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Patient safety and metrics: Obtain good data
Risk managers are collecting data and using metrics in many ways lately, and patient safety should be a primary focus, says David G. Danielson, JD, CPA, senior vice president of clinical risk management at Sanford Health in Sioux Falls, SD.
Patient safety can be improved by the use of metrics, but that improvement first depends on having good data, Danielson says. He recommends, at a minimum, that providers collect data related to the National Quality Forum's Safe Practices for Better Healthcare -- 2010 Update. (The safe practices guide is available at www.qualityforum.org/About_NQF/CSAC/Safe_Practices_Table.aspx.)
"Tracking and trending will help a system identify potential problems. From there, solutions can be developed," Danielson says. "The key is the implementation of the solutions. An organization must have both the awareness and the capability to make solutions stick. This is heavy work, as the inertia of the status quo fights against the changes."
Metrics can help isolate the problems, making it possible to correct them and improve patient safety, Danielson says. "We regularly hold multi-causal analysis forums to look for ways we can improve our clinical practice," he says. "I use the data to change policies and procedures, talk with clinical departments and providers, and report to senior management about improving safety for our staff and patients."
Danielson and his colleagues did just that with a medication reconciliation project. The pharmacy was able to gather data about the types and locations of drug variances, and that information was presented to senior management. The senior managers authorized an education program about the importance of making sure there was a correct listing of each patient's medications. "Using the data, we focused on both the higher risk areas as well as those areas with higher variances," he says. "After the education, we again tracked and trended the variances and we have improved."
Useful information can be obtained by performing a root cause analysis or failure mode analysis when an adverse event occurs, to find out what went on behind the event, says Alan Rosenstein, MD, MBA, medical director of Physician Wellness Services, a company in Minneapolis that provides services to troubled physicians and their employers. "The analysis often finds that there were failures in communication and/or collaboration," he says.
Rosenstein notes that, according to The Joint Commission, 65% of sentinel events can be traced back to an error in communication. When performing post-event analysis, risk managers need to evaluate the contribution of human factor issues as well as structural process issues. Then the risk manager should look for solutions that will address communication gaps to prevent an unwanted reoccurrence of a potentially preventable adverse event, he says.
"Additionally, it is important to implement standard patient safety and quality indicators in each department or area with measurements specific to each department or area," Rosenstein says.
An indirect measure of patient safety and quality is patient satisfaction, Rosenstein notes, which can be determined through surveys. In such a survey, include questions that address the patient's comfort and the ability to interact with providers and obtain the information they thought was necessary to understand their situation and make the right decisions, he says. Research has shown that poor patient satisfaction correlates with higher medical malpractice risk, he says.
These surveys also can be extended to an organization's staff to determine safety culture and staff satisfaction, he suggests. "These surveys should include questions based around specific behaviors and perceptions around communication and collaboration," Rosenstein says. "Poor communication and collaboration are strongly linked to adverse events and outcomes." One example of a survey question that can help evaluate the safety culture is "How would you rate the effectiveness of physician communication/ nurse communication in helping you understand your medical condition?"
Change sometimes can best be achieved by addressing the "human factor" issues at the individual level through education for all staff members to encourage and facilitate better communication and improved collaboration between team members, he says.
"The education should raise the level of awareness of what disruptive and unprofessional behaviors are and how they can negatively impact work relationships, communication flow, and team collaboration, and how they can adversely impact outcomes of patient care," Rosenstein says. "Stress the importance of holding individuals accountable for their actions. Provide workshops on improving communication skills. Stress the importance of timely intervention, coaching, and counseling, and if needed, more comprehensive interventions."
Coaching also helps individuals understand what they are doing to impede patient safety and also helps improve staff member performance. Examples would be helping individuals see how their behaviors might be perceived by others (raising emotional intelligence), and providing tools and techniques that will help them deal appropriately with factors affecting their behaviors. Additionally, an intervention might be necessary for individuals who are non-compliant or whose actions pose an immediate risk to patient safety, he says.
Rosenstein's company once helped coach a physician who was perceived as "hotheaded" and "unapproachable" by his physician peers. He described himself as passionate and committed and was resistant to change. He failed to see how his "message" was consistently misinterpreted or lost totally due to his delivery of the message, Rosenstein says.
Through coaching he was able to increase his awareness of how his delivery of messages was destructive vs. constructive, recognize how to better manage the day-to-day stress and frustration inherent in clinic practices, and more selectively choose the issues he felt strongest about. He realized he had been regularly asked to "carry the flag" on behalf of his colleagues he were unwilling to bring the issue forward, which he stopped doing.
The coaching helped the physician engage in a process of consciously identifying "new behavior" vs "old behavior" and intentional efforts to gravitate toward "new behaviors."
"In any of these instances, having hard data through capturing these metrics will create a much more compelling case for change," he says.