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'Spread' remains challenge in patient safety improvement
The good news: Top performers show that errors can be eliminated
This March, the industry once again celebrated National Patient Safety Awareness Week an apropos title as quality professionals have certainly become increasingly aware of the importance of patient safety in recent years. But how well have we done?
Experts interviewed by HBQI give the industry a mixed report card; top-performing hospitals have demonstrated that it's possible to reduce errors in specific areas to zero, but not all facilities are mirroring that level of achievement. Many facilities have achieved excellence on specific units, but have not yet carried that excellence hospitalwide.
"Our leadership in healthcare has been trained for years in command and control; we are very good at seeing a problem or a task, understanding it and fixing it, and when we're done, moving on to the next problem," says Diane C. Pinakiewicz, president of the Boston-based National Patient Safety Foundation, which instituted National Patient Safety Awareness Week. "That approach to performance improvement is what we do best. So, we see very well-proven, evidence-based processes, but what we do not see is spread and sustainability, because we approach problems the way we're used to approaching them. When you get to your solution to problem number five, your solution to number one potentially starts to unravel behind you."
Patient safety improvement, she continues, "abounds in pockets but it's not being spread and getting us in the aggregate where we want it to be."
Those variations occur between hospitals as well, adds Leah Binder, CEO of The Leapfrog Group. "We've achieved the highest standards in some hospitals, while others are frankly dangerous; there remains huge variation."
So, she continues, best practices have been identified in a number of areas. "What some have done with central-line infections is brilliant. Surgical checklists have been very successful. We know what works and how to do it, but what we can't figure out is how to get every hospital to do it," she says.
"We hear a lot of people talk about central-line infections, and many will say they have done well in the ICU," adds Carol R. Haraden, PhD, vice president of the Cambridge, MA-based Institute for Healthcare Improvement. "But there's also pediatrics, oncology, dialysis. It's not an ICU change, but an all patients with central lines change," she notes.
She suggests that QI teams map the areas in their hospitals where every patient would benefit from a positive change in processes. "Do we have a prototype? Yes, in intensive care, but wherever you go in a hospital you should get the best practice. Variability is still the norm, and it's a huge problem," she says.
Binder agrees. "The fundamentals that work with a problem work across the board; best practices must be hard-wired through policies and leadership," she says, but adds that this has been difficult to implement.
Attitude adjustment required
Most experts agree that while awareness of the importance of patient safety has increased, many hospitals have not succeeded in creating true culture change.
"Safety has risen way up on the priority list as a strategic imperative; most everyone gets the essence of it," says Pinakiewicz. "The challenge is not raising awareness, but helping people understand how to prioritize and focus on it."
"Hospitals are not doing what they should be doing to avoid errors," Binder adds. "Take the example of hand hygiene. Has a policy been passed by the board? Are there education programs? Do staff members do what every American you stop on the street says would be easy?"
She says that in a recent Leapfrog survey 70% of its reporting hospitals had appropriate policies in place. "But these hospitals tend to do better," she observes. "That's a nice majority, but what about the 30% that don't? Not to put in place the most basic, fundamental prevention hand-hygiene practices we know? That's very disturbing."
"Hand-washing is a challenge because we've chosen it to be," adds Haraden. "Right now there is a bacteriostatic curtain material available, but hospitals have decided it's too expensive and will not use it. We go the cheap way, relying on posters, which you become habituated to in a week and a half. The two things we rely on most are admonition and hard work as if they would work; they are the two weakest approaches. You can keep after people, but in a very busy environment, errors will happen." She says a "continual feedback loop" is needed. "You almost have to film someone, show it to them, and say, 'Here are four opportunities you missed today,'" she offers.
Haraden also sees the need for an attitude adjustment. "We fail to see all harm as preventable," she says. "We know there are some things where patients are harmed as a natural by-product of care, but if we define it as inevitable, we will lose curiosity. Sure, there is some irreducible number of errors, but we are nowhere close to it. We can reduce errors so much further than we have."
"The biggest challenge is changing peoples' attitudes towards safety," says John Combes, MD, senior vice president of the American Hospital Association. "In healthcare, on a one-to-one basis we underestimate the danger of what we do, and we have to change that attitude everything we do comes with extreme risk. In order to do that we must be mindful, open to all sorts of input, rely on standard operating procedure when things go well and when they don't, rely on the ability to contain risk through teamwork, and allow ourselves to be directed by the members of the team that have the most information."
