Presentation on theme: "The Changing Landscape of Patient Safety"— Presentation transcript:
1 The Changing Landscape of Patient Safety Tejal Gandhi, MD, MPH, CPPSPresident, National Patient Safety FoundationAssociate Professor, Harvard Medical School
2 Institute of Medicine’s First Quality Report: To Err Is Human – November 1999 Preventable lapses in safety:44,000 to 98,000 Americans die each yearEighth leading cause of death in the United StatesAnnual cost as much as $29 billion annuallyConclusion: the majority of these problems are systemic, not the fault of individual providers
3 The Safety Movement in the 2000’s Hospital-focusedKey initiatives to improve safety culture (change from blame to nonpunitive to just)Focus on increasing safety reportingSystems approach to errorHuman factors, reliabilityTeam trainingSafety often focused on issues such as wrong-site surgery, wrong procedure, falls, medication errors
4 The Safety Movement in the 2000’s The Joint Commission plays a key roleNational Patient Safety Goals, Failure Mode and Effects Analysis (FMEA)Public reporting beginsSerious Reportable Events (SREs), Leapfrog, Hospital-Acquired Infections (HAIs)
7 What’s driving the future? Hospitals face ever-increasing numbers of existing and new prioritiesHealthcare Reform - Accountable Care Organizations (ACOs) - cost reductionHealth Information Technology (HIT) - meaningful useReducing Readmissions - bundled payment, public reporting30-Day All-Cause Mortality - public reportingHospital-Acquired Conditions (HACs) - nonpaymentAHRQ Patient Safety Indicators (PSIs) - public reportingCMS National Hospital Quality Measures (NHQMs) – Acute Myocardial Infarction, Congestive Heart Failure, Pneumonia, Surgical Care Improvement Project and more to comePopulation Health/Care across the continuum is a new focus
8 The Changing Landscape of Safety All of the same concepts are still relevant and extremely importantCultureReportingSystemsRegulationsTransparency
9 Changing Landscape: New or Expanded Focus Care across the continuumPatient/family engagement and experienceThe workforceTransparency and metricsUse of health information technology
10 Care across the Continuum Changing Landscape: 1Care across the Continuum
11 Ambulatory Safety- What is “Ambulatory”? Most studies done in primary care settingBut we can’t forget…Specialty practicesAmbulatory surgical centersDialysis centersNursing homesRehabsCare in the home (including large variety of devices)And many others…
12 What is different about ambulatory care? Long feedback loopsEpisodic (from provider and patient perspective)Signal to noise ratio is lowWidely distributedLimited resources, redundanciesPatients and providers have many degrees of freedom
13 What do we know about ambulatory safety? Medication safetyTransitions of careMissed and delayed diagnosisTest result follow-upReferral managementJust the tip of the iceberg . . .
14 Outpatient Medication Safety Adverse drug events are common and often ameliorable (25% of patients in one study)1,879 prescriptions reviewedMedication errors 143 (7.6%)Potential ADEs 62 (3%)Life-threatening 1 (2%)Serious 15 (24%)Significant 46 (74%)Gandhi TK et al. NEJM 2003, JGIM 2005
15 Impact of E-Prescribing Study of 15 providers before and after implementation of e-prescribingError rates reduced from 42/100 prescriptions to 6/100 prescriptionsPre-post study in multispecialty practicePrescription errors decreased from 18% to 8%Largest reductions:IllegibilityInappropriate abbreviationsMissing informationKaushal R et al. JGIM 2010Devine E et al. JAMIA 2010
16 NonadherenceIn one study of 195,000 newly prescribed e-prescriptions, only 72% were filledNonadherence was common for medications for chronic conditions such as hypertension, diabetes, hyperlipidemia“Medication nonadherence: A diagnosable and treatable condition”Often undetected and untreatedClinicians not trained to screen or treatNeed to understand patient beliefs and valuesNow tied into quality measuresFischer M. et al. JGIM 2010Marcum ZA et al. JAMA editorial 2013
17 Missed and Delayed Diagnosis Errors Most common type of ambulatory malpractice casesMost-often missed cancerOccur in primary care practices
18 Diagnostic Process of Care in Ambulatory Setting Patient notes problem andseeks carePhysician performs history / physicalOrdering of diagnostic / lab testsPerformance of testsInterpretation of testsReceipt / transmittal of test resultsPatient adherence to planFollow-up plan & referral (if indicated)Gandhi TK et al. Ann Intern Med 2006
19 Preventing Missed and Delayed Diagnosis Errors Strategies to reduce cognitive errorsDouble checksDecision supportStrategies to reduce systems errorsClosed-loop test result managementClosed-loop referral managementPatient engagement
20 Transitions of CareHandoffs and transitions are particularly high risk for adverse eventsAdverse events after dischargeMedication issuesPending testsUnresolved medical issues
21 Strategies to error-proof high-risk transitions Improve handoffs in careStandard templates for transitionsImproved discharge processes and handoffs (SBAR)Improved safeguards for post-discharge period (phone calls, appointments, etc.)Medication reconciliationTJC requirementsShould be done in inpatient and outpatient settingsAll potentially leading to reduced readmissions!
