The Quality Cost Connection: Patient safety: Just old wine in a new bottle?
February 1, 2002 6 minutes read
The Quality Cost Connection: Patient safety: Just old wine in a new bottle?
Leaders must not delegate their responsibility
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
Is patient safety improvement just a new version of what quality and risk managers have been doing for years?
Patient safety does involve a systematic approach to improving the quality of processes and enhancing the prospect of better patient outcomes. It does involve identifying and evaluating risks and trying to prevent them. However, in dealing with patient safety improvement, managers and caregivers should not adopt a "business-as-usual" stance. If we truly want to make patient care safer, process improvements must be done differently from projects conducted in the past.
One of the differences is our mindset. We cannot afford to adopt a recumbent posture. It is not enough to hope for the best. The best only happens when it has been thought about and carefully planned. Too often, safety problems have been dealt with only after something has gone wrong. Prevention is easy after a disaster. This is not good enough for at least three reasons: Money spent compensating the victims of carelessness is money not available for patient care. There also must be a notion of professional pride; if the service is not the best, then it is not good enough. And there is a moral dimension; no patient should suffer because health care professionals failed to take steps to eliminate safety risks.
Past improvement projects have been limited to just a few people, with the project team being responsible for determining the best way of improving the process. In patient safety, everyone has a part to play. There must be leadership from the top. The chief executive is obliged to show enthusiasm and continued commitment. An individual or group is put in charge of patient safety, not necessarily to do it, but to see that it is done — by everyone. All physicians and other caregivers should be acutely aware of the risks inherent in patient care, and they must be personally involved in identifying and minimizing these risks. No one person or group can deal with all the patient safety issues. Everyone must know how to recognize and avoid problem situations.
When total quality management was introduced into health care in the early 1990s, organizations were urged to adopt a new culture. CEOs were expected to lead a quality revolution in which all employees in all departments would improve procedures and systems to give customers economical, useful, and high-quality health care services. In 1993 and ’94, Joint Commission on Accreditation of Healthcare Organizations standards were updated to reflect the importance of leadership’s commitment to quality. Often, top-level commitment merely translated into more responsibilities being given to the quality director, with leadership expecting middle managers to lead the quality charge.
Patient safety has to be done differently. If we are to be successful at reducing adverse events, leaders cannot delegate their responsibilities. The organization’s capacity to provide safer patient care must be enhanced. Key elements include focusing resources on quality rather than quantity, staff development and training, technical support, and use of knowledge-based information for continuous improvement. A safer environment can only be realized if people are accountable for achieving results. Leaders must establish quality and safety standards and hold people to them. Key elements include accountability demands that are commensurate with resources and capacity, engagement of physicians and employees in developing less error-prone processes, timely feedback of performance information, and rewards for improved safety.
Expanded control mechanisms
Traditional performance improvement and risk management activities in health care organizations primarily have relied on four mechanisms to control the risk of patient injury:
- well-structured systems;
- explicit processes;
- professional standards of practice (e.g., licensure, credentialing);
- assurance of competence (staff performance evaluation and medical staff peer review).
These mechanisms have had some success in ensuring patient safety, but adverse events still occur. Research in other industries suggests that many accidents are the result of simple human error. In air traffic control, for example, 80% to 90% of accidents are caused by human mistakes rather than technical causes. Figures for the medical domain point in the same direction: Chopra, et al. having found human mistakes as the cause for adverse patient outcomes in 70% of surgical mishaps. Thankfully, many of the errors we make in the delivery of health care services go undetected. Of those that result in a reportable patient incident, only a few cause patient injury. The rarity of accidental patient harm has given us a false sense of security. On the surface, it appears that the mechanisms we’ve been using in the past to control risks have been entirely successful. And yet, significant patient injuries still are occurring. Why? Because we expect people to be infallible. Any hint that someone is unable to live up to our expectations brings threats of closer scrutiny, disciplinary action, or even dismissal. This trust in the infallibility of people has perpetuated the use of poorly designed health care processes.
To improve patient safety, we must add a fifth control mechanism — error resistant processes. We’ve flowcharted innumerable activities and implemented lots of changes, but we’ve failed to substantially reduce the risk of human error. Now it’s time for health care organizations to supplement traditional methods of control with human factors analysis. This involves the study of the "human aspects" of work activities, which originated in the field of ergonomics. The proactive process improvement technique known as failure mode, effects and criticality analysis (FMECA) is a human factors analysis method that the Joint Commission is encouraging health care organizations to use. The FMECA technique forces people to look at what might go wrong so that processes can be redesigned to prevent such a failure from occurring.
Traditional process redesign activities focused primarily on efficiency improvements through elimination of nonvalue-added steps and streamlining of activities. Rarely did we redesign processes with the intention of reducing the risk of human errors; we just expected people not to make mistakes. We must learn how to create processes that are more mistake-proof. Management and caregivers have to embrace three basic tenets regarding human error:
- Everyone commits errors.
- Human error generally is the result of circumstances that are beyond the conscious control of those committing the errors.
- Products or systems that depend on perfect human performance are fatally flawed.
We must admit mistakes happen so that we can redesign our processes to be both efficient and more resistant to human error. Our traditional methods of controlling risk need to be expanded to include human factors analysis of work processes.
Risk management in health care services is not new, but formal patient safety improvement programs are relatively recent additions. However, don’t presume that patient safety is just new labeling for something that we’ve done for years, or we’ll end up with what we’ve had for years: occasional incidents that significantly harm patients.
Improving patient safety requires more than the application of traditional risk management and continuous quality improvement techniques. We must change attitudes and garner visible leadership support. We must redesign processes with the intent of preventing simple mistakes from reaching patients. Illegible physician orders should not lead to administration of a deadly dose of medication. Bath water should not scald patients. People should not slip and fall because corridor floors are left soapy. A mistyped patient name should not result in a wrong-site surgery. The risk of human error must be anticipated and contained. Patient safety improvement is a new and essential addition to our long-established performance management activities.
Recommended reading
1. Van Cott H. "Human errors: Their Causes and Reduction." In: Bogner S, ed. Human Error in Medicine. New Jersey: Lawrence Erlbaum Associates; 1994.
2. Chopra V, et al. Reported significant observations during anesthesia: A prospective analysis over an 18-month period. Br J Anesth 1992; 68:13-17.
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