EDITOR’S NOTE: Every day, patients are harmed or nearly harmed at healthcare facilities across the nation. Is there a certain procedure or specific department where a higher percentage of patients are put at greater risk for injury? If so, when is the last time your organization re-evaluated the processes in place to protect patients from accidental injury? Dr. Robert A. Dowling, MD, is the Vice President of Scientific Affairs and Policy at IntrisiQ Specialty Solutions, specializing in EMR implementation and conversion and integrating quality measures and the electronic health record. The story below provides his insight on how to create a safer culture for your patients and staff.
Almost 12 years have passed since the National Quality Forum (NQF) released its 2003 consensus recommendations entitled, “Safe Practices for Better Healthcare.” The initial release was primarily driven by the Institute of Medicine’s sentinel report on medical errors (“To Err is Human: Building a Better Health System”) and was aimed at inpatient hospital environments. NQF updated its Safe Practices recommendations in January 2014.
Many of the 34 safe practices remain unchanged from their original issue, are generalizable to the office setting, and incorporate strong evidence of reducing harm to patients. Yet the penetration of these practices and principles in community urology practice remains uncertain and unmeasured. How much safer are patients than they were 10 years ago?
According to the report, “Every day, patients are still harmed, or nearly harmed, in healthcare institutions across the country. This harm is not intentional; however, it usually can be avoided. The errors that create harm often stem back to organizational system failures, leadership shortfalls, and predictable human behavioral factors.”
In a series of articles, I will review aspects of this important report that are relevant to quality and safety in urologic practice. After reading these articles, urologists should reflect honestly on their own opportunities to improve the safety of care in their own practices.
Barriers to creating culture of safety
Health care is a highly complex, error-prone activity where many barriers exist to creating and sustaining a culture of safety. These barriers include expectations that physicians will perform perfectly and errors are caused only by negligence or incompetence; lack of open communication when errors do occur; lack of awareness about the prevalence of risks, errors, and adverse outcomes; a lack of systems thinking; and a lack of safety-oriented leadership.
NQF’s Safe Practice 1 addresses these barriers with recommendations for structures and systems that raise awareness of the problem, implement measurement and accountability for safe practices, and lead to actions and investments. In a urology practice, these practices could involve incorporating safety in a mission statement, appointing a physician or staff member as the patient safety officer, creating a patient safety committee (in a larger practice), encouraging reports of errors and near misses without fear of consequences, patient safety education for all staff members, and communication strategies by leadership to the other physicians and staff.
In a closely related recommendation, Safe Practice 2 reads: “Healthcare organizations must measure their culture, provide feedback to the leadership and staff, and undertake interventions that will reduce patient safety risk.” This recommendation is very easy for the urology practice to implement, and if for the first time, should probably be done before addressing the leadership issues of Safe Practice 1.
The Agency for Healthcare Research and Quality has developed the Medical Office Survey on Patient Safety Culture, a free, easy-to-implement validated instrument complete with Spanish version, implementation webinar and user guides, a data entry tool (for large practices), and a comparative database that is even broken down by specialty to allow bench marking. Survey domains include questions about teamwork; patient follow-up; overall perceptions; organizational learning; staff training; communications about errors; support from leadership regarding safety, office practices, and standardization; and work pressure and pace. All members of the health care team, including physicians, are surveyed.
In 2014, there were 27,103 survey responses from 935 office practices, including 109 responses from urology. These results are critical context for understanding the responses from your own practice, analyzing the results, and developing actions based upon this knowledge.
Safe Practice 4 is the effective identification (and then mitigation) of risks and hazards in the health care setting. In hospital settings, one common approach to identifying risks involves the analysis of adverse events; for example, the Institute for Healthcare Improvement’s (IHI) Global Trigger Tool.
Analyzing, mitigating risks
A more proactive approach includes the IHI’s Failure Mode and Effects Analysis Tool, where processes with risk are taken apart into steps, the possible things that could go wrong are identified, and the causes and effects of those failures are identified with the purpose of addressing the causes before they result in a “failure.” Most urology practices do not have the resources to conduct these formal studies, but can borrow from the principles to conduct their own risk assessment. For example, consider this simple series of steps:
- Identify five procedures in your office that involve risks to patient safety (examples: prostate biopsy, vasectomy, cystoscopy, bacillus Calmette-Guérin instillation, office injections/implantations).
- For each procedure, identify five things (failure modes) that could go wrong (examples: wrong patient, wrong procedure, wrong or broken equipment, infection/contamination, anaphylactic reaction).
- For each failure mode, identify five possible causes (example for infection: equipment not properly sterilized, antibiotics not taken, cross contamination from lubricating jelly, patient colonized with resistant organism because of recent antibiotic use, break in sterile technique).
- For each possible cause, identify all prevention strategies and opportunities for improvement (example: “AUA/SUNA White Paper on the Incidence, Prevention and Treatment of Complications Related to Prostate Needle Biopsy”).
Another approach might involve hiring a consultant to conduct a formal risk assessment based upon a site visit and/or personal observation. An outsider may bring a level of distance and objectivity to the process that avoids any bias introduced by members of the staff who may be inured to some of the potential risks they have failed to recognize in their busy daily routines.
Bottom line: Safety is an unspoken yet fundamental expectation of all patients, and health care delivery—even in the office—is a complicated and error-prone business. Creating and maintaining a culture that improves the safety of patients requires active steps by practice leaders. Simple tools and procedures are available and can be used in urology practices of all sizes and shapes.