22 Safety Issues in Nursing Homes Nearly 1 in 3 Medicare beneficiaries who went to SNFs (35 days or fewer; avg 15 days) experienced an adverse event (OIG report 2014)59% preventable; many as a result of failure to monitor or delay in careMore than half of the residents who experienced harm were hospitalizedMost common: Medication related (37%), resident care (37%), infections (26%)
23 Safety Issues in Ambulatory Surgery Surgical site infection rate in ambulatory surgery is 3/1000 proceduresHowever, millions of procedures done each year so still significant numbers affectedOwens et al. JAMA 2014
24 Safety Issues in Home Care Home care adverse event rate per client-year is 10%56% of AEs were judged preventable.The most frequent were injuries from falls, wound infections, psychosocial, behavioral or mental health problems, andmedication errors.Clients' decisions or actions contributed to 48.4% of AEs, informal caregivers 20.4% of AEs, and healthcare personnel 46.2% of AEs.Blais et al. BMJ Qual Saf 2013
25 Safety Issues in Office Procedure Settings Checklists not uniformly used in the office settings that perform procedures (small study)Top barriers:No incentive to use a checklist (78%)No mandate from a federal or local regulatory agency (44%)Time consuming (33%)Lack of training (33%)Shapiro, et al. Am Soc Healthcare Risk MgmtNeed more research to better identify safety concerns across all settings
26 Outpatient Safety Infrastructure Many principles in place in inpatient settingsCulture changeEvent identification and analysisSystems approachProactive assessmentNeed to transfer these to all outpatient settingsProcedure areasNursing homes, rehab centersAmbulatory and office
27 Patient/Family Engagement and Experience Changing Landscape: 2Patient/Family Engagement and Experience
28 The Value of Patient- and Family-Centered Care Patients are the only source of information about many aspects of safety and qualityThe patient’s experience is linked to improved clinical outcomes and ability to manage chronic conductions, as well as reductions in readmissions, mortality, and malpracticePartnering with patients and families to redesign and/or improve care brings a wealth of knowledge to carePartnerships with patients inspire and energize clinicians, staff, and leaders, while grounding them in reality, focused on the “right” solutionsEdgman-Levitan S. NQF April 2012
29 Safety Is Personal: Partnering with Patients and Families for the Safest Care From NPSF’s Lucian Leape Institute Roundtable on Consumer EngagementAvailable for Download at
30 Background on the Issue What is patient and family engagement?“Patients, families, their representatives, and health professionals working in active partnership at various levels across the health care system—in direct care, organizational design and governance, and policy making—to improve health and health care.” (adapted from Carman 2013):Studies link patient engagement with patient satisfaction, safer care, improved work experience for caregivers, and better health outcomes.
