In March 2019, a Tennessee woman filed suit against Nashville-based Vanderbilt University Medical Center, claiming surgeons operated on her wrong kidney. As a result, the patient had to have a second surgery to correct the mistake, and she now needs dialysis for life. While this case was both rare and extreme, the fact remains that damaging medical errors are quite common, yet often preventable.
The World Health Organization (WHO) says more than 1 million patients die every year from surgical complications. And, there is a 1 in 300 chance of a patient being harmed during health care.
Clearly, more should be done to improve healthcare safety and quality and reduce risks to patients. Yet to say that the challenges of healthcare risk management are complex would be an understatement. Existing processes for risk management are fragmented and lack standardization. Many healthcare providers continue to use inferior systems that fail to analyze and synthesize data in a meaningful way. And all this in a rapid-fire environment, where threats can materialize in an instant.
When viewed as an individual benchmark, medical error reports only uncover so much. For example, an incident report of the Vanderbilt case would certainly show that the wrong site was operated on. But the more important question is Why? Perhaps the surgeon had been working too many consecutive hours. Maybe there was misinformation between departments. Or maybe a critical pre-op step, such as marking the operation site on the body, was overlooked. And if it was, why?
The how and why behind an incident are the real agents of change.
Finding the root causes behind errors in patient care is critical if we hope to prevent them from happening again. In fact, the only good that can come of such mistakes is the opportunity to learn from them and make process improvements – ultimately improving the standard of care and saving lives.
Reducing errors in patient care is not about having more medical knowledge, it’s about operational performance. And a basic incident report won’t change much.
When a safety event occurs, the first step is to record the basic facts in a patient’s medical record. While this step is both necessary and required, it excludes the information that is most important for analysis, learning, and operational change in the organization.
When things go wrong, both front line staff and healthcare administrators need access to comprehensive facts and circumstances surrounding the incident – as well as a clear, streamlined, and accountable improvement process. Fortunately, the right performance improvement platform can both identify and offer cues towards effective corrective and preventative actions, or CAPAs.
Hospitals, regional clinics, and surgery centers will benefit greatly from a single, comprehensive system for risk management., particularly one that integrates the many performance measures across the board, and that integrates all these activities into a goal-oriented, coherent whole. In order to keep up with the pace of care, they need analysis and synthesis of data in real-time. And most importantly, they need clear and manageable action plans based on that analysis.
The right platform for quality-safety improvement can provide insight into past incidents, identify existing performance trends, and offer a view of the future. ActionCue CI’s comprehensive dashboard facilitates the collection of information and circumstances surrounding healthcare incidents including planning errors, process errors, and failures to act.
Here are some of the key ways ActionCue CI makes quality-safety tracking and improvement more effective:
While some of these features may be of particular interest or importance to various users, the real power of ActionCue CI is that it was designed for a specific purpose – facilitating all stakeholders having a fundamentally different relationship with the data that allows them to better leverage their time and energy for true improvement. While the change-averse may initially balk at such a dramatic shift, it is the right approach for long-term gains throughout the organization. Optimal gains can only be achieved through a platform designed for this purpose.
Mistakes in healthcare have bad consequences for everyone, from injured patients to physicians who may face legal and professional troubles. By working to eliminate medical missteps, healthcare professionals can protect patients and themselves while lowering operational and cost inefficiencies in delivering better care. But if institutional practices do not change, nothing will change.
Healthcare has too many moving parts. It’s a common cry in the industry, especially for healthcare quality and safety professionals.
In January 2019, the Institute for Healthcare Improvement (IHI) polled a group of members embarking on a large-scale project to reduce maternal and newborn mortality. When asked what aspects of the project made them most nervous and what made them most excited, “managing all the moving parts” was the top cause of concern.
As the poll indicates, between reporting, forms, metrics and insurance, plus the innate complexities of patient care – things can get complicated very quickly.
The “moving parts” dilemma is all too familiar to healthcare quality and safety professionals. When it comes to patient care and process improvement, it’s always been a delicate balance between quality, safety, and context.
