By Donna Prosser
Millions of Americans are harmed, and more than 200,000 die, due to preventable medical error every year.
While there will always be adverse events in healthcare that are unavoidable and harmful, such as a patient having a deadly allergic reaction to a medication they have never received, preventable harm is avoidable. Preventable harm can range from wrong site surgeries to a patient receiving a medication that they have a documented allergy to.
The cost of preventable harm
Preventable medical errors are estimated to cost the U.S. healthcare system at least $19.8 billion annually due to additional medical care and lost productivity. Additionally, the fragmented systems and processes that lead to preventable harm result in unsatisfactory quality outcomes. Last year, 774 U.S. hospitals were penalized for poor performance and fined 1% of Medicare payments as a result, which can significantly impact financial health as most hospitals are surviving on a 2-3 percent margin.
The case for high reliability
Most healthcare systems rely on quality and safety data to inform whether they are safe and efficient. However, this data isn’t representative of all quality and safety processes. In addition, healthcare is focused on improving what is reported, so those data points may look good despite the lack of a solid foundation for safe and reliable care. To truly minimize preventable harm, healthcare needs to become a highly reliable industry, such as aviation or nuclear power, which anticipate problems before they occur and are transparent about errors and root causes when they do happen. Designing safer, more highly reliable systems in healthcare can reduce the incidence of preventable harm, save lives and improve financial performance.
Understanding if your health system organization is highly reliable
Healthcare leaders can start by completing an assessment of the current state of the organization. Some questions to consider include:
1. Are clinicians and staff comfortable speaking up when there is a problem? Is the reporting of near misses an expectation that is easy for staff to complete? When an error occurs, are processes examined for gaps, rather than blaming individuals for making mistakes?
2. Are patients and families actively involved in their own care and an equal part of the care team? Are they invited to participate in performance improvement activities?
3. Is there a standardized, consistently applied framework for continuous improvement? Is there alignment between improvement activities and the strategic plan?
4. Is your education and training program aligned with your improvement plan? Are your policies and procedures written in simple language that makes it very clear what the frontline is supposed to do? Are they easily accessible when needed?
5. Do you invest heavily in leadership development and hardwiring the improvement skills leaders need to successfully implement change? Do your leaders understand human factors and their effect on sustainment of the change?
If the answer to any of these questions is “no,” then your organization has an opportunity to become more highly reliable.
Becoming highly reliable
The journey to high reliability requires a significant shift in organizational culture but that doesn’t mean that it has to be expensive or complex. It also requires significant commitment by the executive team and governing body. Becoming highly reliable will not succeed without their buy-in, continuous reinforcement, and modeling of behavior. Some organizations choose to hire consultants to help them through this process, but many cannot afford to. The good news is that with strong leadership you can begin this work on your own:
1. Create awareness about patient safety across the organization. Most clinicians and administrators are so focused on their own practice that they do not see how fragmentation across the continuum of care leads to safety breakdowns. Talk about safety at every opportunity and help everyone understand the “why”.
2. Train leaders and staff in improvement science. Involve your safety, quality and education departments to create fun, interactive activities that reinforce improvement concepts.
3. Model the behavior you want to see. Be transparent, open and honest with your teams. Admit when you make mistakes and avoid blaming individuals for making mistakes.
There are several excellent, free resources available online that can help organizations create more highly reliable systems and processes. While not an easy journey, it is an imperative one that leads to significant savings in both lives and dollars.
About the author: Donna Prosser, DNP, RN, NE-BC, FACHE, BCPA, is the chief clinical officer at the Patient Safety Movement Foundation.