31 Barriers to Patient and Family Engagement Fragmented health care systemHistorically paternalistic/dysfunctional culture in health careLack of understanding/knowledge/commitment on the part of health care leaders to embrace patient and family engagement as an essential part of their missionWorkflow design flawsLack of effective engagement tools and trainingLack of awareness among patients and familiesProblems with health literacy, limited social support, or fear of speaking up on the part of patients
32 Observations from the LLI Roundtable Move the system from asking patients “What’s the matter?” to “What matters to you?”It is very hard to speak up, even for the most empoweredBurden cannot be off-loaded to patientsEngagement is a shared responsibilityPatients who are alone are at highest riskDon’t scare the patient – they need to feel they are safe and do not have to be constantly vigilant
33 Whitepaper Recommendations Based on evidence that patient engagement improves patient safetyFor Leaders of Health Care SystemsEstablish patient and family engagement as a core value for the organizationInvolve patients and families as equal partners in all organizational improvement and redesign activitiesEducate and train all personnel to be effective partners with patients and familiesPartner with patient advocacy groups and other community resources
34 Whitepaper Recommendations For Health Care Clinicians and StaffProvide information and tools that support patients and families to engage effectively in their own careEngage patients as equal partners in safety improvement and care design activitiesProvide clear information, apologies, and support to patients and families when things go wrongFor Health Care Policy MakersInvolve patients in all policy-making committees and programsDevelop, implement, and report safety metrics that foster transparency, accountability, and improvementRequire that patients be involved in setting and implementing the research agenda
35 Tools for Health Systems Patient family advisory councilsShared decision making toolsHealth literacy tools/trainingBedside roundsPatient activated rapid response systemsPatient reporting systemsPatients on root cause analyses
36 Whitepaper Recommendations For Patients, Families, and the PublicWhile placing the responsibility for patient safety on health care providers and organizations, the report also urges patients, families, and the public to view themselves as full and active members of the health care system and recommends the following:Ask questions about the risks and benefits of recommendations until you understand the answersDon’t go alone to the hospital or to doctor visitsDocument and share your medications, including names, why, how, and dose with all providersBe very sure you understand the plan of action for your careRepeat back to clinicians in your own words what you think they have told youArrange to get any recommended lab tests done before a visitDetermine who is in charge of your care
37 A Focus on the Workforce Changing Landscape: 3A Focus on the Workforce
38 Joy and Meaning in Work Joy and meaning are not sentimental notions “Workplace safety is inextricably linked to patient safety. Unless caregivers are given the protection, respect, and support they need, they are more likely to make errors, fail to follow safe practices, and not work well in teams.”
39 Joy and Meaning in Work Currently health care workers suffer harm Emotionally (bullying, demeaning)Physically (injuries, assault)Up to 1/3 of nurses experience back or musculoskeletal injuries in a yearStress from complex and demanding tasks under severe time constraintsCosts of burnout, litigation, lost work hours, turnover are high
40 Injury and Illness Rates, 1989–2011 In 2011, U.S. hospitals recorded 58,860 work-related injuries and illnesses that caused employees to miss work.1 In terms of lost-time case rates, it is more hazardous to work in a hospital than in construction or manufacturing. “Days away from work” include only the more severe injuries, and they do not account for injuries where an employee continues to work, but on modified duty. Thus, the problem is even larger than the graph below suggests.
41 Vulnerable Workplaces Physical HarmHealth care workforce injuries 30 times higher than other industriesMore FTE days are lost due to occupational illness and injury in health care each year than in industries such as mining, machinery manufacturing and construction76% of nurses in national survey indicated that unsafe working conditions interfere with the delivery of quality careAn RN or MD as a 5-6 times higher chance of being assaulted than a cab driver in an urban area
42 Vulnerable Workplaces Psychological HarmLack of respect- A root cause, if not THE root cause, of dysfunctional cultures- 95% of nurses report it; 100% of medical students report itLack of supportLack of appreciationNon-value add workProduction pressuresScheduling demands and fatiguePoor design of work environments and work flows
43 Costs of InactionBurnout, lost work hours, turnover, inability to attract newcomers to caring professionsLess vigilance with regard to safety practices – both for patients and for workforceIncreased opportunities for medical errorsImpact on patient experience
44 What are the seven things an organization must do? Develop and embody shared core values of mutual respect and civility; transparency and truth telling; safety of all workers and patients; and alignment and accountability from the boardroom through the front lines.Adopt the explicit aim to eliminate harm to the workforce and to patients.Commit to creating a high-reliability organization (HRO) and demonstrate the discipline to achieve highly reliable performance.
45 What are the seven things an organization must do? – cont. Create a learning and improvement system and adopt evidence-based management skills for reliability.Establish data capture, database, and performance metrics for accountability and improvement.Recognize and celebrate the work and accomplishments of the workforce, regularly and with high visibility.Support industry-wide research to design and conduct studies that will explore issues and conditions in health care that are harming our workforce and patients.
46 Paul O’Neill ALCOA Example: Can every person in your organization answer YES to the following questions each day?Am I treated with dignity and respect by everyone, every day, by everyone I encounter, without regard to race, ethnicity, nationality, gender, religious belief, sexual orientation, title, pay grade, or number of degrees?Do I have the things I need: education, training, tools, financial support, encouragement, so I can make a contribution to this organization…that gives meaning to my life?Am I recognized and thanked for what I do?