Too often, there exists a large gap between “ticking the box” and the actual process of conceiving, planning and evaluating improvements. When metrics and event reporting become mutually exclusive tasks within healthcare organizations, everyone suffers. Departments miss out on the benefit of shared information, and the level of patient care remains stagnant or worse, declines.
There are a few healthcare IT products on the market that aim to tackle the moving parts problem – but most of them fall short. You find yourself manually moving and processing data or repeating tasks because system modules don’t “talk to each other”. Simple calculations are left to the user. Navigation of the application is overly complex and language unintuitive. Users’ engagement with the various systems and methodologically-driven manual processes is daunting and painful.
Healthcare organizations are looking for the most efficient ways to leverage human, financial, and physical resources in support of top-notch patient care. Despite best efforts though, non-universal systems & software, and information silos between departments often get in the way of progress. The result is a lot of fractured effort and reduced productivity.
What if you could spend less time managing “moving parts” and more time providing and improving patient care?
What hospitals need most are healthcare technologies that not only collect data, but also provide context and insights that lead to better and safer patient experiences. They need software solutions that are easy-to-use, intuitive, collaborative and, most of all, coherent.
Quality performance metrics matter, but they don’t tell the whole story. Metrics force you to work with simple data, while what you really need are the actionable insights derived from that data. And, managers and executives trying to drive improvement need answers to “How did we get here ?” and “What are we doing to fix this ?” without going on a safari or waiting on an analyst or staffer to chase and manufacture those answers.
Our number one goal behind the design of ActionCue CI was smoothly bringing together all those “moving parts”. Separate functions and departments for Quality Management, Event Reporting and Performance improvement don’t reflect, and don’t contribute well to, the true, unified goal of optimizing patient care and its costs. More than just another set of spreadsheets, event reporting software, and assembled briefing book – metrics, facts and progress tracking are synthesized into valuable insights with corresponding cues. The innovative new technology supports patient-centered care by facilitating management and work for performance improvement projects. One Goal. One Platform. Coherent Insight.
How enabled is your team? Does it matter? The answer to the second question is “Yes”. But how do you enable employees at all levels of a healthcare organization to make a positive impact on the quality-safety of patients and participate in performance improvement in meaningful ways? Prista’s ActionCue Clinical Intelligence application was designed so that all users are able to efficiently and intuitively engage with the platform and process to both provide and interpret data in meaningful ways.
Most healthcare IT applications have user administration based on profiles, roles and permissions, and many also associate the user’s roles with specific parts of the organization. These roles should be straightforward and easy to administer, in order to eliminate the frequently seen dependence on billable services from a vendor or additional analysts and specialists within the organization. This means users see only the things relevant to, and used by, themselves and mostly only at the time those functions are likely to be of interest. This makes it much easier to get to and act on exactly what they need, simplifies or shortens everyone’s learning curve, and significantly helps users stay focused on what they engaged with the application to do.
Probably no one benefits from this aspect more than the CEO and other C-level executives. Because of the typical complexity and numerous moving parts of the quality-safety efforts as described above, those at the top of the organization with enterprise-wide responsibilities very often have to choose between detaching themselves from the workings of quality-safety improvement or drowning in the details, because information is too often not collected or presented in a way that lends itself to a reasonable manner and degree of executive oversight. A common compromise is to add data analysts who work on a constant stream of ad hoc research and reporting requests. Not only is that “solution” expensive, but it also adds cycle time and disrupts the evolving pursuit from one answer to the next question as the skilled executive chases insights in a complex, dynamic environment.
An efficient platform must apply technology advances to directly facilitate the enablement and engagement of all users—even busy executives—with the insights and work being accomplished by the entire staff within the platform. ActionCue CI’s performance dashboard presents that big picture, with easy-to-follow links to additional presentations of related data, information and insight. Data hierarchies are designed to match the cognitive pathways of a healthcare leader, providing easily accessible, real-time insight. Whether it is the insights sought, the contribution of content, the user skill level or the cognitive pathway the user undertakes, a successful platform adapts to the user to deliver a productive and enjoyable experience. Implementing technology to facilitate both productivity and performance improvement is one of the most meaningful ways to enable your organization’s team.
