Managing quality and patient safety through a combined proactive and reactive approach
When a medical institution aspires towards excellence and patient safety, quality management proves to be a key factor essential to the process.
It goes without saying that there are countless risks in the healthcare system and that it is always a priority to minimize these. There is nothing new about that. However, this article takes the innovative stance that the inevitable reactive approach to negative events is not the only method which can be used to reduce risks and therefore enhance quality. We will examine how a combined approach with an equal emphasis on preventative measures can be a highly effective management pattern which breaks down barriers and cuts through conventions.
Patient safety is defined as a healthcare discipline primarily involving the reporting, analysis and prevention of medical or process errors which can lead to adverse healthcare events.
Quality in public health is understood to be the degree to which policies, programs, services and research for the population increase the desired healthcare outcome and conditions in which the population can be healthy.
Despite a general consensus that everyone wants to achieve the goal of optimum quality and patient safety, why is this target so difficult to reach?
Healthcare institutions invest enormous efforts and resources in order to improve quality and patient safety, but often fail to reach that aspired “ultra-safe” environment. The following factors have been identified as typical system barriers in striving towards this goal:
To summarize the above, an environment with technical and organizational complexity and process opaqueness obscures the route to excellence and makes it easy to overlook risks to patients.
The legislators in the U.S. are already “reacting” to this situation by taking a “proactive” approach to “encourage” participants to embrace change:
The “Patient Protection and Affordable Care Act” is a new healthcare regulation which, when it comes into force in the U.S.A, will intensify the need to overcome the aforementioned barriers.
Before we consider how healthcare companies can adjust to change, let us briefly examine the impact which this new legislation will have on the medical sector:
These new conditions have been a major incentive to Tefen to develop an innovative methodology which will assist healthcare organiziations to prepare for the above changes, while simultaneously helping them to achieve excellent quality and patient safety.
Based on the current, traditional approach, healthcare systems typically wait until an adverse event occurs during medical treatment and then react to this. The organization then conducts “Lessons Learned Exercises” based on the event that occurred – initiating action and “repairing” projects as a follow on to lessons learned from previous adverse events.
These actions and projects usually contain “local fixing” acts which address the safety issues that caused the event. Apart from this “reaction”, the organization usually continues its customary daily routine until the next unforeseen problem or chain of problems occurs.
“Now think about the things you‘ll do tomorrow if an adverse event occurs due to something involving your area of responsibility, then go back to your office and do it today”.
The less frequent and more difficult method to implement is the preventative approach. A proactive stance encourages an organization to take action now in order to prevent the next adverse event from happening. Revealing the risk factors before they cause an accident is not an easy task.
A combination of the two above mentioned approaches was found to be most suitable for the daily reality of healthcare systems. This combination offers more benefits than either approach on its own.
Step one – analyze current position on 2 axes diagram.
Initially, the organization should analyze its current position on the 2 axes diagram shown below.
The classic total quality management methodology (TQM) used for this article forms the foundation for the P&R methodology developed by Tefen in order to reach excellence in quality and patient safety and overcome key barriers by combining proactive and reactive approaches.
In order to perform this analysis, use TQM factors which are measured by TQM tools according to the following table:
Step two – How do we know what is going to cause the next accident…?
We need to identify and define inevitable/expected events, such as infections. In order to pinpoint risks which are hard to recognize, hospitals should analyze processes and the customer-supplier value chain etc. To allow this step to be repeated continuously, organizations should systematically collect data, regularly monitoring and integrating information from a variety of safety hazard sources. They can encourage staff to report errors by ensuring anonymity. This data should be used only for safety analysis and not for punitive action. By comparing aggregated data and benchmarks with national data sets, a point of reference can then be created. Most hospitals know they should identify events – they need a tool to do so – something such as the UHC-PSN tool.
Step three – means of actions and measurements
This is the time to define a proactive approach for prevention of the inevitable/expected events and to derive specific means of action. This should be backed up by designing a methodology to measure the efficiency of defined safety solutions to known problems. Possible TQM tools for this include audits, surveys, control charts, brainstorming and fishbone diagrams. This should be a continuous process aimed at eliminating potential problems.
