A New Culture of Care

Patient Safety
Hospital administrators take a closer look at patient safety.

It’s not that patient safety has been overlooked up to now. But, hospital administrators have moved beyond recognizing the problem to addressing it.

About 10 percent of all patients incur some type of medical mistake, be it infection or wrong identification, according to Peter Angood, M.D., VP and chief patient safety officer at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The Commonwealth Fund, a private foundation that promotes high performing healthcare systems by supporting independent research on healthcare, shows that up to one third of patients with serious health problems encounter mistakes through its research, he points out.

A culture of safety
“[Hospitals] must create a culture of safety that is headed by top administrators and leaders,” says Angood. “Investing in safety means revising the process of care and reporting errors such that it is non-punitive. If more reporting can occur, more evaluation can take place and standards can be established.”

In fact, IDNs must move beyond the traditional “blame and shame” attitude, according to Michelle Krauss, executive director, clinical education and outreach, MedAssets Supply Chain Systems. “We need to [reach a point where we] see swift and visible change of unsafe practices,” she says. And, this will not happen without educating staff and identifying hospital leaders who can encourage and support patient safety outcomes.

While medication errors, infection control issues and communication breakdowns clearly are obstacles to a strong patient safety culture, some believe that to thoroughly address patient safety, administrators must first focus on hospitals from a systems perspective.

“From a systems perspective, components of the health system are not aligned,” says Kathryn Leonhardt, M.D., MPH patient safety officer at Aurora Health Care (Elm Grove, Wis.). The Premier customer believes it is time to involve experts from outside the healthcare industry, such as industrial engineers, who can look at the big picture rather than focus only on communication flaws or inadequate record keeping.

“We have to look at the big picture in order to get to the root of safety issues,” she says. “This means aligning different levels and departments within a hospital system, multiple levels and providers of care, inpatient, outpatient, retail pharmacy, home healthcare, and the current healthcare reimbursement system to outcomes in patient care.”

Indeed, the handoff of a patient from one hospital department or facility to another is often an opportunity for errors to occur, according to Angood. The information is not transferred smoothly enough.

Furthermore, if different sectors of a hospital or hospital system do not interconnect, even the most sophisticated technology won’t facilitate patient safety. “Once we look at how the different [hospital] systems interact, then we can [evaluate] where new technology fits in,” Leonhardt adds.

A good safety program
Once a culture of safety has been established, complete with supportive leaders and interconnected departments and facilities, safety experts can look at the nuts and bolts details that can make – or break – a good safety program.

Communication, both among caregivers and between caregivers and patients, is key to patient safety, according to experts. Communication breakdowns, whether oral or written, often lead to medication and device errors, says Kraus. Equally important to communication is education. “It is [essential] to educate and re-educate caregivers on technology and devices,” says Kraus. In addition, caregivers must educate their patients and get them directly involved in their safety, she adds.

Of course, patient errors may occur, in spite of steps taken to prevent them. When they do, hospitals should follow a safety protocol that involves reporting errors, evaluating them and precipitating change, according to Angood.

Elizabeth Duthie, RN, MA, director of patient safety, NYU Hospitals Center, agrees. There are two critical points of an effective safety program, notes the Premier member: First, everyone in the organization should know what his or her role is in supporting patient safety. Second, once an error-reporting program is established, specific individuals should be in charge of providing feedback. “If people do not see the value of their error reporting, they are likely to give up,” says Duthie. “When people see the value of their efforts, they are more likely to participate.”

Safety goals
An increased focus on safety by hospitals and organizations signifies progress toward better patient care. Along with the talk and strategizing, however, hospitals must create and work toward specific patient safety goals, note the experts. Such goals play an important role in precipitating change and enhancing patient safety.

JCAHO has established patient safety goals for hospitals to follow, says Angood. “JCAHO-accredited hospitals must show that they are working toward these goals,” he says. “Some of these goals include better patient identification, better communication among caregivers, [enhanced] medication safety and [reduced] healthcare-associated infection.” These goals address such issues as communication, patient concerns and general care-giving, he adds.

Similarly, Aurora Health Care System establishes specific patient safety goals each year for its 100 clinics and 14 hospitals. It then uses different indicators and hospital-generated data to measure its progress toward these goals, according to Leonhardt. “Our goals [focus on] improving patient communication, medication reconciliation and [evaluating] the organization’s culture of safety,” she says. “We also look at the Leapfrog Group [safety] survey and [the state of] Wisconsin’s safety measures.”

In addition, Aurora Health Care has obtained a grant through the Agency for Healthcare Research and Quality (AHRQ) to implement a patient safety advisory council. The council, which is comprised of 11 patients and 12 healthcare providers, meets monthly to discuss patient safety for patients 55 years and older in the outpatient setting. “We have patients and providers working collaboratively at the grass roots level, identifying ways to assure that an accurate medication list can be developed and shared among caregivers,” says Leonhardt. “We want to find tools and interventions that can improve communication between patients and their providers – doctors, nurses, retail pharmacists – regarding their medications. We want the patients and their doctors to have the same medication lists.”

