Category Archives for Healthcare Quality

Healthcare Innovation, Leadership and Action—Part 3

In a recent webinar for our ActionCue clients, Prista’s panel of experts answered questions about healthcare innovation and the role of leadership in creating action that improves patient safety and quality.

We covered six of these questions in previous posts—Part 1 and Part 2—and in this one, we will discuss three more questions. Before we begin, let’s review who the panelists in this webinar were.

As President and Founder of Prista, Don Jarrell brings more than 30 years of technology experience in products management, application design, technology strategy and intellectual property management licensing. Don has provided the vision for Prista and for the ActionCue application.

Billie Anne Schoppman is a Registered Nurse and CPHQ (Certified Professional in Healthcare Quality) with more than 30 years of experience in the healthcare industry. As the Chief Mission Officer at Prista, she brings her passion to create the most efficient environment for improvement.

Dr. Jake Redden is a member of Prista’s Advisory Board with expertise in patient safety, healthcare quality, human factors, crew resource management, and safety culture, and is certified in healthcare quality and patient safety.

7. Why would innovation in the quality and safety improvement process help with other pressures and demands on healthcare executives, like finance, regulatory and operations issues?

Don Jarrell: I wouldn’t want to be a healthcare CEO these days. The pressure is enormous and it’s coming from every sort of angle, internally and externally. We respect that and want to address the areas of greatest concern for hospital executives, particularly CEOs.

Quality doesn’t occupy the same space as when it was simply delegated to a mid-level team member and not given much attention. Thanks to the pay-for-performance landscape—with macro NIPS, ACOs and everything else—you’re either going to get penalized for bad quality or safety issues, or you’re going to miss out on incremental income if your quality and safety, and performance track records don’t reflect the right things.

There’s a direct link between quality, safety and your financial considerations, as well as your regulatory issues, because when licensure is on the line, you want to live up to all of those standards. However, many C-level executives spend most of their time trying to actually run the operation and struggle to find time to address other crucial issues.

By taking good care of the quality, safety and improvement process, we are essentially taking some of the pain away from the C-levels so they can spend more of their time looking at those other areas. The quality and safety efficiencies we focus on also have a favorable impact on all of these other areas.

By getting an efficient, comprehensive look at their quality and safety situation, C-levels and the individuals who report directly to them can immediately link that to what their organization is doing. That makes the entire executive review process, given the sort of CEO’s mindset or perspective, much more efficient.

8. How can a software application really impact leadership and why is that effect more sustained than when it’s gained from leadership classes?

Dr. Jake Redden: Nothing replaces the foundational understanding of patients’ safety within the total leadership curriculum. That is the reason almost all hospital CEO jobs require an MHA or graduate degree. Most leadership courses are not going to take you much further than answering the “why” question or trying to help build a platform which leadership can act upon.

Leadership classes and seminars will not tell you what has to be done every day in your hospital. Building a culture of quality and leaning towards a higher liability organization of care delivery takes everyone working together, with real time insight and meaningful feedback on how their efforts are contributing to the improvement of patient care throughout the entire hospital.

One of the suggestions from the National Patient Safety Foundation last month was to insure that technology is safe and optimized for patient safety. This certainly applies to medical monitoring, decision support software and electronic medical records, but it also applies to the tools that senior leaders are using to monitor and improve the safety landscape for hospitals.

By now, almost all executives realize unintended consequences related to implementing any new technology happen almost every time. Implementing a new technology inadvertently changes the way people work and reduces new and unanticipated problems that we’ve got to deal with.

Our executives are quick to acknowledge this realization and deal with adjustments out on the floor with our patient flows. However, we are bad with making those adjustments to our own personal work processes that can result in maximizing the benefits of any new technology and what it’s supposed to provide us as a decision maker.

As executives, we have to dedicate time every week to review reports and patient safety indicators that are unique to our organizations. We have to let our frontline experts make the improvement, but we also have to be there to provide support.

More importantly, leadership needs to provide the accountability to insure that improvement efforts and innovation are occurring at every single opportunity, big or small. Every unsafe condition, outdated care process, or safety report that gets completed should have a senior leader devoting protected time to the right oversight of patient safety, and driving innovative change and solid improvements.

Don Jarrell: From an outside analyst view, people use the term culture of quality a lot, but in a presentation I did for ASHRM, I talked about what it really means to have an operative culture of quality. It’s not the slogans, the posters on the wall or the methodology that’s named. It’s really how people feel about the culture of quality.