Step four – a prioritizing policy
The policy should equally prioritize issues with quicker and more apparent outcomes as well as longer and less apparent processes. Classic TQM implementation usually requires long-term resource allocation at the expense of short-term, urgent resource requirements. Prioritizing both long and short term activities may help you explain the value of the long-term, less apparent benefits of a process to the staff, thus increasing their motivation and understanding of the final goals.
The innovative methodology described above has been designed by Tefen, and is relevant to any healthcare organization wishing to overcome barriers in order to thoroughly improve and manage quality and patient safety.
Expert opinion by Dr. Hoffmann regarding quality and patient safety in healthcare
Peter R. Hoffmann, M.D., M.Phil., is currently a Clinical Professor of Medicine at the University of Texas Southwestern Medical School and formerly the Chief Quality Officer and Senior Vice President for Quality of Care at Parkland Hospital, Dallas, Texas, where his activities included overseeing quality of medical care, patient safety and risk management, infection prevention activities and utilization management.
Dr. Hoffmann uses the terms “quality of care” and “patient safety”, defined at the beginning of this article, in a broad sense. In his opinion, “patient safety” not only deals with medical errors which lead to adverse events, but also includes process problems which actually cause most of the harm to patients. For example, a patient may have received the wrong medication, but what were the steps involved in getting that medication to the patient? This means that, in order to detect the root cause of an adverse event, the organization must analyze the processes which led to that event and then address the factors which should and could have prevented harm from reaching the patient. In contrast, “quality of care” refers to improving health outcomes.
A common quality and patient safety definition released by the Institute of Medicine employs the acronym S.T.E.E.E.P:
These categories lead to measurable parameters that can help an organization detect whether or not it is improving its quality and patient safety.
Nowadays, most hospitals do not dedicate enough time and resources to tracking problems, analyzing the causes of adverse events or directly interviewing patients to find out “what is bothering them”.
Despite the efforts of many hospitals in the U.S.A to build internal quality departments, Dr. Hoffmann comes to the conclusion that “We still don‘t do as good a job in improving the quality of care as we should. Hospitals often don‘t identify significant problems, or don‘t identify them quickly enough, due to insufficient staffing, failures in the problem identification mechanisms, difficulties prioritizing the problems, an inability to examine the root causes of problems and most importantly, failure to implement change. Medical staff understandably find it challenging to perform problem analysis in addition to their primary role – taking care of patients”.
According to Dr. Hoffmann, the barriers in achieving excellence as specified in this article are of real and current relevance to the healthcare sector and he elaborates: “Not only do we have an inadequate error reporting system but we have difficulty in easily identifying errors”. For example, although it is simple to detect when the wrong medicine is administered, failures or near misses caused by process errors are more difficult to identify.
Another barrier to improving quality and patient safety as stated by Dr. Hoffmann, is the difficulty in achieving cultural change. Cultural change is needed when a problematic factor is identified and needs to be changed. Organizations find it particularly challenging to alter staff routines and habits and ultimately maintain these changes in the long term.
According to Dr. Hoffmann, “Organizations should start assessing their own performance, and they should have done it yesterday”. If we use the example of the U.S., where change in legislation has resulted in a wake-up call, hospitals should begin preparing for quality audits in which failure or success will have real consequences on the organization, such as their Medicare billing.
Because of the difficulty in performing root cause analysis in addition to hectic daily routines, Dr. Hoffmann suggests hospitals use an external service provider to help build an internal quality assessment and improvement department.
Dr. Hoffmann explains that most healthcare organizations do not yet use a proactive approach. In order to implement change, companies must combine traditional reaction with preventative measures. In addition, Dr. Hoffmann believes that implementation and sustainment of the changes will pose a challenge as this requires skills more akin to a business environment than a healthcare center: project management, constant measurement, monitoring and great attention to feedback and communication.
On the other hand, we should never forget that, while we are demanding these skills, the primary function of a health care center is the care of patients, and staff must have the time, focus, and medical expertise required to do that.
The first step that hospitals need to undertake is to identify their problems and systematically assess their performance as detailed in the steps suggested in this article. In order to do so, Dr. Hoffmann recommends that organizations develop a suitable and sustainable reporting system for errors or near misses and start small, by focusing on the simple things that you can fix, improve or prevent in the foreseeable future, thereby showing your staff how implementation of change can be realized, monitored and sustained.
By Thomas Guglielmo, President, Tefen USA
Tamar Mass, Consultant, Tefen Israel