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.
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.
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.
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.
Don Jarrell has over 35 years of technical and business experience in product management, technology strategy and intellectual property management and licensing. Don is a primary driver of Prista’s vision and mission for the ActionCue Clinical Intelligence application.