To put it another way, it’s that voice we hope is inside everyone’s head on the clinical staff repeating over and over, “This is how we do our work.” If you really want to hook into that in a way that is sustained, it can’t be just a speech the CEO gives. The continuity of leadership and leader participation is important, but to really get it to continually present for the users and clinical staff, you need to make it a part of their daily work.

That’s why we focus on actually giving organizations a workbench and a working platform for their collaboration, reporting and investigation, so we can change their behaviors directly as they work toward the goal of quality and safety.

Actually addressing the work rather than the mind has been a strong teaching method of behavioral psychologists for a long time. They typically contend that you don’t change attitude to change thinking and actions, you change actions to change thinking and attitude. We come in with a very behaviorist approach to changing the working environment by changing the working platform.

9. What best supports the expectation that these innovations will make a positive impact on our organization’s quality and safety efforts?

Billie Anne Schoppman: It’s tough to find one thing, but mine is action. We need to take action now to make a positive impact on our organizations. There’s always change in healthcare. Now is the time. Innovation is the new strategy.

Everywhere you look, whether it’s online or with evidence-based data, the movement is toward innovation. Why? Because we are doing operations well. You want to be efficient? That’s great. You want to be predictable? That’s good. But we want growth. We want to meet the demands of the future. We want to prove our value to the community and to our customers. That’s innovation.

We have processes that have been in place for years. Let’s allow people in the organization to be creative, because if they are, they will take risks, which will lead to actions that drive change. That’s the one thing that can have the most positive impact on organizations right now. Take a risk, be an entrepreneur and take action.

Dr. Jake Redden: I always help organizations fix things more effectively the first time. When the frontline staff sees a level of consistent engagement from the executive team, it increases support from other frontline employees. We see the enthusiasm and overall improved safety culture grow.

Consistency is where we fail. We start out with a lot of enthusiasm in the C-suite, but by the third month, we’ve stopped having our regular, protected time check-in meetings, and we’re bypassing stuff. It ends up looking like a lot of lip service to those frontlines, so executives have to be available and present, and expect improvement.

Accountability is where their money comes from on those frontlines. They’ve got to not only trust, but verify as well. They’ve got to go out and make sure that we actually fixed the things that were reported last month in order to do that consistently, every single day, and every single opportunity, big or small.

We hope you will read our final installation in the series about Healthcare Innovation, Leadership and Action, coming soon. Reach out to us via email or on social media if you have questions or comments, and let us know what challenges you’re facing and how ActionCue CI can make a difference for your patients.

Healthcare Innovation, Leadership and Action—Part 2

In a recent webinar for our ActionCue clients, Prista’s panel of experts answered questions about healthcare innovation and the role of leadership in creating action that improves patient safety and quality.

A total of 12 questions were addressed in depth by our panelists. In this article, we will discuss the second three questions and cover the remaining six in future posts. Check out the first three questions here if you missed them. Before we begin, let’s do a quick introduction to the panelists in this webinar.

As President and Founder of Prista, Don Jarrell brings more than 30 years of technology experience in products management, application design, technology strategy and intellectual property management licensing. Don has provided the vision for Prista and for the ActionCue application.

Billie Anne Schoppman is a Registered Nurse and CPHQ (Certified Professional in Healthcare Quality) with more than 30 years of experience in the healthcare industry. As the Chief Mission Officer at Prista, she brings her passion to create the most efficient environment for improvement.

Dr. Jake Redden is a member of Prista’s Advisory Board with expertise in patient safety, healthcare quality, human factors, crew resource management, and safety culture, and is certified in healthcare quality and patient safety.

4. How much value is there in the UI/UX and design of a new application if the staff has already learned how to use another quality and safety system?

Don Jarrell: The design of the user interface and user experience is really important when people are first trying to learn how to use the application, but in my experience, it’s even more important once the people are routinely using an application in production.

Rather than just the aesthetic or the intuitiveness of the application itself, UX is about users getting things done relative to their whole job. The user’s objectives can really be supported when the application is designed from a standpoint of understanding the mindset and the needs of the user as they are starting to engage the application for a task, when they’re actually doing the tasks, and what they are likely to want or do next. Of course, it helps when the integration extends not just to the activities within the application, but to the real 24 or eight hour-a-day job of the various users.

By improving the productivity and making the process enjoyable, people have a subliminal relationship with the application making them positively disposed toward the work that they’re doing in the application.

With all of that going on, you really do want the people to enjoy using the application. You don’t want it to be frustrating, unpleasant or a drag on their productivity.

