Better reporting, rapid response and zero tolerance for errors make hospitals a safer place for patients.
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Thanks to widespread attention by such groups as the Centers for Medicare and Medicaid Services (CMS), the Institute for Healthcare Improvement and the Agency for Healthcare Research and Quality, awareness of patient safety is at an all time high. But has patient safety actually improved in hospitals?
“I think patient safety is definitely improving,” says Tammy Merryman, vice president, center for quality improvement and innovation, University of Pittsburgh Medical Center member. “The Institute of Medicine report (“To Err is Human, Building a Safety Health Center”)” was a wakeup call to healthcare leaders across the country.”
Merryman points to a number of trends that have taken hold in the past years. “CMS is doing a better [job] of reporting [adverse events],” she says. “And the mortality rates have dropped throughout the country.” The staff at the University of Pittsburgh Medical Center has become increasingly comfortable reporting safety issues and errors, she says. “Our nurses feel empowered to call our rapid response team and bring attention to safety issues. The trick [for us] is to look at [events] after the first sign of something going wrong.”
Patient safety starts with awareness. “As we increase our awareness of the need for patient safety, we will see more of what’s going on, says Diane Redmond, director of hospital quality, Memorial Health System, Colorado Springs, Colo. The hospital has become much more focused on measuring outcomes, she says. “For instance, we measure the number of patient days on ventilation and look at how this impacts patients’ length of stay in the hospital.”
“There used to be a mindset that physicians knew what was best for the patient,” she adds. “Today, [healthcare] recognizes that patients must be involved in their own care.” In addition, there is a zero tolerance policy today, she says. Whereas healthcare workers once believed that it was inevitable for some patients to develop infections in the hospital, today there is no tolerance for errors.
Culture of safety
The culture of safety, or general orientation toward safety, means something different for all organizations, according to Peter Angood, M.D., vice president and chief patient safety officer, The Joint Commission (Oakbrook Terrace, Ill.). But for most, it reflects the facility’s mindset toward safety and determines how successful its safety program will be.
“The culture of safety reflects the degree of leadership engagement,” says Angood. It’s the extent to which CEOs and top management suggest initiatives and then implement them. Management, staff and physicians, in turn, must understand the importance of these initiatives and act on them, he adds.
The culture of safety must also reflect an organization’s degree of transparency, says Redmond. “How comfortable is the staff when it comes to reporting errors,” she asks. “How open is the facility in reporting errors?”
However, an increase in reporting at a hospital doesn’t necessarily mean that its safety program is lapsing, says Lori Glover, manager of clinical informatics and performance improvement, University Medical Center, Southern Nevada (Las Vegas). “It just means we are paying attention to safety and addressing it.”
In a culture of safety, “everyone in the hospital sees [himself or herself] as a caregiver and an advocate for each patient,” adds Merryman. “Everyone sees it as [his or her] job to make the hospital a safer place.”
Taking the lead
Patient safety begins with the IDN’s leadership. “Where goes the leader, there goes the staff,” says Merryman. The CEO must set the tone for patient safety, she says. “Executive teams should talk about safety and conduct safety rounds. They should spend time with employees and ask them what keeps them up at night. They should ask staff and employees where [the facility’s] next patient error will occur.”
“The executive team members should listen to their employees and then follow up, even if it’s doing something as simple as fixing a rug that trips people in the hospital,” she says. Most important, executive members should avoid reacting adversely to staff reports on safety. “They can’t flinch when their staff tells them something,” she says. “Their staff is watching them. If [a member of the executive team] responds inappropriately, the staff may feel [he or she] is placing blame.” Glover agrees: “Hospital leadership should talk to the staff and hear its concerns,” she says. “Ask questions and become involved. Make it a safe place for people to report errors and [discuss] patient safety.”
A program that works
Depending on the IDN’s infrastructure and patient demographics, its safety goals may vary. Still, all providers must tackle similar safety issues, says Merryman, even if they have different infrastructure and tools for dealing with those issues. “We all like to think we are unique, but we really are very similar,” she says. “I think about 80 percent of patient safety, including dealing with negative outcomes and procuring medications, is the same across the board. [The other] 20 percent is unique to each hospital.”
Experts agree that an organization’s safety program must incorporate some basic elements in order to be successful. These usually include the following:
- The board of trustees, as well as the CEO and CFO, must believe a safety program is necessary
- Safety issues must be on the board’s agenda, and they must be discussed
- There must be a solid incidence-reporting program, with no assigning of blame
- There must be a transparency agenda for dealing with adverse events if/when they occur. Hospital clinicians should sit down with the patient’s family to explain why the error happened and discuss further steps or solutions to prevent a similar event from occurring later on
- Contracting decisions for technology and pharmaceuticals must reflect patient safety, not just cost containment.
- Staff evaluations should cover patient safety to emphasize that everyone in the hospital is responsible for it.
- Patient safety goals should be assigned to groups that can evaluate and implement them.
Safety goals should be integrated very carefully into the structure of the organization, says Marlyn Conti, patient safety coordinator, Intermountain Healthcare, Salt Lake City, Utah. “Some hospitals may not have the infrastructure to support certain goals,” she says. “We can’t have corporate people saying they will [accomplish] X, Y and Z if they haven’t the means for facilitating this.”
The cost of safety
What’s the cost of patient safety? That depends. Last year, Intermountain bought therapeutic mattresses for almost all of its beds in an effort to reduce pressure ulcers. “We have 20 hospitals, so we had to [consider] the cost of replacing mattresses for all of our hospitals,” says Conti. However, since replacing its mattresses, the IDN has reduced its rate of pressure ulcers from 10 to 5 percent. “Patient safety only works if it is seen as an integral part of the hospital process,” she adds.
Other times, doing things the right way from the start costs a facility little or nothing – particularly compared with the expense of dealing with an adverse event. “It costs about $25,000 to treat a central line infection,” says Merryman. These infections often are caused by poor technique inserting a catheter or by poor hand washing habits by staff or the patient’s family. “We make sure that central lines are put in by people who use correct barriers,” she says. These include caps, gowns, gloves and masks. “We also make sure our central line kits are stocked with the right items.”
Over the past six years, the facility has reduced its rate of central line infections from 4.2 percent to .5 percent, according to Merryman. “This means we have prevented 270 central line infections, which would have cost us $6.7 million. And, about 18 percent of patients who get central line infections die, so we have also saved 49 lives during that same six-year period.”
Still, for the hospital CEO who must consider the bottom line in dollars and cents, much of the cost benefit of practicing safer medicine is hidden. “There are new technology costs and inflation,” says Merryman. “So, when expensive changes must be made up front, it can be difficult to come up with the money. All hospitals want to do the right thing, but they face challenges.”
“We need to look at nuggets of change,” she continues. “It’s the cumulative, repetitive, sometimes painfully boring changes that make a difference.”
“This is a world of Maseratis and garbage cans,” says Merryman. “Hospitals are buying [high-tech] CT scanners and at the same time, I worry if the garbage cans are placed in the right area so that no one gets sick. But, our small changes add up.” After all, these changes are for future generations, she adds.