Viewpoint
Building Patient Safety into the System
By William Schumacher, M.D.
Early in my career as an emergency medicine physician, I believed that patient safety was almost entirely a matter best left in the hands of doctors. Like many physicians, I believed that, as the leader of the medical team, all would be well cared for as long as I kept a clear head.
However, because of the complexities of delivering health care services today, this attitude is not tenable, if it ever was. The numbers of both hospital admissions and emergency department visits keep rising, while employer and personnel resources are often limited. The ED, already one of the most complex operating systems in the hospital, is becoming even more demanding.
It seems that every year, physicians, nurses and other members of the delivery team are expected to do more with less. Medical errors in this increasingly problematic environment are more a matter of when than if. This was confirmed by the Institute of Medicine's 1999 report asserting that up to 98,000 deaths per year can be attributed to preventable medical errors, and has been further validated by subsequent reports.
A major effort by government, physician groups, hospitals, payers and consumer groups has been undertaken to improve patient safety, with considerable attention directed toward raising clinical staffing levels and competencies, and to enhancing patient safety awareness at the individual clinician level.
These efforts are important, but they do not get to the heart of the matter. In today's health care environment, adding more and better trained employees is not enough, and, in many cases, provides a false sense of security. Physicians and other providers need the broader support of processes and systems that direct them to certain behaviors and encourage those behaviors.
That's why it's vital that trustees support the implementation of process standardization common to many other industries, but often lacking in health care. Such process change, however, depends on the support trustees can give to a transformation in organizational culture, that is, a culture of inclusive decision-making that opens the lines of communication among everyone involved in patient care.
Working with administrators, trustees can help improve patient safety by encouraging their hospitals to:
- Keep things simple. Some of the biggest gains in efficiency and "operational hygiene" in health care have been achieved through simple, nontechnical means. The "checkoff complaint" list for ED documentation used by emergency medicine physicians is a good example. This paper system, now used by more than 50 percent of hospital EDs, leads physicians through customized treatment guidelines as they care for patients and order tests and services. The system prompts physician behaviors keyed to patient safety without inhibiting the creativity or compassion the physician brings to bear in treating patients.
The system is equally valuable because of how easy it is to learn and use. Such a standardized set of protocols requires major buy-in of only one stakeholder--the doctor--for successful implementation. Its simplicity requires little of the training and technical support that can increase the potential for system failures exponentially. Trustees should ask their CEO if their hospital uses a documentation system that ensures physicians are directed toward safe, standardized procedures.
- Embrace technology (with caveats). Electronic medical records (EMRs) are a vital tool to enhance patient safety, but EMRs and other technical options can create additional problems and risks if they are not practical and easy to use. Electronic management and documentation systems tend to work best in stable environments, such as a pharmacy, where they can be used to track doses and look for contraindications. Other examples of narrowly focused functions whose efficiency and efficacy are improved by electronic systems are automated aftercare instructions and prescription-writing electronic systems that are designed to minimize the need for comprehensive integration of multiple stakeholders or IT support systems.
However, successful EMR implementation is often difficult in chaotic environments such as the ED, where patient volume is high, conditions are volatile, patient care decisions are time-sensitive, and many different providers are involved. Additionally, support staff turnover is high, and staff orientation and training are already a challenge.
The long-term reliability of an EMR system depends on constant training and orientation in an industry that often fails to commit resources to these functions. Also, the environmental clutter caused by some electronic record systems may offset the indisputable patient safety value of a complete and comprehensive electronic medical record. Therefore, hospitals may have to settle temporarily for a system with a partial, narrow focus until a clear front-runner in the EMR race presents itself.
This is not to say that there aren't hospitals that have successfully implemented the comprehensive electronic medical record. But the list of problematic or failed installs are exponentially greater. That's why timing and caution are so important, because all patient care documentation will eventually become electronic. It is critical to establish an EMR strategy that enables better patient care while reducing risks and costs.
- Promote the use of teams. One person--typically the physician--can't do it all. Your hospital should be promoting a team approach to care in which everyone can express their opinions. Again, this can be process-directed by implementing systems that call for team member input at regular intervals along the patient care continuum. Physician and hospital employee orientation and training must encourage anyone with a concern about a patient's safety to voice that concern and, if not satisfied with the response they receive, have the right and a process to seek higher authority for review of that concern.
Along these lines, some hospitals are experimenting with joint physician and nurse attestations--sessions in which everyone's input is encouraged and concurrence prior to discharging a patient from the emergency department is required. Whether one uses attestations or other policies or procedures that demand such "inclusive care," success will ultimately depend on buy-in at all levels. Without a cultural commitment to team development and to inclusive care, the likelihood of success will always be minimized.
- Create a culture of patient safety. Establishing a culture of patient safety is an organic process that must grow from project to project and person to person. In health care today, multiple stakeholders are involved in the most seemingly simple patient encounters. For example, it is not unusual for 10 to 15 different hospital staff and clinicians (e.g., ward clerks, nurses, physicians, laboratory technicians, X-ray technicians, etc.) to be involved in the care of a patient who has a sore throat. Patient safety efforts therefore must be part of a cultural transformation that engages as many of these parties as possible.
Trustees can help by encouraging their hospitals to start with a safety program they are confident will be successful. Management should pick a specific safety problem, set an achievable goal, and use this project, once successful, as a building block toward creating a patient safety culture. As an example, a trustee might inquire as to how long it takes to get an EKG for a patient in the ED with chest pain. Regrettably, the answer in the majority of hospitals is "too long." The hospital should try fixing this one problem and move on.
Several not-for-profit organizations, such as the National Patient Safety Foundation, have programs that help create the platforms needed to support any cultural transformation. Much of this information can be accessed by visiting the Foundation's Web page (www.npsf.org), or by contacting them directly at (703) 506-3280.
What can't be forgotten in the pursuit of better patient safety is the acknowledgement that health care is provided by individuals, and their personal skills are vital to quality outcomes. Nevertheless, it is processes and systems that enhance efficiency and safety in other industries, and such processes and systems must be instituted in hospitals before the health care that all those people provide can be their best.
William "Kip" Schumacher, M.D., is board certified in emergency medicine and is CEO of The Schumacher Group, a national emergency medicine management firm based in Lafayette, La. He can be reached at kip_schumacher @tsged.com.
This article 1st appeared in the December 2099 issue of Trustee Magazine.
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