Category Archives for Patient Safety

Re-Thinking: Four Ways to Advance Healthcare Quality and Safety

For decades, I practiced and taught others a model of developing new software products in which the creator begins with at least two innovation concepts before thinking about technology choices, features or even architecture. These concepts must represent a new way to reach important objectives, not just tweak current tasks and activities. They must eliminate current hurdles and transcend problems. This model has proven to be the best way to ensure that the benefits of the product stem from fundamental values, are sustainable, provide room for growth, and build on an evergreen strategy.

In some cases, healthcare staff, management and executive IT users are hesitant to change the way they do things, but such changes have been proven to be the only way to make substantive progress. These innovative concepts are at the core of Prista’s ActionCue Clinical Intelligence platform, helping healthcare professionals reach real quality improvement goals that are fundamental in alleviating the operational, financial and regulatory issues with which hospital leaders wrestle every day. Even if hospital leaders believe the quality and safety activities in their organization are productive and successful, we believe those activities could be significantly more effective, positively impacting patient outcomes, revenue, staff workload, management and executive participation, and the culture of quality in the organization. The following are four ways healthcare organizations and management can advance healthcare quality and safety.

1. Shift focus toward goals instead of traditional activities 

For individuals and organizations, doing “what we’ve always done” is comforting, pays respect to past decisions and accomplishments, and, importantly, avoids any risk in trying to improve by doing things differently. Some will focus on “risk” in that statement; others on “better.” Improvement, something we discuss often, inescapably means change, and the degree to which we avoid changes in process can systematically limit improvement. The tendency is to start rationalizing complacency and praising stability, solidarity and tradition.

The problem with the willingness to hold on to traditional activities manifests itself when organizations maintain the functional silos of Quality, Risk Management and Performance Improvement in hospitals. Whether individuals, groups or entire departments, tradition supports these institutions having different leaders, processes, tools, methodologies and data. With these functions compartmentalized, their objectives—and rewards—are limited to their respective stages of development instead of contributing to the overall goal of improvement. Simply reporting metrics and incidents is the finish line for some, while others carry on with other activities. This leads to dependence upon human endeavor to unify all those differences, in traditional mechanical ways, to serve the goal all healthcare organizations should be working toward: better patient care and outcomes delivered with efficiency.

The ActionCue application provides innovative consolidation of all performance metrics. No more silo-ing of core measures, audits, EOC, or protocols. Event reporting and investigation and improvement action plans are highly integrated. All data and information flows together and is readily accessible, enabling each task and activity to tie into performance improvement.  Not only does this design serve the common goal better, it saves the staff, managers and executives a lot of time and mental exertion.

2. Own quality-safety improvement internally and make it efficient 

Historically, most of a hospital quality department’s activities were focused on submitting data, reports and documents to external regulators and other stakeholders. A good portion of that information is intended for licensure/accreditation, long-term research and, especially in recent years, reimbursement. The aim in hospitals, typically among overworked managers, has become to “check the box” noting required submissions have been accomplished. Using the compiled information internally to improve quality and safety has become secondary to executives looking for checked boxes, and such perspectives tend to trickle down as real and perceived guidance. Yet, the return and yield from the submissions to those external organizations, in terms of enabling patient care improvement, is usually disappointing and always later than desired. With that view of comparative value, it is sometimes difficult for clinicians to remain motivated to genuinely improve quality and safety, and it’s equally difficult to get budgetary investment for innovative, efficient tools and processes as opposed to maintaining the traditional—and sub-optimal—activities and approaches.

ActionCue is far more than a reporting tool. It is a composite platform for the entire clinical staff, management and other stakeholders to work collaboratively and efficiently, while pursuing continuous improvement, which has long been little more than a slogan or buzzword.  Its value in executive awareness and required reporting is exceptional. Users report a near elimination of “survey preparation” and surveyors from several states, as well as accreditors such as CIHQ, TJC and DNV, have commended its clarity, accessibility, accountability and demonstrated utilization and results.

3. Improve division of labor between humans and technology 

Many healthcare IT users have come to understand that many applications are little more than an electronic filing cabinet, mostly utilized for storage and retrieval of information in the same format as that in which it was input. This places a burden on staff to compile commonly used information, perform calculations, and turn raw data into intelligence and insight. For a long time, organizations’ leaders have accepted that quality and safety efforts require a large amount of time and effort in mundane process mechanics. Applications serving important enterprise functions should focus on collaboration and workflows that not only match the natural tasks and processes of users, but also shape the users’ behavior by embodying methodologies and disciplines that yield the targeted results with efficiency and accountability.