It can be done
Combes points to the latest findings of the Comprehensive Unit-based Safety Program (CUSP) as an example of changing attitudes as a key ingredient in achieving patient safety improvement. "The program developed by Peter Pronovost addresses a lot of change that has to come not only to technology, but adaptive changes behavioral, cultural to take up and implementation," he explains. "CUSP in the unit addresses cultural change, participating in teamwork and communicating developing mutual accountability. CUSP takes a cultural approach at a unit level to adapt intervention in this case the central-line bundle in a certain way, such as insertion only when necessary, being fully gowned, and so on. Some call this a checklist but to get it to work you have to get people to do it."
In this case, they clearly seem to have done that. With more than 1,000 hospitals in 48 states participating, representing about 2,000 units, "Initial data has shown a reduction of the central-line infection rate of about 80%," says Combes. "That mirrors the recent CDC report."
"The report from the CDC shows they fell 58% from 43,000 in 2001 to 18,000 in 2009," notes Binder. "That's impressive, and a good number of hospitals was at zero or close to zero; that's exciting in the progress of patient safety."
Combes cites another critical aspect of CUSP: "It also measures changes in patient safety culture; it's really comprehensive," he says. (For more information on CUSP, go to: http://www.onthecuspstophai.org/Abou-7631.html.)
Culture change has long been recognized as one of the most challenging undertakings in patient safety improvement. What does Combes consider the keys to success? "Leadership engagement and support from the top are absolutely critical," he asserts. "For it all to work, is has to be supported by senior managers of the organization, and considered a priority. Progress has to be held up in front of the whole organization as an important way to change."
Pinakiewicz agrees. "What it gets back to is, the culture is the context become what you are and practice it," she says. "It's not good enough to find a solution; someone has to make you understand you are completely accountable for the care you deliver."
For example, she continues, people talk a lot about accountability for clinical outcomes. "However, if you look at hospital bylaws, you see they oversee practice and deal with outliers, but what they do not deal with is accountability for behavior," she says. "You can have a disruptive doctor who's a large revenue generator, and as long as the outcomes are good do nothing about their behavior."
However, she says, "We understand now that this is a huge issue. If you have a doctor who disrespects another member of the team, or is not receptive to the fact there may be something to look at because they feel they are completely in charge, then you have people who are uncomfortable about speaking out; you have a subculture that does not allow for the practice of safe care. We now understand that can't be accepted, and leadership needs to be [intolerant] of that type of stuff. It gets back to accountability."
What is required, she says, is having "all people look at the process together and feel comfortable speaking up when part of the process is working in a way you are not comfortable about it being safe."
Combes agrees that engagement of physicians is a critical component of culture change. "They have to be seen as a critical part of the team," says Combes. "And their partners nurses and other staff have to be included in accountability. If you learn to act as a team there is no problem being challenged when you are not following a checklist, not gowning completely or not using the right scrub."
Learn to prioritize
Pinakiewicz notes that with so many proven success stories, "People are overwhelmed by what they should do next and where to focus next. They have resource constraints that are worsening."
So how do you prioritize? "It depends on the individual organizational infrastructure, and what resources you have," she says. "But there are certain things you can do that cost nothing ensuring you practice transparency, open disclosure to patients, and recognize that as a provider organization you're a guest in the life of the patient and do not have the right to withhold any information."
There are way too many errors that occur because providers choose to ignore the patient or family member, she asserts. "When you have a parent sit there and say there's something wrong with the child, the doctor may not listen because they think the parent is being emotional, not clinical. But who knows child better?" she says.
Finally, Pinakiewicz sums up her approach to improving patient safety with the following: "The work of patient safety is really not something that should be a project; it should be the way you do your work."
[For more information, contact:
Leah Binder, CEO, The Leapfrog Group, c/o Academy Health, 1150 17th Street NW, Suite 600, Washington, DC 20036; Phone: (202) 292-6713; Fax: (202) 292-6813; E-mail: email@example.com.
John Combes, MD, Senior Vice President, American Hospital Association, 155 N. Wacker Dr., Chicago, IL 60606; Phone: (312) 422-3000.
Carol R. Haraden, PhD, Vice President, Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138 USA; Phone: (617) 301-4800; Toll-Free: (866) 787-0831; Fax: (617) 301-4848.
Diane C. Pinakiewicz, President, National Patient Safety Foundation, 268 Summer St., 6th Floor, Boston, MA 02210; Phone: (617) 391-9900; Fax: (617) 391-9999; Email: firstname.lastname@example.org.