When we’re talking about reporting, we can also get into some very interesting benefits from understanding the perceptive science or neuroscience of a user and injecting that into the application. When you present data in a way that conflicts with the natural functioning of the brain and perception of the user, it can be bad.

We’ve all been to quality council meetings or governing board meetings where people jump around with all sorts of differently formatted spreadsheets and graphs and illustrations of various kinds, many of which are badly designed in terms of neuroscience. Often people leave those three and four hour meetings with a headache, not just because of the subject matter that they’re dealing with, but because of how it was presented.

We spend a lot of time trying to make sure that we bring in the neuroscience, the perceptive science, the technology design work and so forth. This approach is equally fed with an understanding of the workflow and environment in healthcare and the settings in which our applications are used, but we bring all of that together for a satisfying and productive user interface and experience.

We also carry that one step forward into what we call enterprise experience (EX), which is important when you’re talking about workflows and collaboration among many people. So, while we’re satisfying the individual users in terms of their engagement with the application to perform their tasks, we’re also satisfying the corporate objectives to get the overall work involving many people done effectively, efficiently and enjoyably.

5. How does executive management support or lead to a culture of quality?

Dr. Jake Redden: Culture truly is the heart of where we’re going to make a lot of our improvements in hospitals, and it has to be led by our executive teams. There have been countless studies documenting how tough this is because of the considerable variations in the perception of safety culture across organizations, and even within a single hospital across different staff roles.

Safety culture has been defined and it can be measured. A lot of us do annual or semi-annual measurements of where our culture is. A poorly perceived safety culture has been directly linked to increased error rates. However, achieving sustained improvements in safety culture has been difficult.

Culture improvement efforts such as the ones Billie Anne mentioned, like executive walkthroughs and unit based safety teams, have all been associated with improvements in safety culture measures, but they have not yet been shown to lower error rates.

Other methods, including SBAR, structured communication methods, and different rapid response teams, have all been implemented to help address cultural issues in a hospital such as rigid hierarchies and communication problems. Again, the effects of these methods in improving overall safety culture and error rates remain unproven.

All experts agree, however, that culture and leadership is where we have to start. There is no blanket approach to improving patient safety. You can’t just bring someone in and expect them to make everything better. It has to start within our own walls and how we’re addressing these issues. We have to be innovative with the information we have in our hospitals.

I’m not going to belabor the value of building a reporting culture. I think most risk managers today are aware that a patient safety reporting program is a must in every healthcare organization. Of course, having employees who want to report involves the presence of a just culture, which is another common discussion point for executives today.

Let’s take a look at two lesser known aspects of safety culture: the informed and learning cultures. I’m a huge fan of these two aspects because they speak directly to the two tenets of high reliability organizations: the reluctance to accept simple explanations for problems and sensitivity to operations.

In an informed culture, every member of the leadership team is aware of not just the most serious safety events or those associated with our publicly reported metrics, but everything that our frontline staff, who are the experts that we should be deferring to, is saying needs to be addressed. Once leadership is aware or informed in an actionable way, then we can address redesigning the work environment.

The reluctance to accept simple explanations for problems helps develop our learning culture. Once we stop letting others give easy answers for negative events or people that are trying to protect their turf or cover up what happens on their units, we can really start to develop higher reliability work processes. We fix things more effectively the first time, and when frontline sees how informative the executive team is, it grows support, enthusiasm, and an overall improved safety culture.

As mentioned, safety culture is a local problem. Wide variations in the perception of that safety culture existing within a single organization further complicate how we approach the work that we do in improvement. These variations regularly contribute to the mixed record of interventions or attempts at making improvement. That’s why we see cycles of things we fixed in the past creeping back in as we continue to try to play the management theme of the month.

Organizational leadership needs to be deeply involved and attentive to the issues that our frontline workers are facing. They must have an understanding of the established norms and hidden culture that often guide our unsafe behaviors.

6. Why should leaders who have been very successful in quality and safety organizations want to change their strategy, process and tools?

Billie Anne Schoppman: Healthcare leaders have been leaders in quality, risk and safety over several years and done an excellent job. We’ve operationally met our regulatory requirements, our financial requirements and worked really hard to actually meet our responsibilities, but as with anything else, things have to change. As Dr. Redden mentioned, we still have a lot of opportunities. There are a lot of things that keep coming around again and again because we really don’t fix them.

