay on task with regard to proper prioritization.

Arun Venkatesh, MD. Chair of the Department of Emergency Medicine at Yale University School of Medicine and Chief of Emergency Services at Yale New Haven Hospital (New Haven, Conn.): As a frontline healthcare worker, the greatest risk to hospital safety and healthcare equity is the unprecedented capacity crisis faced in acute hospital care. Virtually every emergency department and hospital in this nation is over capacity, resulting in delayed or missed diagnoses in patients who leave the emergency department without evaluations for acute conditions, increased mortality while awaiting a hospital bed in an emergency department hallway, and even critically ill patients unable to receive access to specialized or critical care. The basic premise of almost any published patient safety conceptual model assumes the availability of basic resources for care delivery, including the minimum staff, space, and materials for acute care. Our current national crisis has put all three at risk as we face record shortages of hospital-based healthcare workers, inpatient bed capacity has not kept pace with population and acuity growth, and supply chains for everything ranging from medications to gauze pads remain fragile. These structural forces may seem insurmountable on the surface, but can be addressed if policymakers and health system leaders embrace safety culture and apply the strong leadership called for by Bates and colleagues. As Coach Lasso would say: "Doing the right thing is never the wrong thing."

Tejal Gandhi, MD. Chief Safety and Transformation Officer at Press Ganey: We need more robust safety measurement, using multiple sources of input. Safety event reporting from frontline staff identifies a subset of safety events and is commonly used as a primary source to identify safety issues. Safety event reporting also has benefits for driving a culture of safety by engaging staff in problem identification and identifying potential solutions. That being said, we have to expand our sources to ensure we are capturing the full range of safety events, using trigger tools, artificial intelligence, and other novel methods. In addition, we should expand such that we are more proactive — capturing risks and intervening, rather than solely measuring harms after the fact. Given innovative technologies that now exist, this is not a future dream but something that the safety field can advance now.

Kenneth Kizer, MD. Adjunct Professor at Stanford (Calif.) University School of Medicine, Distinguished Professor Emeritus at UC Davis School of Medicine in Sacramento, Calif., and Founding President and CEO of the National Quality Forum: If we are to eliminate avoidable healthcare harm, then new safety technologies must be developed and incorporated into the processes of care. Even though medication errors remain the largest cause of preventable harm, this is also the area where the most improvement has occurred over the past 20 years, largely due to barcode medication administration. A promising technological development currently being pursued at selected health systems in the U.S. is black boxes in the operation room. And a much less grand but highly successful technological innovation developed by the VA Health Care System is the use of 3D printing to make thermal fuse covers for home oxygenators to prevent patients from removing thermal fuses that prevent fires. Other technological innovations are at varying stages of development at diverse locations. A concerted effort is needed to develop, test, and operationalize innovative safety technologies.

Read the comments in full from the 13 leaders here

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