|
A Way Forward on Patient Safety?
Recently, a group of thought-leaders in the field of patient safety have considered the rather alarming slippage in patient safety results related, in part, to the pandemic stress test. 1 They began their report by noting important progress had been made in the twenty years prior to the pandemic. “Most patient safety breakthroughs came from system design focused on care delivery processes, where errors are considered to be consequences related to upstream systemic factors.” So, what went wrong? “We find that two systems- level factors contributed to those pandemic-related losses: highly variable deployments of patient safety systems across care delivery groups, and high rates of turnover of frontline staff arising from clinician burnout.” “First, regardless of the particular safety metric at issue, almost all previous and current patient safety efforts focused on elements such as establishing senior management commitment, creating a “culture of safety,” ensuring workforce safety, and seeking patient engagement, rather than focusing on nationwide frontline care processes that span across all care delivery systems and account for the vast majority of care-associated injuries…” What happened is that each organization that seriously engaged in safety efforts had to develop its own local, context specific approach to system management, which depended heavily on the tacit knowledge of existing staff to operate successfully. As we have considered previously, the massive increase in staff turnover experienced by almost all health care organizations during the pandemic, shattered processes that were layered onto usual clinical training and that required extended training to be able to use successfully. As the authors put it, “The result of this pandemic-prompted disruption, which exposed the systemic fragility of frontline staffing models, was the loss of comprehensive, coordinated care, the foundation upon which safe care rests.” In response to this analysis, the authors propose all the existing patient safety organizations come together and work to identify best practices at the standard level and disseminate these to essentially everyone. This would include standard measurement systems that would be used by every care system, and so presumably not proprietary, and aligning professional training with safety systems. In this schema, a “travel nurse” would expect to find the same safety processes and monitoring systems in place no matter where he/she was currently assigned, which, as the authors acknowledge, would help, but not solve the problem of staffing issues. This short paper is an idea piece, not a detailed roadmap, and implementation would take time, effort, and money. But it does seem to be a positive first step in changing the way we do safety, in a manner that is an improvement over the past, where we have usually added it on. 7 January 2023 1 James BC, Savitz L, Fairbanks RJ, Bisognano M, Pronovost P. Patient Safety Performance: Reversing Recent Declines Through Shared Profession-Wide, System-Level Solutions. 12 December 2022. doi:10.1056/CAT.22.0318. Accessed 5 January 2023 at https://catalyst.nejm.org/topic/catalyst-article- type/commentary. |
Further Reading
Accountability If asked about the greatest advances I have seen, my outside the box answer would be the insight that the quality and safety of medical care is as much about system design as it is about human performance. Current efforts to make providers financially accountable, though, threaten the utility of this insight. Staff Shortages When there is no room at the inn due to staff shortages, the standard of practice will have to change. We need to think about what this might mean. System Failure Medicine has adopted the language of manufacturing with terms such as efficiency, reliability, and “lean processes.” An unintended consequence may be increased risk of system failure. The Center Effect Some dialysis units have consistently better performance than others, even after adjusting for individual patient variables, which is termed the center effect. This has important implications for hospitals and health care organizations as they respond to public reporting of data. The Work-Around A work-around get past a problem with addressing either the root cause or a solution. Health care abounds with work-arounds. |