To become a high reliability organization, we need to stress some requirements. This is something that many organizations are already addressing, but it’s an ongoing process. It’s not something that you can implement and then walk away from it. It will not be hardwired unless you take the time to hardwire it. The safety culture is the sum of what an organization is and does every day in the pursuit of safety, and it involves everyone in the organization.

Let’s look at a couple of building blocks and things that we all need to think about. Instead of maintaining the status quo, focus on organizational activities that need to become daily a routine and can help you achieve those safe operations. Everything is important. Every way that you can get the visitors, patients and the staff involved in identifying safety opportunities is a change in the culture.

We talked about a blame-free environment, but does it really exist? Are people still focused on who instead of what? Instead of the process? I always liked Demings’ comment that 85% of the causes of customer dissatisfaction are the result of inefficiencies in systems and processes.

What we want to focus on to be a highly reliable organization is processes. Let technology take the place of a lot of the inefficient processes that you have. Let it work for you instead of you having to work for it all the time.

Let’s also talk about collaboration across the processes. Everything in healthcare is still siloed. Day shift, night shift, respiratory versus nursing, laboratory versus nursing, radiology versus nursing, etc. Much of that has been repaired, but there’s still the mentality of siloing operations, departments and processes.

We need to collaborate across those barriers. Nothing in healthcare is siloed, so every department needs to be involved in everything that’s happening. Think of the same thing as far as your systems. How many systems do you have that don’t talk to each other? How many systems do you have that may do one function instead of all three integrated functions, or instead of giving you information that you need at your fingertips so you can act?

Organizations also have to be committed to resources. Does your organization provide the system that you really need to identify safety concerns, track and trend them, and improve them?

Dr. Redden mentioned some of the tenets of a safety culture. I’m sure all of you are aware of the Sentinel Event Alert 57 that highlights the role of leadership in developing a safety culture. This is a great start. It’s a start for you to sit down, ask the questions and do a self-analysis. Take one thing at a time to start approaching your safety culture.

We hope you will keep reading over the next several weeks as we continue our series about Healthcare Innovation, Leadership and Action. Reach out to us via email or on social media if you have questions or comments, and let us know what challenges you’re facing and how ActionCue CI can make a difference for your patients.

Healthcare Innovation, Leadership and Action—Part 1

In a recent webinar for our ActionCue clients, Prista’s panel of experts answered questions about healthcare innovation and the role of leadership in creating action that improves patient safety and quality. A total of 12 questions were addressed in depth by our panelists. In this article, we will discuss the first three questions. Before we begin, let’s do a quick introduction to the panelists in this webinar.

As President and Founder of Prista, Don Jarrell brings more than 30 years of technology experience in products management, application design, technology strategy and intellectual property management licensing. Don has provided the vision for Prista and for the ActionCue application.

Billie Anne Schoppman is a Registered Nurse and CPHQ (Certified Professional in Healthcare Quality) with more than 30 years of experience in the healthcare industry. As the Chief Mission Officer at Prista, she brings her passion to create the most efficient environment for improvement.

Dr. Jake Redden is a member of Prista’s Advisory Board with expertise in patient safety, healthcare quality, human factors, crew resource management, and safety culture, and is certified in healthcare quality and patient safety.

1. Why is quality safety so important to healthcare, and how should top healthcare executives take action every day?

Dr. Jake Redden: It’s estimated that more than 400,000 patients die every year from preventable medical errors in the U.S. Of course, this is the most extreme outcome of patient safety events, and there are many more incidences that are nearly impossible to capture and analyze nationally. Nonetheless, our patient safety error rates have improved very little since the 1999 report To Err Is Human.

The surprising thing we’ve learned about medical errors is that, with all the change that’s taken place in our hospitals since that IMO report came out, only hospital acquired infections (HAIs) have shown any improvement, dropping 17% during a five year period and resulting in 87,000 fewer deaths in our hospitals.

Of course, this is a minority subset of quality and patient safety issues. An original California study reported an injury rate of five patients harmed for every 100 hospitalizations, and subsequent studies now have consistently found 10% to 12% of patients are experiencing harm while hospitalized, with half of those considered preventable cases.

Last year, the British Medical Journal reported that medical errors in US hospitals and other hospital healthcare facilities are so incredibly common that they are now the third leading cause of death in the United States, taking more lives than respiratory disease, accidents, stroke or Alzheimer’s.

In individual organizations, most executives spend a lot of time addressing the very top safety events and almost no time looking into the frequent hazardous conditions or unsafe acts, even when reported through reporting systems. The reality is, if we were to focus our efforts on reducing the latter, we would reduce the likelihood of more serious events tenfold.

