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Hardwiring Safety: A Florida Thunderstorm

Carol was recently scheduled for surgery which would require a 3-day hospital stay. Despite a rather routine surgery by an experienced and familiar surgeon, Carol was extremely apprehensive about undergoing the procedure. She had delayed the surgery for several months, fretted about it, and imagined worst-case scenario outcomes. She had full understanding that delaying the surgery would increase her risk, and worsen her condition, but she was literally scared to death.

The crux of the situation is Carol is an experienced Perioperative Nurse who understands the consequences of delaying a surgery of her type, but she was terrified of being hospitalized. Throughout her career, she has seen devastating wrong site surgeries, medication errors, and retained foreign objects, just to name a few serious safety events.

As consumers of healthcare, we often take a serious approach to our own healthcare and that of our loved ones, but I believe sometimes in healthcare, we (providers) underestimate the severity and prevalence of serious safety events. We perform our task day in and out, with a level of complacency, going about our business and simply “do the best we can”. We might occasionally hear about a serious safety event in the media and wonder how an organization could ever allow it to happen, while scoffing that “it would never happen here”. How often after a safety event, does the team conduct the root cause analysis and submits the action plan; rubber stamps it and done, it is filed away…then back to business again, and again? We all know the term “Complacency Kills”….

What if the same serious rigor and commitment to safety was applied as in other industries such as nuclear power plants and aviation? For example, there is a 1 in a million chance of a person being harmed while travelling by plane. In comparison, there is a 1 in 300 chance of a patient being harmed during health care, and a shocking 1 out of every 10 patients are harmed in hospitals.

What if we applied the same rigor and commitment to safety in healthcare as in the way we prevent personal injury or risk?

If you have ever fished in South Florida in the spring and early summer, then you will understand the seriousness of heading for shore when a thunderstorm rolls in off the ocean. The am weather forecast may reveal a great day for fishing, but the waves can instantly swell up, and the rain becomes so thick that there is a “white out” where you cannot see anything around you; the shore disappears behind a wall of rain. The winds change directions, and the current becomes fierce. The situation gets very dangerous on the water in less than a moments notice. The only thing that keeps you safe is a rigorous attention to every detail (the wind, rain, current, speed and compass), while keeping your bow in the wind.

Your experience on the water is critical and you must apply an arsenal of skills, developed over time and practiced while on the water. A smart captain always prepares for the worst-case scenario by using a safety checklist to ensure working equipment and checks the engine before leaving shore. He then briefs with his team about the trip and relies on his skill and experience to guide him home, but he never underestimates the safety element, or takes it for granted. How prepared is your organization for the next major thunderstorm, do you drill for it, and does everyone understand their role and accountability in safety?

We protect ourselves from personal injury and risk at all cost; we are proactive in our approach and critically evaluate a potential risk before it happens, while eliminating all inherent barriers to safety. We are vigilant to

watch for the signs of danger, and take immediate action to ensure safety, then we monitor to ensure processes are in place to keep us or our family safe. Shouldn’t we also apply the same rigor to ensure our patient’s safety while in our care?

The following statistics are staggering, and every event has a face and a name, to be remembered and recognized.

  • Harm is the 14th leading cause of morbidity and mortality globally.

  • $42 billion US dollars are spent annually on medication errors alone.

  • 15% of spending in hospitals are related to adverse events.

  • 7 million people worldwide experience complications from surgery and 1 million die annually.

  • 4,500 to 6,000 retained surgical item cases occur annually in the U.S, with over 80% being sponge related.

  • 10% of deaths are due to diagnostic errors, in the US annually.

Now if you think these statistics are too far removed, let’s take a closer look. Within about 10 minutes of research, there are over a dozen articles on serious patient safety events in the US healthcare market, just this last year, and many more resulting in hospital closures, and fines.

For example, one state collectively issued $1,052,505 in fines to 13 hospitals for licensing compliance issues that caused or were likely to cause patient harm or death. These events included wrong site surgeries, retained objects and medication errors.

Two large hospital systems closed their heart programs due to lack of qualified doctors and/or mortality concerns. Basically, because of the low number of heart surgeries, they could not ensure safety and quality. The Center for Medicare and Medicaid Services (CMS) also threatened to close a hospital after an employee washed surgical instruments by hand and did not monitor a patient who delivered a baby prematurely on a bathroom floor. This hospital’s emergency room was closed in 2016 and although health service officials tried to improve care at the facility and later reopened the ED, they closed the facility's surgical and OB-GYN departments.

In addition, the Leapfrog Group gave 17 hospitals an “F” in its fall 2018 Hospital Safety Grades released Nov. 8, and 4 hospitals out of the 17 received an F the previous period. Of the more than 2,600 hospitals graded, 32 percent earned an "A" grade, 24 percent earned a "B," 37 percent earned a "C," 6 percent earned a "D," and 1 percent earned an "F." Forty-two hospitals nationwide have earned an "A" rating in every scoring update since the ranking system's inception in spring 2012. These are the hospitals who hardwire continuous quality improvement practices, and who own a culture of safety! Every healthcare organization who received anything below an “A” should be asking “what can we do different” and learning from the “A” rated facilities.

There are organizations who have demonstrated performance excellence in quality and safety. For example, Dignity Health has gone five years with zero retained surgical sponges after any cesarean section at all 36 of their maternity hospitals. They applied standardized processes and a formal management system to their sponge counts. Additionally, Sutter Roseville Medical Center in California went 7 years without a CLABSI. They accomplished this due to strict bundle adherence and standardization.

The National Committee on Quality Assurance recommends a healthcare system that adopts systems thinking and principles of human-centered design and human factors. They note that specific design principles should include full transparency; co-design with patients, staff and communities; care that is anticipatory and predictive rather than reactive; care that reflects societal values; and care that bases decisions on clear evidence, continuous feedback and learning.

In 2019, is your organization standing vigilant in safety? To check the pulse of your organization, ask staff members what the action plan is for the last serious safety event; do they know about it and can they speak to what they are doing to keep the next patient safe? Pull the last two years of Root Cause Analysis Action Plans and ask how your team is measuring and monitoring for compliance, then ask to see the results. Lastly, do staff members speak up for safety; are they holding am & pm briefings, and immediate post event debriefings, and sharing the vital learnings with their team members; is the action plan visible and performance metrics posted for patients and family members to see and participate in?

Match Healthcare Design and Innovation partners with healthcare organizations to hardwire clinical quality outcomes, improve efficiency and eliminate waste through application of the Restoration Healthcare Design Model. This trademark model targets the DNA of the healthcare safety problem, by applying Lean Principles, Human Engineering Concepts, proven Quality Improvement Strategies and Chaos Theory. This complex bundled approach includes very specific comprehensive assessments of the work environment, people, processes, policies and culture. We go to the GEMBA to discover the opportunities, then work directly with your teams to recommend sustainable long-term targeted safety solutions, improve efficiency and reduce waste.

Start 2019 off with a new plan to provide the highest quality of care that you would want for your loved one, despite whatever storm you may encounter.

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