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CHAPTER 1
A Call to Action: The US Patient Safety Crisis1
A safety crisis is brewing in healthcare. Medical errors currently rank third among causes of death in the United States (exhibit 1.1), with 210,000 to 440,000 US residents dying each year from preventable hospital medical errors (Cha 2016; James 2013).
Healthcare safety programs have evolved over the past 20 years, and many organizations have made progress. However, many more struggle to provide consistently safe, high-quality care. In its 2016 nationwide safety survey of hospitals, the Leapfrog Group found that 40 percent received a C, a D, or an F rating in hospital safety.
CURRENT STATE OF SAFETY
As part of an ongoing effort to determine the reasons so many hospitals receive poor safety grades, one of the authors (J.B.) conducted a workshop with about 30 finance leaders from hospitals across the United States. The specific aims were to (1) explore the organizational factors that lead to lapses in safety or occurrences of sentinel events and (2) find out where patient safety ranks as a priority for healthcare finance executives.
To establish context for the discussion, the following information was shared with the group:
• Preventable adverse events account for "roughly one-sixth of all deaths that occur in the U.S. each year" (James 2013).
• More than 1,000 people die every day from preventable accidents in hospitals (McCann 2014).
• Errors of omission and commission, complications, readmissions, and avoidable mortality cost the US economy billions of dollars each year (Zajac 2009).
• On average, a hospitalized patient in the United States experiences at least one medication-related error — the most common type of error — each day (IOM 2007).
• In 2011, an estimated 722,000 hospital-acquired infections (HAIs) occurred in US acute care hospitals, and approximately 75,000 patients with HAIs died during their hospitalizations (CDC 2016).
• Among all US acute care hospitals, a report based on 2014 data found a 17 percent decrease in surgical site infections (SSIs). However, SSIs and pneumonia are still the most frequently occurring HAIs, afflicting an estimated 157,500 patients per year (CDC 2016).
Key Takeaways
As discussion ensued at the workshop, several key issues became apparent. More than a handful of leaders were unaware that preventable adverse events in hospitals rank so highly among the leading causes of death in the United States. Although all the participants knew the ranking was higher than acceptable, their lack of awareness about exactly how high signaled a great need to educate healthcare organizations — from the board to the front line — about this crisis.
Furthermore, many of the finance leaders in attendance did not realize they already had most of the data needed to study their organization's own errors, complications, readmissions, and mortality rates. Much of this information can be found in the incident-reporting and finance or cost accounting systems of every hospital.
Most acknowledged that their physician and nursing leaders likely lacked adequate training in safety science, the characteristics of high-reliability organizations (HROs), and process design to feel comfortable tackling the reduction of patient harm. Safety science and HRO design were not part of the clinical and educational curriculum when most individuals currently serving in leadership positions were trained in their clinical discipline.
When asked how much money the finance leaders were willing to invest to remove medical errors as a leading cause of death nationwide, several said, "Whatever it takes." But some were noncommittal when pressed to name an investment level they would support.
About half the leaders in attendance felt patient safety was a priority in their organization. But only a few described it as the top priority. By the end of the workshop, most felt it should be the number one priority, given the facts they now had in hand.
Finally, when asked, "Is safety discussed at every executive leadership meeting?" most said "no." While the workshop survey was not scientific, the discussion seemed to align with the findings of most reported hospital safety scores.
SOLUTIONS WITHIN REACH
Many organizations still have significant work ahead to solve the safety crisis, requiring a focused effort, committed executive teams, and the willingness to invest the necessary resources.
That said, the resource investment is less significant than many executives expect. For instance, in the authors' experience, among average-sized community hospitals, the net addition of three or fewer full-time-equivalent (FTE) staff members can help achieve gains in safety. However, although only a few new staff may be needed, they — along with the entire workforce — need to be trained in safety science and operational process redesign.
The healthcare workforce is missing an entire body of knowledge in safety science and process redesign, and gaining that knowledge is the most obvious solution to the healthcare safety crisis. Once organizations gain the necessary skills to operate safely and efficiently, the healthcare system will have solved a huge part of the problem.
In addition to strong, effective senior leadership and unwavering commitment, then, the effort requires a cultural transformation (the topic of chapter 2) to an HRO-level status and investment in organization-wide training.
To solve this crisis, each individual in the organization is responsible for accomplishing and sustaining zero patient harm. We know the US healthcare system can do better. Together we can make healthcare much safer for everyone.