This post is part 4 of our 7 Innovation series. Interested in reading more? Download the 7 Innovations that Deliver Strategic Value in Healthcare White Paper
Have you ever found yourself staring at row after row and column after column of data and asking yourself “What does this MEAN?”? One of the most valuable skills in today’s workforce is an ability to take all of the data that technology allows us to collect and to make sense of it in meaningful and actionable ways. We believe that all aspects of a quality-safety and performance improvement platform should boil down to this. Prista’s ActionCue Clinical Intelligence application consolidates your data and includes built-in reporting tools to provide instant insight into the most impactful issues that need to be addressed. That’s why we call it the Fast Path to Insight.
At Prista, our mission is to help healthcare leaders achieve optimal clinical and operational performance in the most effective, efficient and sustainable means possible. By addressing a wide variety of entrenched inefficiencies, particularly through the diligent application of technology, human behavior and design principles, our ActionCue Clinical Intelligence application helps those leaders find and prioritize their clinical- and financial-related issues, focus on corrective and preventive actions, and build and sustain an improvement in quality-safety culture.
Instead of delivering dead data in the form of reports, the ActionCue application facilitates action in the management of the improvement process by enhancing communication, focus, learning and accountability. The integration of data into useful insight enables staff at all levels of healthcare organizations to focus on quality and safety improvement and creates enormous positive financial impact. Reductions in fall with injury, hospital acquired infections, re-admissions and many other measurable and actionable issues not only avoid punitive revenue reductions in the Pay for Performance model, but these quality of care and patient experience measures are also meaningful messages to drive engagement and goodwill within the communities served by healthcare organizations.
By creating intuitive and user-friendly experiences, through simplifying on-going and required reporting initiatives, ActionCue CI improves results across multiple goal sets, and delivers real-dollar ROI. By managing clinical performance through meaningful dialogue and easily-tracked performance improvement plans, healthcare leaders can become less reactive and more proactive and step up their leadership in an environment in which it is direly needed.
This post is part 3 of our 7 Innovation series. Interested in reading more? Download the 7 Innovations that Deliver Strategic Value in Healthcare White Paper
Have healthcare IT tools successfully improved the ability of organizations to provide exceptional patient care?
Our application designers, with expertise in technology, learning psychology and perceptive science, have listened intently to hundreds of healthcare leaders describe their experiences with numerous healthcare IT products. This research led us to identify several common weaknesses in the design of many such products and understand them in the perspective of the evolution of systems design over the past several decades.
Several challenges contribute to the commonly lamented fundamental issue of “too many moving parts”. Some key components that contribute to negative productivity are:
These inefficiencies hinder an organization’s ability to achieve its goals, fulfill its mission and purpose, and work effectively and efficiently. One of the most impactful ways to address these issues is to enable active and appropriately-informed C-suite participation.
By focusing on and uniting the three essential questions of executive oversight—where are we, how did we get here, and what is being done to improve—such a platform can be the hub of management communication. All the meaningful information for both frontline staff and management is seen and acted upon in unison and is easy to access and understand so analysts and assistants do not have to intermediate. This delivers the spirit of Hoshin Kanri, in a facilitated workflow that ensures the strategic goals of a company are communicated through the organization to drive progress and action at every level within the organization, without dependence on complicated and time-consuming diagrams and other artifacts.
Instead of just delivering dead data in the form of reports, the ActionCue application facilitates action in the management of the improvement process by enhancing communication, focus, learning and accountability. Prista’s ActionCue Clinical Intelligence platform was specifically designed to enable a “Fast Path to Insight” – which creates intuitive communication tools throughout the organization and allows real-time collaboration to drive performance improvement. It goes beyond mere quality-safety reporting and empowers users at all levels of the organization to engage with an IT tool that optimizes both data collection and analysis.
This post is part 2 of our 7 Innovation series. Interested in reading more? Download the 7 Innovations that Deliver Strategic Value in Healthcare White Paper