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Patient Safety: Creating a Shared Language to Drive Safer Care

Author: Morgan Beschle | Director, Product Management

The Problem: Our Unsafe Healthcare System

We are in desperate need of a nationwide effort to improve patient safety in American hospitals.  According to a recent Frost & Sullivan analysis, adverse safety events will cost the U.S. and Europe $384 Billion over the next four years.  Ask, however, just what are those ‘adverse events’ or, furthermore, what drives them, and the answer is that we simply don’t know.

There are, of course, many ideas currently being deployed and tested in hospitals across the U.S. every day to try and bend the curve on this troubling and enigmatic issue, and I’m privileged to work with some of the largest and most sophisticated health systems in the country to learn with them through their efforts and struggles.  Our system is predicated upon a belief that patients should be able to enter fearlessly through the doors of a system’s healthcare facilities with the assumption that they will leave, if not better, then at least no worse than when they arrived.  The risk teams I work with are often singularly focused on being stewards of this vision; the teams are comprised of very smart, hard-working experts who keep their fingers on the pulse of the latest literature, workflow processes, technologies, and interventions available to improve safety and reduce harm.  With all this investment in programs and interventions to address the drivers of adverse events, particularly preventable ones, what’s stalling the system on working together to diagnose, assess, and intervene on the underlying root causes?  Why are hospital systems toiling so hard at ‘inventing the wheel’ one system at a time for largely universal challenges where there should be a clear best practice?

The Barrier: Lack of Shared Language

From where I sit, the major barrier to a cross-system effort towards improvement is the lack of a shared language.

Despite mandated safety event reporting, hospitals are often left to their own logic and devices to describe what a safety event means to them.  A fall event in one hospital may be counted as a ‘delay in care’ at another.  Because of this, we have no comprehensive, standard ability to measure what types of events are occurring, how often, and where.  Without a baseline of understanding, furthermore, it proves difficult to correlate drivers and common causes–or better yet, interventions with differing outcomes.  Buzzwords such as ‘integration’ and ‘interoperability’ are rife in healthcare today—but without a standard way of describing safety occurrences, there’s hardly any use in sharing information if no one will understand it.  

As a nation, we’re sitting on a powerful dataset of safety events tracked, reported, and investigated at every hospital every day.  We could and should be studying the trends in the types of events reported by the:

  • circumstances surrounding them,
  • physical and human-geographic context,
  • time and day of occurrence,
  • staffing levels at the time of occurrence,
  • contributory, common, proximate, and root causes reported, and
  • lessons learned.  

However, many hospitals and organizations have invented their own ways of categorizing and naming safety events, making it nearly impossible to compare trends and diagnose differences in approach or assess replicability of interventions across or even within sites of the same larger organization.  We’ve essentially measured ourselves out of sharing valuable innovations in safety, leaving every hospital in it for themselves.

What’s particularly limiting by only living within your own dataset and categorization methodology is the very small universe of safety events that occur within any one facility.  With focus and protocols, many health systems are reducing the number of safety events within their walls, so you’re working with a small number.  Take, in addition, that we already know barely 15% of adverse events are reported voluntarily by hospital staff, not to mention all the near misses, close calls, and unsafe conditions that are missed.  If we’re only able to learn from the data inside the walls of one organization, there’s not enough data to learn from.  Remember that some safety events are “never events” and, with discipline and luck, may only occur in one hospital once over the course of multiple decades.

Some responses I see to this are to encourage more reporting, especially of the events we know exist but can’t see.  Although staff engagement and fear of retribution may contribute to the lack of reporting, we should acknowledge and celebrate that the first obligation of the provider is caring for the patient.  Putting another layer of administrative burden on them is not only unfair, but not their core competency and role in the care process.  According to Elizabeth Rosenthal in her recent book, An American Sickness, doctors are now spending one sixth of their time on administrative tasks—that’s nearly one day a week.  We can’t keep asking clinicians to participate in more suffocating administrative responsibility, without a clear connection between that administrative task and downstream gain in long-term high-quality patient care, or innovative scientific and medical discovery.

The Solution: Standardized, Configurable Measurement

A good analogy for exploring an approach for solving this problem is the building of a custom house.  To save cost and reap the benefits of efficiencies of scale, you could buy a townhouse being built by a developer within a development of similar homes.  You’d get the same fundamental “bones” as everyone else, from the electrical work to the plumbing, all in compliance with current building codes.  This would mean that anytime you needed to get a system serviced, any plumber or electrician, even those not associated with the original developer, could generally work on the house.  There are very few good reasons to get creative when installing a toilet.  Where you want to assert your individuality, instead, is in a much smaller set of choices, like paint colors, finishes and lighting, customized to your taste and priorities.  This is configuration built on a standardized foundation.  We seem to understand the need for this kind of approach with consistent diagnostic categorization and billing coding systems like ICD-10, CPT, and DRG, so why haven’t we made the same leap in safety?

With a standardized approach in safety, we could increase the precision of voluntary event reporting, and combine that with analytical surveillance methods to capture events automatically.  If a fall is defined and captured with the same standard in Seattle as it is in Boston, we can start to compare trends, adjust those trends by other external key differences like hospital type and the patient’s underlying risk factors, and start to understand if this is truly unwarranted variation in care.  Once we know where the unwarranted variation in care is, we can start to spend our finite, limited resources on investigating only those “hot spots” likely to uncover the distinct causes of–and effective solutions to–unsafe conditions.

What I hear a lot from our clients and partners is, “Can you tell me what’s normal?  Are we normal?” while also asking, “Can we customize the system to support my laser focus on improving and innovating within my own organization’s context and business processes?”  If we’re smart, we should be able to answer both questions.

It’s often said that when you’ve seen one hospital, you’ve only seen one hospital.  An ability to customize the capture of safety data and mold it to an organization’s own specific workflow and business setting is important.  For example, an organization in California may have specific data elements that need to be captured to report on state mandated workplace violence reporting or a behavioral health center may want to dive deeper on patient non-compliance issues but disable issues around labor and delivery.  I certainly want to choose my own curtains, light fixtures, and cabinets!  However, there’s a way to do that while keeping the foundation of standardization in place in order to benefit from that apples-to-apples comparison, both within the organization and as compared to others.  In other words, I can configure my house to my own taste, but I rely on experts in the field to make sure my house’s foundation is set correctly.  Left to my own devices, I might choose European standards for wiring the house and then be out of compliance with standard U.S. codes, preventing me from every selling again.

I’m a big believer in evidence-based, data-driven approaches to solving problems.   I enjoy partnering with our clients every day to scale disciplined, adaptive measurement and reporting solutions that use big data science to make ‘small’ human experiences better for the patient and staff of the facilities that we serve.  As a healthcare system, we need to make some intentional, difficult choices to enable evidence-based change to make care safer for patients, their visitors, and their families.

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