NYU Hospitals Center has taken specific measures to achieve two strategic goals. “First, we [strive] to reduce the number of preventable deaths, which are frequently caused by medication errors and infection,” says Duthie. “To do this, we have set up an active work group of nurses and staff, which implements Centers for Disease and Prevention (CDC) guidelines, monitors these guidelines and provides other hospital staff with feedback.”

In addition, NYU Hospitals works to strengthen the safety culture at an organizational level, Duthie adds. “We are instituting a computer-based incident reporting system that everyone will have access to,” she says. The system was expected to be up and running by the end of March 2006.

Expensive mistakes
Patient health complications and lost lives are unfortunate outcomes of medical errors. So is the estimated $29 billion in annual costs to the United States due to preventable patient errors, according to Angood. It is difficult to determine a direct correlation between patient safety and financial outcomes. Still, the relationship is apparent.

“The [exact] savings are difficult to determine,” says Curtis Ohashi, COO, Ventura County Medical Center (Ventura, Calif.). “Still, there is the cost of an extended patient stay when a patient develops an infection, as well as liability costs and time needed for peer review.” The Amerinet member believes that there is a trend toward standardization in error reporting, which may help groups better quantify the financial impact of patient errors.

“The economic results are fuzzy,” adds Angood. “But, we can state that promoting safe patient care [leads to] fewer complications, shorter patient hospital stays and a need for fewer resources for each patient.”

Some estimates of costs associated with hospital-related errors include the following:

  • Every patient on a respirator who develops pneumonia can be expected to remain in the intensive care unit for an extra 14 days, costing the hospital an additional $40,000 or more, according to Duthie.
  • Every patient who develops a bloodstream infection from an IV catheter can be expected to remain hospitalized four more days, costing the hospital an additional $25,000, according to Duthie.
  • Hospital-acquired infections can cost the United States an additional $5 billion annually, according to the Centers for Disease Control and Prevention.

There are two reasons why it is challenging to correlate patient safety and financial savings, according to Ken Smithson, M.D., VP of research at VHA Inc. “First, the organizations usually have very little information on the incidence of patient injuries,” says Smithson. “Unless there is a conspicuous occurrence, such as a death, fall or major medication error, most episodes go unreported. So, most estimates of economic consequences are based only on major injuries, even though we know that for every fatal episode, there are dozens of minor injuries.”

Second, the Medicare reimbursement system often rewards complications, including patient injuries, Smithson continues. Medicare patients may be moved into a higher-paying DRG classification; or, if they die early in their stays, the hospital might actually spend less on their care. Meanwhile, private insurance may reimburse the hospital for additional care it must provide, meaning the hospital can generate additional income, he adds.

Nevertheless, when complications do occur, the hospital must provide extra services, which often exceed any additional revenue generated, notes Smithson. “The economic consequences need to be considered on a case-by-case basis.”

VHA is developing a tool kit designed to help performance improvement, and patient safety leaders estimate the financial benefits of their safety programs. The kit, which was expected to be launched in late February, includes an interactive spreadsheet that hospital executives can use to calculate the economic benefits of their programs. “The aim is to foster closer cooperation between clinical improvement staff and the finance staff, to improve the design of projects and to reinforce the value of better care and improved patient safety,” Smithson explains.

Promising technologies
The market continually generates new patient management and medical technologies, which, to a point, can help facilitate patient safety. Some of these include:

  • Computerized physician order entry
  • Electronic health records
  • Electronic prescription writing
  • Barcode medication administration.

However, the multitude of cutting-edge electronics and new devices call for standardization, improved communication among caregivers and constant training and education for proper use. As promising as new technology can be, these systems have to be integrated or linked from one facility to another within an IDN, notes Leonhardt. And caregivers should be able to use new devices and computer systems to full capacity for them to be truly effective.

“One of the conclusions we have drawn over the last few years is that technology alone is unlikely to solve the patient safety problem,” says Smithson. “The expectation is that computers and scanners will eliminate human error, when all too often they accelerate it.” In light of this, there has been a greater focus on improving processes, creating effective treatment guidelines and eliminating variation, he adds.

Spirit of collaboration
Today, there appears to be a spirit of collaboration among different healthcare institutions, notes Angood. “We see more sharing of information [among hospitals], which should enable the standardization of safety protocols,” he says.

“We should start to see in healthcare what the aviation industry did,” adds Duthie. “As more information is shared among [hospital systems], more standards for patient safety will be established. Right now, patient safety efforts are still so new, there are no tried and true methods.”

Continued education of caregivers, greater patient involvement and pay-for-performance programs are expected to facilitate more accurate error reporting and better protocols for precipitating change. And, institutions, such as JCAHO, the Centers for Medicare and Medicaid Services, and the Institute for Healthcare Improvement’s 100,000 Lives Campaign are evaluating “whether healthcare providers [are doing] the right things, for the right patients, at the right time,” all of which should promote process improvement, says Smithson.

“There has yet to be a consensus on what is the ‘gold standard’ of an excellent safety program,” says Leonhardt. At this point, hospitals and organizations have identified key elements that should be in place for a safety program to be successful. Through enhanced leadership support, an event reporting system, intercommunication among institutions and a community of trust, a culture of safety should evolve.

About the Author

Laura Thill
Laura Thill is a contributing editor for The Journal of Healthcare Contracting.