CHAPTER 2
Transformation to a Safety Culture
Culture has been defined as the arts and other manifestations of human intellectual achievement regarded collectively. Another definition is the sum of ways by which a particular population lives that has been built over time and transmitted from one generation to the next.
The notion of patient safety culture was introduced following publication of the Institute of Medicine's (IOM) landmark report, To Err Is Human: Building a Safer Health System, in 2000. This report encourages healthcare systems to "create an environment in which safety is a top priority driven by leadership." It describes a safety culture as one that focuses on preventing, detecting, and minimizing hazards and error without attaching blame to individuals.
Thus, understanding patient safety culture and how to achieve it is a relatively new area of study. Research conducted thus far generally supports a number of components in the process of building a culture of safety, but as with any sociological element, culture can be highly correlated with the people who are a part of it (Sammer and James 2011), meaning the people involved are seen as the cultural "bundle" in healthcare, just as clinical practices have process bundles.
KEYS TO SAFETY CULTURE TRANSFORMATION
Leadership is a key aspect of success in improving safety culture outcomes. Senior leaders must collectively commit to integrating high-reliability tactics into their own daily work. Such tactics include rounding to influence, whereby leaders are visible and interact with operations and frontline staff at the microsystem level on a regular basis. In an HRO, structures are set in place to inform senior leaders of any safety risks and to update them on safety metrics and improvement efforts. Deference to the expertise of individuals — staff and leaders alike — is another requirement for an organization to achieve improvements in safety, and it is cultivated through regular, open discussions with all levels of leadership and staff. Such ongoing vigilance is the only way to sustain initial gains that take place. Leadership is also responsible for engaging the physician community and providing education, resources, and opportunities to be involved with safety culture improvements. More leadership tools and tactics are discussed in chapter 9.
A balanced and "right" culture for staff and physicians is an important factor as well (Marx 2017). Often referred to as a just culture, such an environment allows the organization to differentiate between individual and system failures, helping improve transparency and error reporting in conjuction with individual performance management. Healthcare has traditionally been a punitive environment, but punishing staff for errors prevents individuals from reporting concerns and mistakes, which then remain cloaked in secrecy. As the organization continues to encourage nonpunitive reporting, its leaders must keep in mind that some individuals may not be in the right role or the right department, as they have developed unsafe practices that put patients and the organization at risk. The concept of just culture is explained at length in chapter 31.
Communication is another key to building a reliable, safe culture. Structuring communication through assertion techniques, which allow staff to raise concerns in the face of a traditional hierarchy; adopting tools such as patient handoff checklists and SBAR, or situation–background–assessment–recommendation; and conducting briefings, read-backs, and repeat-backs have proven to be effective techniques as demonstrated by a number of studies in the literature (Boyd et al. 2014; Pagano 2016). In addition to effective clinical communications, targeted dialogue must occur between the leaders and the physicians and staff. Communication modalities for safety culture processes include 5:1 positive feedback strategies, whereby leaders are encouraged to provide five positive pieces of feedback for every one negative portion of feedback; follow-up on event reporting; safety storytelling; and safety alerts.
Patient-centric cultures use their efforts in improving patient safety as a baseline for positive patient experiences. Organizations that have a strong record of providing an outstanding patient experience can build a reliable safety culture more easily than can hospitals and health systems that have demonstrated poor or uneven patient safety. One way to solidify a safety culture is to have patients and families participate in the culture improvements; this approach improves the level of acceptance of these improvements by leaders, staff, and physicians. Patients and families can share valuable information about their care and the care of their loved ones. Including them in rounds and care conferences ultimately decreases the chances that patients experience an error.
In 2001, 18-month-old Josie King died of dehydration and a wrongly administered narcotic at Johns Hopkins Hospital. Her mother, Sorrel, offered invaluable input into the development of a patient- and family-centered approach to rapid response (Ayd 2004). The rapid response approach involves identifying a small group of people, such as the unit charge nurse, hospital supervisor, and hospitalist or division fellow physician, to respond to a patient or family member who feels he or she is not being heard regarding a concern.
Another approach to improving safety culture is the sharing of safety stories. Telling stories from across the healthcare system can powerfully engage staff and physicians because the stories help dispel the myth that "this could not happen here." Staff need to know that errors and events do happen in their organization, and storytelling not only reinforces that recognition but also offers lessons on how other staff worked to prevent them from recurring. Staff and physicians are compassionate professionals who want to take exceptional care of patients. A compassionate culture is one in which, at the very least, a patient is not harmed (Sammer and James 2011).