Patient safety events serve as a serious distraction for our executives and are preventing us from moving high speed into our strategic initiatives. Whether it’s agreeing to participate in the RCA, litigation, responding to negative publicly reported information, or meeting with an affected patient or family member, quality and safety issues are operationally problematic and distract from daily operations. This affects not just our executive team, but our front line staff as well. These visible, unsafe practices have serious effects on our organization’s core values, mission and reputation.

While many hospitals are pledging to make safety a priority, most executives are spending a disproportional amount of time on this effort compared to other strategic or mission priorities. Our outcomes have not improved in decades as a result of the disproportional amount of senior leaders’ time and focus. This is why quality and safety have to be so important in healthcare and the top executives absolutely have to take action every day.

2. Why should healthcare organizations change the way that they work on quality, safety and performance improvement?

Don Jarrell: Too often, organizations that are trying to improve some aspect of their quality and safety process will do some degree of process change. However, they often only focus on the activities and artifacts that they’ve been working with for a very long time. What they’re really doing is just reshuffling things and not taking the opportunity to create meaningful progress towards the overall goal of quality, safety and performance improvement. In other words, they’re more focused on the process than the goal.

We need to think in terms of the cognitive arc through which the managers and leaders want to move, from the realization that there is an issue, to the corrective and preventive actions put into place, and then measure outcomes from there.

A huge part of this has to do with de-siloing the very practice base of quality and safety in performance improvement, which are quite frequently carried out by different people, teams or entire departments in larger organizations. All of these are really seamlessly integrated, and when an application can make use of technology to create a workflow that crosses all the boundaries, the quality and safety activities flow directly into performance improvement. That’s where the ROI is gained.

When you have these processes segregated, you’re not only wasting a lot of time in potential duplication and fragmentation of effort, you also have a lot of people stopping or disconnecting at their end point. Perhaps a quality report or a safety report may have been issued and they checked the box, but they don’t realize the full attainment of an improvement by which they can actually increase ROI.

When the application is properly designed to utilize technology rather than forcing humans to do all the work (gathering, integration, analysis, etc.) that’s where the real innovations in quality, safety and performance improvement occur.

3. Why is integrating a PI tool and process into the quality and safety reporting workflow so important?

Billie Anne Schoppman: Not only is it important, but it’s innovation, and it’s the new strategy in healthcare today. Our application truly integrates quality with risk and performance improvement.

I came across an article the other day on readmission compliance that made me sit back and think for a second. The statistics show once a hospital is penalized in the first year, they are consistently penalized year after year. Not only are they penalized repeatedly, but the penalty is actually doubled over that amount of time.

So, what are we doing and what should we be doing differently? For years I’ve been championing the fact that quality is risk and performance improvement. They should never be separated. I hear from a lot of our clients and potential clients how much duplication of work and inefficiencies occur when their risk department is totally separate from their quality department.

The use of methodology and workflow process in quality is not used on the risk side, which is really focusing more on that incident. Let’s fix that one incident. Let’s make sure the liability is low. Let’s make sure we’re not being charged, or the cost is manageable for our incident.

If we look at that process, we should be saying to ourselves, “There’s a better way.” Recently I read an article about medical safety management systems that says what I have been campaigning for years—that quality, plus safety, plus risk management should be your internal system for operations.

Quality is driven by performance improvement. You can use PDSA or any other scientific process, but it’s a continuous cycle of improvement. Risk, on the other hand, is looking at a large number of accidental injuries and fatalities and figuring out how to stop and prevent those from happening. Combining these will give us what we need to have for a system management.

This all needs to start from the top, with senior management committing to safety every day. But it doesn’t stop there. It needs to flow through the whole workflow process: How is the information disseminated to your staff? How often do they get that information? Do you listen to your workforce? Do you encourage them to report safety issues? All of this is involved in creating a culture of safety where performance improvement through integration of these three systems will be a standard operational system.

We hope you will keep reading over the next several weeks as we continue our series about healthcare innovation, leadership and action. Reach out to us via email or on social media if you have questions or comments, and let us know what challenges you’re facing and how ActionCue CI can make a difference for your patients.

Tackling the Top 10 Patient Safety Concerns with a Culture of Safety – Part 2

The ECRI Institute recently published their Top 10 Patient Safety Concerns for Healthcare Organizations for 2017. In part 1 of this article, we explored some ways you can target these concerns by developing a culture of safety.

Let’s finish our countdown with the remaining top 5 patient safety concerns for healthcare organizations.  

