Director Patient Safety Partners Healthcare USA.
Physician Leader Patient Safety Kaiser Permanente USA.
To consistently deliver superior clinical quality and value, healthcare organisations must ensure that their strategy and structure are well coordinated. Organisations that succeed will be able to deliver superior clinical care and outcomes, and will have market advantage in brand reputation and operational efficiency. Success requires work in four areas: 1. Leadership—senior, administrative and clinical 2. human factors 3. reliable care systems and 4. patient–centric care.
Leaders must model and live organisational values everyday. If there is notable difference between the values inscribed on the hospital wall and what staff and patients experience every day, then habitual excellence is not possible. Cultural surveys have been useful in American hospitals to assess the real perceptions of staff as to their perception of management, the quality of their work experience, and how safe they feel to advocate for safe care.
Effective leaders translate their strategic goals into a few simple statements that everyone working in the organisation can understand and to which they can align their behaviour. If too many, or, made too complex, front line workers can neither remember the goals nor, while providing care, consistently align their behaviour to them. By contrast, Ascension Healthcare, the largest faith-based American health system with 67 hospitals, espouses 3 goals for everybody everyday: care that is safe, care that works (reliable delivery of evidence based medicine), and care that leaves no one behind (fulfilling their social mission of providing care to disenfranchised patients without health insurance or other care options). The mantra at Ascension is that “by the year 2008, we will have no preventable patient harm or deaths.” If achieved, this mission will be a competitive advantage as clear measures of quality and patient safety become more readily available for patients and purchasers.
At Brigham & Women’s Hospital in Boston a management tool called Leadership Patient Safety WalkRounds engages senior leadership on a weekly basis with front line staff. Through careful planning, the WalkRounds appear as relaxed conversations where staff can feel safe discussing any topic including errors. On these rounds, a scribe’s sole job is to record every issue brought forth and by whom, so it can be evaluated, and feedback given to every staff member who contributes. The topics discussed during WalkRounds are evaluated for risk, assigned to appropriate individuals, and tracked to ensure resolution. After six years and hundreds of rounds, employees and physicians know that they can be forthright in their comments without a punitive response, and that their concerns will be acted upon. Visible physician leadership is critically important in the adoption of collaborative clinical practice necessary to achieve superior clinical outcomes. The traditional educational approach of physicians as individual experts and vigilance as the mechanism to ensure safety is not an effective strategy given the complexity of modern medical care. Yes, we need skilled experts, but as we have learned from other high-risk industries – such as aviation, nuclear power and military operations – the ability to work collaboratively within reliable systems is a critical success factor. This perspective is best understood when viewing the behaviour of stellar physician leaders in the first couple of minutes when a team comes together. They establish effective team behaviour and an environment of supportive respect by actively engaging all participants in a discussion of plans, disavowing personal perfection (“We’re all experts, but because we’re human we’ll all make mistakes. That includes me.”), and clarifying the goals and pitfalls of the job ahead.
Applied human factors science provides tools to support effective teamwork and communication. Communication failures are the central theme in the overwhelming majority of avoidable adverse patient outcomes. Often, healthcare providers hesitate to speak up about their concerns because they don’t know the plan of care (and worry they will appear ineffective) or they were previously treated with disrespect when they did voice concerns. The other common pitfall is “the assumption we’re all in the same movie”, rather than using structured communication such as a read-back to ensure all have the same understanding of the plan of care. The authors have taught human factors and team work training in multiple American health systems. The four elements necessary for effective teamwork and communication are:
This basic communication package can be embedded within a few clinical elements that clinicians use every day to care for patients. High risk clinical areas like obstetrics, surgical services, emergency medicine, critical care and others are natural areas for intervention, though virtually any clinical area can benefit from the systematic adoption of these tools and behaviours.
The concept of reliability—defined as defect free care over time for a patient—has evolved from high risk industries and is gaining traction in healthcare. Reliable systems support the delivery of consistent, superior care. For example, in surgical care, infection rates are affected by administration of prophylactic antibiotics within 60 minutes prior to incision. The tracking of antibiotic administration and surgical infection rates are currently required metrics in American healthcare. In many ICUs ventilator associated pneumonias, previously considered an irreducible cost of long term ventilation, has virtually been eliminated by the combination of peptic ulcer disease and deep venous thrombosis prophylaxis, elevating the head-of-the–bed 30 degrees and sedation vacations.
Many healthcare systems have adopted improvement methods like Toyota Lean or Six Sigma, which allow frontline experts to contribute to process improvement and elimination of waste. The organisations that are making quantum leaps in quality and safety—and are realising substantial operational efficiencies—have embedded these techniques within their culture. Similar to Toyota, they relentlessly focus on how to improve the way they improve, rather than applying a solution and declaring victory.
Patient-centric care, ultimately the singular goal of all healthcare efforts, is to deliver safe and reliable care for all. Leading health systems continuously learn about the patient experience and how medical care is perceived by patients and families. In America, a common failing is that physicians and hospitals ascertain success by assessing the technical delivery of care, i.e. how long did it take to successfully intervene in patients with acute myocardial ischemia? Interestingly, we have learned that these technical markers are often invisible to patients, who process their medical care as a profound social experience. Understanding this, we must redefine what constitutes successful care. It is not adequate to intervene technically, we must engage patients so that they understand the care they receive and feel supported throughout. This then highlights health literacy as a major problem because in America, the average citizen reads at an 8th grade level, while frequently we provide them with information formulated at a college reading level. Patients with health literacy issues consume four times the average resources annually, and consistently have poorer clinical outcomes.
Two simple techniques from the American Medical Association have shown great benefit: Ask Me Three—that every patient and their family must understand three aspects of every component of care— “ what is my basic medical problem, why is it important that I understand this, and what needs to happen for me to get better?” The second technique is the “Teach Back”, in which instead of asking them if they understand and having the patient politely nod in agreement, we ask “you have heard us talk about your care, now please take a minute and tell me how you will explain it to your family.”
Often we have assumed patients and families understand, but on closer inspection their lack of understanding can seriously impact their care process and health status.
In regards the endeavour to achieve safe and reliable healthcare, we are at best at the end of the beginning, but over the past decade the pattern, form and shape of success have become clear. The tapestry of safe and reliable healthcare is woven with the threads of leadership engagement, human factors theory application, reliable design implementation, and understanding of patients’ holistic needs. “Safety and Reliability” is not a series of projects, it is an overarching strategy formulated into understandable and simple goals and supported by extraordinarily elegant organisational structure, all of which can be envisioned only by enlightened leadership.