Reducing Preventable Errors Requires a Sustained Shift in Processes and Culture

Preventable medical errors are a serious issue in healthcare and are estimated to be the third leading cause of death in the US, behind cancer and heart disease. The issue has garnered more attention within recent years, and for good reason, as according to a Mayo Clinic study, 8.9% of surgeons reported they believe t have made a major medical error within the last three months. There are many causes for medical errors, including communication problems, organizational transfer of knowledge, staffing patterns/workflow, and more.

Hospital administrators have seen a certain level of improvement in the number of medical errors by taking action based upon the findings and recommendations of several private- and public-sector organizations aimed at increasing communication, information sharing and teamwork among providers. While these methods can be effective, healthcare leaders must take their efforts a step further to create impactful change. Perhaps first and foremost, healthcare executives must drive efficiency and a value proposition into the consideration of changes. Sadly, many of those recommendations coming from traditional experts and thought leaders in healthcare amount to a hospital’s staff doing more supportive and administrative work for the sake of improving the quality and safety of patient care. This cannot be a good way to lower costs and improve patient care on a sustainable basis.

Sustained improvement in quality of care requires a significant shift in culture, facilitated by the optimization of work processes for clinical staff, increased involvement and leadership by executives, and an unrelenting focus on patient safety and quality. A subtle, but very important, aspect of this shift in approach is to orient the changes and innovations around the goal, rather than the historical activities and artifacts used in previous decades in managing and improving quality-safety. While applying information technology can be a major contributor to optimizing these processes, success – including the streamlining, reduction or even elimination of some steps and artifacts – requires that the IT be very well designed around the capabilities of the technology, the human/user factors and a keen knowledge of the work environment and goals.

Achieving quality goals requires a commitment to creating a “Culture of Quality,” in which senior healthcare executives both lead and participate. It requires open, transparent and bi-directional communication at all levels, but in order to get true “buy in” from clinical staff, the processes and procedures that make up their day-to-day must be efficient, intuitive and sensible. Quality improvement must be woven into every facet of their daily actions, with a continuous reminder of shared goals, as well as updates on progress. Placing the improvement process itself at the center of the overall quality-safety effort leads to reverse engineering and optimizing the pathway to the goals of better patient care, lower costs and a sustainable culture around both.

We kept these guiding principles in mind when developing the ActionCue Clinical Intelligence quality and performance improvement platform. We designed the application to save time among users, by ensuring their day-to-day functions are not only easy to use and understand, but also intuitively match their natural tasks. Furthermore, the system works to effectively shape their behavior through the encouragement of effective quality improvement methodologies. When clinical staff are presented with quality improvement technology that is efficient and helpful, they are more likely to remain committed to improving quality of care.

Effective leadership is essential in creating a sustained culture shift. Executives must remain committed to improving patient safety through involvement in staff’s daily functions, and monitoring of clinical issues and what’s being done to resolve them. ActionCue’s reporting feature allows staff to prepare reports in minutes, making it easy to provide executives with insight into quality improvement progress. This not only saves time, it allows upper management to remain an active participant and leader in the achievement of quality improvement goals.

Reducing medical errors requires a commitment from both clinical staff and hospital management to a “Culture of Quality.” ActionCue CI can help hospitals achieve this sustained culture shift through one easy-to-use online platform. If you’d like to learn more about how ActionCue is using innovation to improve patient care, download our recent white paper.