5. Antimicrobial Stewardship

The CDC has been pushing antimicrobial stewardship for quite some time, and it’s still a major issue. We just don’t have antibiotics anymore that can treat bacterial infections because we’ve been abusing them for so long. So, what can organizations do?

The first strategy is to hold subscribers accountable. If physicians are prescribing, we have to hold them accountable and set the guidelines. Some organizations have started with a physician advocate since physicians are more likely to listen to other physicians. Educating patients, families and the general public is important too, as are automatic stop orders.

Once again, leadership from the top is essential in addressing this safety issue. Leadership includes your medical staff and your pharmacist as well. Everyone has to be committed to the outcome and be held accountable. Use your physician peer-to-peer relationship and include your pharmacist as well as your physicians.

Once you have leadership buy-in, work on tracking your safety events. You need to be doing this in real-time, not after the fact or three months later. There’s no point in presenting data to a committee with information that’s so old it can’t possibly be used.

You also need to be tracking your implementation of your processes, including automatic stop orders. Does your pharmacist have a way to report interventions with an automated process that uses one sheet, one entry form and one process? When they click, is all the information they need available? Let technology work for you. Technology should always be one of the action steps that you put in your performance improvement action plans. It’s not just about tracking action tracking. It’s improving so you can take action.

One way to start is with a hierarchy of action steps. We all tend to do the same things over and over again and then wonder why the problem pops up again next year. The National Center for Patient Safety offers a recommended hierarchy of actions, ranging from stronger to weaker actions. Looking at the weaker actions, we can see that often, the only steps we take are about creating a new process. We say, “Let’s just change the policy. Let’s just train everybody, because the problem is always the staff. We have to train them, educate them and coach them.”

This is the wrong approach. Look at the process instead. Weight and monitor your strong actions and see what’s working best at your facility. Take new devices, for example. Do you have a safety event that lets your staff enter near misses and the actual events that happened as a result of equipment? Whether it’s IT, medical equipment or alarms, you want to be able to get those near misses up front so you can identify what needs to be bought. Equipment costs money, and we know how hard that is to get sometimes.

Device use, purchasing and testing is another high strong action plan. Standardizing equipment can be done with new practices and processes streamlined to eliminate redundancy. Engineering control or interlock (forcing functions) allows you to create your systems that can walk you through a workflow process. Workflow processes are great because they lock you out forcing you into the right direction and educating you along the way.

Don’t forget to include checklists. This is a perfect process to use with a mobile device. As you are walking around the facility, you can be looking at information like patient identification and surgical procedures and watching people work in real time. Read back is also critical. Enhancing the documentation and communication is a good weighted action step.

Now that you’re empowered with this information, go back and look at your action plans. Help your staff. Get them excited about really doing something productive. They need to not just be blaming someone but looking at the process.

4. Critical Test Result Reporting and Follow-Up

We’ve been doing critical test results for a very long time, but they’re still a problem because clinicians and departments are still so focused on tasks. You’ve got to get the paper filled out, the order done, the lab drawn and get the test. Then what? What are you supposed to do next?

The first step is to analyze your test process. Have a very specific safety event that doesn’t focus just on labs, but radiology too. All of the accreditation agencies are looking at radiologic testing, and this process has a huge impact from a safety perspective. Have all the steps in the processes and create a report immediately, with a click of the button, and drill down to your problems.

This process can give you a huge return on investment. When you go back to your facilities, you can tell them that you need a process that’s going to give you real-time information, right now, that you can click and filter and drill down into. You need dynamic data, not dead data, so you can get information back immediately and actually analyze and use it.

3. Implementation and Use of Clinical Decision Support

This safety concern is mostly about your EHR. However, while EHR has an important function and is concerned with the care of the patient, decision support is something you can be doing as well. Quality risk is operations. Let’s look at some of the strategies you can use to support your staff.

You’re probably already using physician order entry with protocol orders. But what about flags and alerts? Everybody thinks about putting them in the EHR, but what about in your safety event processes? What about in your quality processes? Do you have a very simple visual way to see exactly what you need to focus and work on?

Visibility and accessibility are very important. Why have data and analysis charts if your staff doesn’t know about them, are the last people to know or are waiting for a paper post to be out on the unit sometime after the committee meeting three months later? You want visibility and accessibility in real-time, with a click of the button.

What about IT and clinical? Although we’re now seeing clinical informatics in facilities, most still rely on history, structure and the way things have always been done. We have to overcome this barrier. We need a workplace focused on performance with quality risk management platform that we can go and use every day as an information management system. That’s a vast improvement over focusing everything on EHR.