47 The Kaiser Workplace Safety Index The index is linked directly to workplace safety injuriesCan be used to predict vulnerable departmentsIdentify areas to improve in the work environment in order to potentially prevent injuriesSimpler and more straightforward direction than previous indicesSlides courtesy of Kathy Gerwig - Kaiser Permanente Vice President, Employee Safety, Health and Wellness and Environmental Stewardship Officer
48 Workplace Safety Index The Kaiser Workplace Safety Index The 3 Rs: Resources, Respect, and RecognitionWorkplace Safety Index28. Necessary steps are taken in my department or work unit to ensure employee and physician safety.41. My immediate supervisor recognizes me when I do a good job.5. Kaiser Permanente provides the resources necessary for me to work effectively (hardware, tools, equipment, supplies, etc.).19. The people with whom I work treat each other with respect despite differences.
49 2013 Higher Scores = Lower Workplace Injuries People PulseWorkplace Safety IndexInjury rates56% lowerBottom 20%WPS IndexTop 20%WPS Index
51 Increased Transparency and Metrics That Matter Changing Landscape: 4Increased Transparency and Metrics That Matter
52 TransparencyA practiced value in everything we do The most important characteristic of a safe culture A precondition to safety
53 Transparency With colleagues With patients and families Sharing performance data, adverse events between providers, departments, and at all levels of the organizationWith patients and familiesClinical transparency re: shared decision making, risks and benefitsAdverse events/early disclosureFinancial incentives
54 Transparency Between organizations With the public Quality, safety dataAdverse event data – Patient Safety Organizations (PSOs), HIT Safety CenterCredentialingMedicare claims dataWith the publicQuality, safety, cost measures for doctors or institutionsMost websites are confusing and hard to follow
55 Challenges Cultural Fear of scaring patients/demoralizing staff Malpractice environmentLack of data/metricsLack of understanding of best way to capture or present the informationUpcoming Lucian Leape Institute white paper to start to address…
56 MetricsWhat should we be measuring for ambulatory or cross-continuum safety?Measures that matter: to clinicians, administration, patients and families?How do we capture patient reported outcomes/measures that matter to patients?Patient-Centered Outcomes Research Institute (PCORI)How do we create metrics that are useful and not overwhelming?
57 Optimizing the Use of HIT to Improve Safety Changing Landscape: 5Optimizing the Use of HIT to Improve Safety
60 Optimize the Use of HITWe know that some technologies reduce errors significantlyComputerized provider order entry (CPOE)BarcodingElectronic prescribingHandoff toolsTest result management systemsReferral management systems
61 Optimize the Use of HIT Need to optimize these systems Reduce over-alertingVariability across vendorsImprove interoperabilityAlso, we know there can be unintended consequencesClinical documentation/cut and paste16% of attendings' notes, 8% of residents' notes, and 38% of nurses' notes went unread by other users, and, overall, 16% of notes were never read by anyoneHripcsak et al. JAMIA 2011Accurate medication and problem listsWho owns them?
62 Unintended Consequences: Inpatient CPOE Workflow/work-aroundsMore work/new workCommunicationOverdependence on technologyShift in powerNever-ending technology demandsEmotionsNew errorsCost creepAsh JS, Sittig DF, Poon EG, et al. JAMIA 2007
63 Unintended Consequences Study showed that 10% of electronic prescriptions had errors1/3 with potential for harmMost frequent were omission errorsSignificant variation across different vendor systemsForcing functions, decision support, and calculators could reduce these errorsAlways a continuous improvement opportunityNanji, et al. JAMIA 2011
64 Sociotechnical Model 8 components Hardware and software Clinical contentHuman computer interfacePeopleWorkflow and communicationPolicies, procedures, culture (internal)Rules, regulations (external)Measurement and monitoringSittig, Singh BMJ Qual Safety 2010
65 Optimize the Use of HIT National focus Meaningful use incentives/certificationIOM report 2011 “Health IT and Patient Safety”User-centered design principlesPromote sharing of safety issuesCriteria to judge the safe use of HITMechanism for reporting HIT related adverse events
66 Optimize the Use of HITONC HIT safety plan 2013 (building on IOM report) includes the following:Make it easier to report HIT hazardsConduct post marketing surveillanceEstablish HIT patient safety priorities for researchR&D for tools and best practices for implementationONC SAFER guides 2013ECRI Collaborative 2014Sharing and analyzing HIT safety hazards/taxonomies
67 Optimize the Use of Health IT FDASIA Health IT Report 2014Recommended the creation of a Health IT Safety CenterGoal of assisting in the creation of a sustainable, integrated health IT learning system
68 Conclusions The landscape of patient safety is changing Scope (cross-continuum)Broader definition of safety: “How care should be”Incentives/penaltiesKey to focus on evolving areasCare across the continuumPatient engagementThe workforceTransparencyTools such as HITPatient safety is more important than everNeed to ensure the safest care and experience for patients while trying to reduce costs and reform care