Additionally, when the application is designed to partner with the user in his or her work through well-known, disciplined workflows, it can provide valuable, relevant, up-to-date content in the context of the task at hand, such as researched industry and academic performance measures, evolving best practices, educational materials, forms, contact information and a wealth of other materials the user, or the user’s work group, no longer have to spend time researching, compiling and updating. This sort of sophisticated, enabling design should become commonplace in healthcare IT applications, as it has been for decades in other fields.

ActionCue’s design goes beyond ease-of-use to advance the way in which healthcare organizations engage with information in an application. The platform proves to be an enjoyable working team member, increasing productivity and facilitating education and improvement towards goals. ActionCue users develop and maintain a strong “Culture of Quality.

4. Opt for a turnkey application utilizing a SaaS model 

The technology used to support hospitals’ important quality and safety work usually starts out as a “toolkit” in which the organization invests a lot of time, money and attention to build and maintain the intended “solution.” Ranging from paper and Excel spreadsheets, to internally developed tools and applications, to major commercial systems that undergo extensive customization by their vendors and “add-on” technicians and analysts, healthcare organizations spend a lot of money and resources—often incrementally staffing consultants and specialists— to get the job done. Despite the high costs, many organizations believe such an approach is the only one that will work, and it is often based largely on what they have used historically. In such a setting, real innovation is rare and very expensive.

When an application provider has utilized healthcare expertise in its core design, delivery and support functions, it can anticipate a great deal of the functionality needed by its users and apply best practices to deliver a “turnkey application,” ready to run right after the sale. Foregoing full customization can be readily accepted as a trade-off for saving tens of thousands of dollars (or more) in visible and hidden costs. Turnkey applications also frequently have value-adding content that is continuously researched and updated, providing constant improvement in the use of the application. Setting a high bar when reviewing turnkey applications and providers has long been the standard approach for organizations of all sizes outside of healthcare that are adept at considering total cost of ownership (TCO).

The next step forward in evaluation of a solution is the true Software as a Service, or SaaS, business model. With the fundamental distinction of being web-based and accessed via a browser, SaaS applications save buyers a great deal by avoiding the costs of acquiring and maintaining expensive computing and storage infrastructure to support on-premise systems.  Leading companies offering SaaS model applications go much further than “renting software,” thought by some to be an unnecessary expense. The best practitioners of the SaaS model accomplish three major things that are impossible, difficult or very expensive with other models.

• Update the application frequently: Because the process of distributing updates is simpler and less expensive than with on-premise software, SaaS-model companies frequently provide quarterly or even monthly updates. Such updates typically include enhancements and extensions of functionality, as well as adaptations required by regulators and other authorities in healthcare. This same advantage in efficiency makes it possible and likely that the delivery of software corrections and “fixes” can take place in hours, instead of weeks or months, as is often the case with on premise software.
• Operate efficiently and pass savings on to customers: SaaS-model companies operate on the latest technology platforms, facilitating rapid development and deployment of changes, making them far easier and less expensive to maintain. Companies that have started out as such build their entire operations around utilizing the most up-to-date technologies and methodologies, so their internal operating expenses are lower than those of traditional software companies. These and other efficiencies allow SaaS-model companies to pass their savings along to customers, driving down prices, usually as non-capitalized monthly or annual subscriptions.
• Provide proactive, expert support: Unrelated to the technology side of the SaaS model, the best of these providers work on the principle of an ongoing collaboration with each of their customers. The frequent updates and efficient operations mentioned above allow SaaS-model companies to focus on providing support staff that are highly skilled, have in many cases done the work of the very users they support, and are responsive to, or anticipatory of, the evolving needs of their customers. In the case of healthcare quality, safety and improvement efforts, this approach involves leveraging research on evolving performance measure definitions, best practices, and information submission mandates carried out by the support staff, and integrating them into the application for all to use, saving a great deal of the users’ time.

Understanding what SaaS-model companies represent and offer, healthcare executives can appreciate that this means of operating is exactly what is needed in the strategic advancement of healthcare information technology.

As a fully actualized example of a SaaS-model offering, Prista and its ActionCue application transform the relationship an organization has with its information technology. No longer a bottom-line cost, source of frustration for staff, or drain on productivity, ActionCue is a critical facilitator of clinical performance improvement, providing tactical and strategic benefits for the organization’s people and processes, and delivering ROI.

Taken one by one, any of these departures from the status quo would be valuable and beneficial to a hospital and even more so for a healthcare system. Each of these steps forward would be truly strategic, with broad and long-term positive effects. But taken altogether, these changes in thinking and the realization of them in a platform like ActionCue Clinical Intelligence is truly a transformational step forward for healthcare organizations.