2. Unrecognized Patient Deterioration

Healthcare has done a great job over the past several years to really monitor care, including following best practices for stroke, heart attacks and similar events. We need to approach patient deterioration the same way. Rapid response teams worked for a long time, but they seem to have dropped off of the radar. We need to go back to assessing the patients, and that goes back to your nursing process.

Assessing a patient’s risk early is not just a check box on an admission documentation, but a thorough assessment that really identifies the risks for deterioration. Teach your staff more and cultivate their competencies. Redevelop that rapid response team. They need to be able to plan appropriate care for everyone’s individual needs based on that risk assessment. It’s not a standard, with standard vital signs, medications and safety rounds. It needs to be individualized. Use your tools, all those clinical systems that create flags, and use your quality risk management platform too. That’s the one that will give you early warning ideas.

Plan for appropriate care and educate your patients as well. It’s critical to involve the patient in everything you do. Your technical monitoring should be monitoring your practice as well as your patients. You already have compliance checklists for things like sepsis, maternal serious events, clinical bundles, etc., so use all of those. Automate them, put them on a mobile and go around and use them in real time.

1. Information Management in EHRs

Information management is about your EHR, and it’s a great system where everything can be standardized and completed. One thing you should have done immediately when implementing your EHR system was to get your frontline staff involved. One problem you might be facing, however, is turnover. When this happens, new staff members fail to adopt the system because some of them don’t like automation. But that doesn’t mean you should stop tracking.

Here are 10 serious issues still plaguing information management. Some of them have been around for a long time and are not only high-volume problems, but also have the highest potential to cause harm.

1. Infusion errors can be deadly if simple safety steps overlooked
2. Inadequate cleaning of complex reusable instruments can lead to infections
3. Missed ventilator alarms can lead to patient harm
4. Undetected opioid-induced respiratory depressions
5. Infection risks with heater-cooler devices used in CV surgery
6. Software management gaps put patients and data at risk
7. Occupational radiation hazards in hybrid ORs
8. Automated dispensing cabinet setup and user errors cause medication mishaps
9. Surgical staples misuse and malfunctions
10. Device failures caused by cleaning products and practices.  

Building a Culture of Safety

When all is said and done, a culture of safety is about core values and behaviors resulting from a collective and sustained commitment by organizational leaders and managers in healthcare that emphasize safety every day.

Every day when your staff walks into the facility, safety should be priority number one. Let’s all do the safety dance, because that’s what it’s all about. Make it fun every day. It’s not a drudgery, but something we need to do for each other.

Tackling the Top 10 Patient Safety Concerns with a Culture of Safety – Part 1

The ECRI Institute recently published their Top 10 Patient Safety Concerns for Healthcare Organizations for 2017. Several of these items were on last year’s list, which means we in healthcare still have work to do to drive improvement and meet targeted goals.

Aside from just highlighting new and recurring safety concerns, this list is also a great starting point for inspiring patient safety discussions and setting priorities in your own organization. Here are some ways you can target these concerns by developing a culture of safety.

Let’s begin by counting down, David Letterman style, from ten to one. Since there is much we can say about each finding, we will be covering only 5 safety concerns in this article and the remaining 5 in a second article.   

10. Inadequate organization systems or processes to improve safety and quality

There are numerous studies that link error prevention to a culture of safety—being proactive and setting strong preventive strategies rather than waiting for patients to be harmed. This is such an important issue that the Sentinel Event Alert recently addressed the essential role of leadership in developing a safety culture.

Unfortunately, healthcare has been very slow to adopt a culture of safety. Let’s take a look at exactly what a culture of safety is and how leadership is essential to creating one in an organization.  

What is a “Culture of Safety”?

Safety cultures have been around a long time, but they’ve only recently been adopted in healthcare. High-reliability organizations are committed to safety by consistently minimizing adverse events at all levels, from frontline providers to managers and executives. This commitment establishes a culture of safety built around the following 7 pillars:

1. Leadership
2. Teamwork
3. Evidence-based
4. Communication
5. Learning
6. Just culture
7. Patient-centered

If you’ve been with The Joint Commission and several of the accreditation agencies, you know that leadership has always been first. We kind of take it with a grain of salt, but we can’t anymore. Leadership has to be the most important thing that happens.

The drive needs to start from the top and involve more than executives just putting a stamp on the policy and the plan. Leadership has to own a culture of safety, and when they own it, the team owns it.