Transparency is crucial for a safety culture to develop. To build a culture characterized by transparency, metrics related to safety need to be gathered and made available to both leaders and staff, accompanied by easy-to-understand education about their meaning. The education required to establish and sustain transparency in turn suggests that the hospital or health system must become a learning organization. One often-overlooked aspect of organizational learning is the need to continually reinforce, through training and other events, the practice of asking why, rather than who, when events and errors occur. The organization needs to mobilize resources toward the prevention of recurrence and have mechanisms in place to discuss the events with all levels of the organization.
Transparency also must exist between the clinicians and the patients and families. Building an environment of transparency is not easy to accomplish. An essential starting point is to understand where the organization is in terms of current transparency levels. Leaders need to understand the importance of — and embrace — broad-based transparency and then work throughout the organization to continually improve transparency.
Multidisciplinary, multigenerational teamwork supports patient safety culture. Embedded in this notion is, again, deference to expertise: the integration of frontline staff into decision-making processes. Research has shown that encouraging the engagement of all disciplines when conducting bedside physician rounding improves outcomes and builds trust among the team members (Mittal et al. 2010). Improved teamwork in turn can flatten the healthcare hierarchy that exists and encourage a questioning attitude in the team. Attaining this level of psychological safety is also imperative to building resilience when errors and events do occur.
Related to deference to expertise is the prerequisite of establishing a culture of respect. Doing so is a complex endeavor, requiring leaders to motivate and engage team members and physicians at all levels to address issues of intimidation, physical safety, and environmental safety. Each person working in the organization needs to feel he or she is an appreciated part of the team.
In the next chapter, we look at successful case studies throughout the United States in building a culture of safety. In general, each of these organizations took a stepwise approach to improving their culture of safety toward becoming an HRO. Some of the approaches they adopted on this journey are an assessment of their current state, the development of high-capacity leadership functions and methods, education regarding safety science and high-reliability tools and methods, the encouragement of incident reporting, a build-up of cause analysis capabilities, the development of a safety metrics dashboard, and the use of in situ simulation. Readers will learn more about each of these methods and tools as we move down the high-reliability path throughout the book.
CHAPTER 3
Proof That This Formula Works: Results from Around the United States
The implementation of safety programs and high-reliability efforts are showing incredible results. In the authors' experience, seeing serious safety event rates (SSERs) plummet by 25, 40, and even 90 percent in well-executed programs is not uncommon. Furthermore, the authors note that the benefits of such programs extend beyond decreased SSERs as organizations experience improvements in other patient safety and quality indicators.
Since 2012, Children's Hospitals' Solutions for Patient Safety (2017), a national effort to eliminate serious patient harm at children's hospitals, has saved 6,944 children from serious harm and reports a consistent upward trend in harm prevented every month, according to data as of September 2016.
Following are just a few of the organizations demonstrating the efficacy of the patient safety concept:
• Helen DeVos Children's Hospital (HDVCH), part of Spectrum Health, Grand Rapids, Michigan, has seen a 68 percent decrease in serious safety events (SSEs) in two years and a 90 percent decrease in SSERs at the four-year mark (Peterson, Teman, and Connors 2012).
• Children's National Medical Center, Washington, D.C., has experienced a 70 percent reduction in serious harm events (Hilliard et al. 2012).
• Nationwide Children's Hospital, Columbus, Ohio, reduced serious harm incidents by 83 percent (Brilli et al. 2013).
• VCU Medical Center, part of VCU Health, affiliated with Virginia Commonwealth University, Richmond, reduced its incidence of serious harm by 50 percent (Putre 2014).
• Sentara Healthcare, based in Suffolk, Virginia, has seen an 80 percent reduction in serious harm events overall, with a 50 percent reduction in harm events in 18 months (Putre 2014).
Next, we take a closer look at two of these high-performing sites: Nationwide Children's Hospital and Helen DeVos Children's Hospital.
CASE STUDY: NATIONWIDE CHILDREN'S HOSPITAL
Nationwide Children's Hospital is a 610-bed pediatric hospital in Columbus, Ohio, with more than 1,280 medical staff members and over 10,000 total employees. In recent years, the hospital has been ranked as one of America's Best Children's Hospitals by US News & World Report. It is the pediatric teaching hospital for The Ohio State University College of Medicine (Nationwide Children's Hospital 2017a).
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Excerpted from "The Safety Playbook"
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