Healthcare Innovation, Leadership and Action—Part 4

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 nine of these questions in previous posts—Part 1, Part 2 and Part 3. In this one, we will discuss the final three 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.

10. What is the biggest or most strategic impact when using the kinds of innovations we’re talking about that directly benefit user organizations?

Don Jarrell: We talk a lot about innovation in terms of daily impact because we’re trying to adjust behavioral interactions regarding the quality and safety efforts, but we’re actually improving the entire management process too.

When we can use technology to shape the workflow and keep it moving so that incident investigations don’t stall, data doesn’t get unreported and various reports don’t drive right into the performance improvement segment, we’re changing the process by which hospitals are managed.

It’s not about giving a motivational speech and turning up the heat on people to get results. It’s about actually changing the process and facilitating what management is expecting by their presence and their actual involvement in the workflows to some degree, not in a way that’s going to overburden them or keep them connected at arm’s length, but in a way that uses all of the leadership principles Dr. Redden talked about.

These things will change the way the organization is actually carrying out its management process, and that’s what we’re really after. We’re not asking anybody to act heroically based on being super revved up in their motivations. We’re simply enabling them to work a little harder and contribute a little more. That will naturally turn into a sense of satisfaction that really helps sustainability.

Dr. Jake Redden: What I always look for from a strategic impact is the production of improvement. We’ve got to measure the amount of work done towards making improvements, whether it’s the number of policies updated, daily process audits, kaizens, rapid process improvement events, standard working element or SOPs.

We’ve got to get our front line employees to first speak up for safety and then be involved in the production of improvements. That is where the real strategic impact is going to come from. We drive innovation with improvement productions in order to make our units in hospitals more efficient, safer and patient focused.

11. What can managers who want to address system issues do when they don’t feel executives are listening? 

Don Jarrell: If the CEO is not responding to input that they’re getting from managers, senior managers should be able to ask “Why don’t you think this is important?” Or phrased more positively, “What could we do to convince you that this is important? What change to the mechanics or the presentation of information or the flow of information could make you feel more engaged and like this was a higher priority?”

I don’t think there’s any way you can force somebody, but you can certainly dialogue with them to start off, just asking them the very simple why or why not questions, in a non-accusatory way, so that you can actually find out what the barrier is and how it can be addressed.

Dr. Jake Redden: The joke I use with my provider partners is the same joke I use for my executive team—you’ve got to tell them something three times before they’ve heard it once, and you’ve got to tell them three more times so they will think it was their idea.

What I always recommend people do is to make things visual for executive teams. They have a limited amount of time, so you’ve got to get in there and make the bad side of the information as visible as possible. Put it up there three different ways and continue to put it up there every single month in a unique, innovative way. Eventually they’re going to say, “You know what? We should do something about that.”

Again, you’ve got to be consistent. You’ve got to stick to it. If they don’t buy it the first time, you’ve got to subtly continue to sell that through frequency. You’ve got to make it visual until they finally admit there’s an issue, and then they’ll get involved with helping make that improvement.

12. Where can I get answers to my questions about performance improvement or healthcare quality?

Dr. Jake Redden: There are a ton of resources out there. Both Billie and I are big fans of the National Association for Healthcare Quality (NAHQ). If you look up what it takes to become certified in healthcare quality, they have an excellent reading list that they keep up-to-date. For patient safety, there’s the National Patient Safety Foundation, in association with the IHI.

It’s really tough being a quality leader in healthcare because there’s no quality school you can go to. I’ve seen hospitals that have just brought in lead engineers or improvement leaders from manufacturing and automotive. They don’t quite adapt to the culture, and they don’t develop the interpersonal relationships or adjust to the uniqueness of provider partners and our nurse leaders.

Of course, you can’t just bring in a nurse or a floor tech and expect them to have that kind of systems thinking ability or the 10,000 foot view of how we drive improvement for the long term through culture changes, either. You’ve got to find individuals who think differently and continually reinvest in those folks through seminars and classes

Billie Anne Schoppman: Drexel University has an online MSN degree in safety and risk management in healthcare, which is a great opportunity for learning. I think they’re going in the right direction and it’s good to see. You can also check out CPHQ and the CPHRM. They’re kind of separated, and I’d love to see them combined. It’s all about integrating it all together.

We are delighted that you have joined us for this series as we reviewed 12 important questions about Healthcare Innovation, Leadership and Action. Reach out to us via email or on social media if you have questions, comments or input on additional questions you think should be addressed.

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.