Getting real, evidence-based data helps with the communication and the learning of your team members. Leaders have to support a just culture of learning rather than blaming and balance individual accountability with organizational responsibility.

Finally, a culture of safety needs to be patient-centered. You need to include the community and the patients in everything that you do.

9. Management of New Oral Anticoagulants

Tracking adverse events for anticoagulant drugs for has been a part of safety reporting for years, but four new oral anticoagulant medications have been approved since 2014. Here are some strategies and questions you may want to consider when managing these new additions.

Standardized order sets based on individual’s indications

Are you using standardized order sets? Maybe it is time to review to validate if they are evidence-based and individualized.

CDS to alert practitioners to duplication of therapy

Do you have clinical decision systems that can alert your practitioners about duplications or errors in protocols? Having flags on your systems is critical.

Multidisciplinary team plans for reversal of anticoagulant therapy

Consider a multidisciplinary approach to assessing, monitoring and treating for reversal of therapy. Break down the silos that have been around too long.

Reversal agents should be readily accessible

What compliance process measures are you tracking? Are the effective in getting you the information you need to improve? In ActionCue CI, we have a measure for tracking Reversal Agent Usage. This is an example of error prevention, analyze and assess where the problems are and fix it.

Collection and analysis of events

Collection and analysis of events is what ActionCue CI does well. Let’s go one step further and take action for improvement.

8. Inadequate Management of Behavioral Health Issues in Non-Behavioral Health Settings

Behavioral health hospitals have been doing this for quite some time, but healthcare hospitals are not as good at recognizing a patient’s behavioral health. It’s essential that you start preventatively tracking behavior before it becomes a norm in the environment. When you do that, you get outcomes that you can analyze and prioritize.

Your tracking system should include clinical as well as unsafe environment special events. ActionCue CI gives users a Behavior event category training staff to be competent on identifying, reporting and resolving issues. One event ActionCue CI tracks is rapid response. Train your staff now to be competent on identifying those issues, early signs and behavior cues. Don’t wait until it gets to be serious.

7. Opioid Administration and Monitoring in Acute Care  

This is a serious situation in this country, not just in acute care. You want to track all of your rescue drug and narcotics usage. But how? Are you looking at narcotic adverse drug events? What’s your reversal drug rate? How many times have you had to use your reversal drugs and for what reasons?

You also need to look at your protocols. What are your protocols for rapid response? Do you have the right equipment? Do you need to buy new equipment? You need to be looking at your medical equipment to make sure it’s up to standards.

Finally, you need to look at the nursing process as you’re investigating events and recommending solutions. You need to go back to look at the basic process so that you’re not forgetting anything as you’re assessing.

6.  Patient Identification

Many healthcare settings have stopped tracking patient identification errors. But when you consider that out of 7, 613 events, 9% resulted in patient injury, including two deaths, this is still a serious issue that needs to be addressed from the leadership down.

Leaders can start by fully supporting patient identification initiatives by prioritizing the issue, engaging clinical and nonclinical staff, and asking staff to identify barriers to safe identification practices.

Go back to tracking your patient identification and include in your policies and procedures the contributing causes to the problems the team identified from the event reports. Make this something in your investigation process that your staff are looking at. Your end users are your best value. They’re the ones who see everything that’s going on and who know what needs to be fixed. Give them the opportunity to be involved.

Imagine if you had a button in your event that would automatically create a performance improvement action team. Let’s say the safety risk manager sees that this is the fifth time he’s seen patient identification as a problem. With the click of a button, he decides to create a team. The team works from within the application which serves as a working platform so they can collaborate. Reports are generated automatically, which include the month-to-month analysis and compares agencies and experts that you want to compare yourself to.

The best thing, however, is that you also get the action plan attached to a scorecard report and run chart in ActionCue CI. This is created in real time so you don’t have to wait. It’s all about efficiency. Why should a quality manager go to a committee meeting, decide that she needs a team and spend 2-4 weeks getting one together? She should be able to have the information she needs at her fingertips that she can drill down into.  

Focus on the Process

It’s difficult and unsustainable to cram everyone’s head so full of education to the degree that they will continually act in a heroic manner to overcome flaws or deficits in institutional processes and leadership. Until we focus on optimizing the work itself with best process innovations, technology, leadership, goals and respect, organizations will “keep on getting what they’ve always got,” which is not the culture of safety we all need.

In part 2 of this article, we will review the remaining top 5 patient safety concerns for healthcare organizations as they apply to our focus on building a culture of safety.