Next Steps – Patient Safety: It’s Not Just About the Technology…
May / June 2005
Next Steps
Patient Safety: It’s Not Just About the Technology…
Patient safety is at the top of the agenda for hospital executives. Every hospital’s growth strategy presumes compliance with accepted medical practices and access to thorough and current patient information at every point where care is administered. Patient safety initiatives focus on improving patient and physician satisfaction, managing costs, lowering risks, releasing healthier patients, and maintaining a healthier bottom line.
As we construct a system to enhance patient safety, often one brick at a time, we’ve reached the phase where most of the bricks are in place. They range from stand-alone systems such as barcoding, “smart” IV pumps, and other advanced clinical devices with built-in rules and alerts, to more integrated systems such as computerized physician order entry (CPOE) and Web-based systems that transfer patient data among caregivers. What we’ve been lacking is strong mortar — seamless integration of disparate devices and systems — that will link processes and procedures throughout the organization. We’re working on it. For example, early development has begun on electronic health records (EHRs) that accumulate and coordinate clinical data in an accessible and portable way.
As we move beyond implementing technology to the next phase of sophistication, we need to address how “hard” technology interacts with “soft” people and processes. It’s an opportunity to help get the next generation of patient safety off to a successful start. Not surprisingly, many hospitals have discovered that supplementing technology implementation with process-oriented measures can be challenging. In our experience, there are five critical steps that hospital leaders must take to effectively address the issue of patient safety:
Align sponsorship.
True care transformation requires responsive, deep change and broad sponsorship that needs to include clinical as well as executive leaders. Physicians and nurses need to know why their job responsibilities are changing, and that the changes are clinically driven and clinically relevant. They want to know their clinical leadership — not just administrators and IT executives — have determined that their new roles and work processes will improve the way they deliver care to the patient.
Establish governance.
Many hospitals lack agile and effective decision-making. There’s too much decisional inertia, so that targeting challenges is often a matter of ready — aim — aim — aim…. New decision-making models are needed, so that medical personnel don’t wait for monthly committee meetings to remedy issues that should have been taken care of immediately. Another problem is ambiguity of authority. The organizational structure of a medical staff is often characterized by innumerable committees with overlapping and ambiguous responsibilities. There’s a lack of clarity around which committee or combination of committees needs to take charge of patient safety initiatives. A client recently described this situation as having “1000 points of veto.” Moreover, many of these committees are not accustomed to behaving in a businesslike manner with tight agendas, facilitation, or documentation that accelerate and support effective decision-making. Bringing industry expertise, proven decision-making methodologies, and strong facilitation into the committees can dramatically improve their ability to implement and support meaningful change. A good plan is to set up a “quality governance council” that oversees the patient safety process and makes decisions in a timely way that does not micromanage the issues, but ends debating among committees regarding who is responsible for patient safety.
Involve clinicians.
Another good idea is to put together a “physicians governance council” to help oversee the strategy and sequencing of patient safety activities. Even if council members make only minor changes to the project’s work plan, giving physicians and other clinicians a measure of ownership and oversight helps to establish a much more effective process.
Caregivers in general and physicians in particular should be involved with all phases of an advanced clinical system project, from current state and needs assessments to process redesign, to system selection, design, build, and testing. A cautionary example of what happens when clinician involvement is given short shrift was provided recently by a client hospital that invested a great deal of money in a medication administration system. The objective was to reduce medication errors by having nurses scan barcodes on each patient’s bracelet and the medication packets at the time and place of administration. Right idea, wrong implementation. The cart containing the laptop computer, wireless LAN connection, barcode reader, and other equipment was very heavy and cumbersome to wheel around, and difficult to maneuver around obstacles. The nurses quickly developed their own workaround — they’d copy the patients’ bar-coded bracelets and tape them to the administration desk. Then, they could scan all the bracelets and meds at the beginning of each shift, and avoid wheeling their massive “cows” (computers on wheels) around the hospital. When caregivers are working around a system, that is clear evidence of a significant process failure. Many times the major problem is that implementing clinical systems is treated just like any other IT initiative, where clinicians weren’t involved in the choice of technology and don’t understand the value in using it.
Getting and keeping clinician involvement poses challenges. Some physicians are reluctant to admit they make mistakes, or that systems that provide alerts and guides to accepted medical practices will lead to better medical judgments. Motivation and consensus-building are required, and in this regard people must be pulled and not pushed. Enforcement methods or “mandatory” processes can bog down a vital project in an unproductive contest of wills. Far more effective are attractive mechanisms that involve people in the decisions that affect their lives and explain “what’s in if for them,” or put them in categories that include the best and the brightest physicians.
Staff appropriately.
Hospital leaders often commit millions of dollars to complex system implementations, then are surprised to learn that they also have to commit valuable staff, sometimes for a year or more. That can lead to competing priorities for internal resources, so that decision-makers are faced with choosing among cost, functionality, and speed-to-results. Nevertheless, sufficient internal resources must be committed to important implementation projects. Outside resources can complement or supplement internal capabilities, but they do not understand the hospital’s priorities, procedures, and culture. People resources must include the right skill mix. Sufficient staffing is needed all the way through the implementation, from project management, to process redesign, to system implementation and testing.
Measure performance.
Improving patient safety requires collecting and analyzing huge amounts of patient data. As systems are developed, they need to provide the baseline metrics to help hospitals understand how their reporting and detection processes are improving. As the systems evolve, they need to expand their measurements to evaluate progress toward the desired future state.
Don’t let technology replace good clinical practices or sound medical judgment.
Applying cutting-edge technology to antiquated clinical processes does nothing to improve patient safety. Hospital leaders need to be vigilant in making sure that their patient safety processes are current, and that their rules and alerts reflect current medical knowledge. We need to be careful to embrace technology where it can add value, but not to depend on it to replace sound medical judgments. It’s easy to fall into the trap of “technology pacification,” or “automation complacency,” where we expect more of technology than it can deliver. An absence of automated alerts does not equate with patient safety.
Technology, when implemented without carefully examining how it will be used and by whom, can introduce its own set of medical errors. Many hospitals have existing systems in which physicians place medication orders electronically. This eliminates errors caused by illegible handwriting, but if a physician inadvertently clicks in the wrong place, the result may be a perfectly legible order that is no less wrong, and may in fact be more dangerous because there’s no red flag such as illegibility to arouse suspicion as to the validity of the order. Customized order sets and context-sensitive prompts are far preferable to selecting from long lists of medications. Hospitals need to keep such human factors in mind when redesigning clinical processes and building clinical systems.
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The goal of patient safety systems is to reduce the occurrence of adverse medical events. Technology, applied with an understanding of desired outcomes, is vital to that goal. But, we have a few generations to go before we have the mature, intelligent systems that we want. Even then, we’ll still need to be very careful about examining the right metrics, providing relevant training, redesigning our clinical processes, and managing change to be sure that we’re not just creating new ways of committing error at lightning speed.
Brian Shea is a senior manager with Capgemini and a leader of the company’s patient safety initiatives. He has dedicated his career to improving the materials and standards applied by the pharmacy and physician communities to improve patient safety. He was a member of the Harvard ADE Prevention Study Group.
Manuel Lowenhaupt is vice president and leader of Capgemini’s clinical transformation practice. He is internationally noted for his work in clinical effectiveness, care management, and clinical informatics. In his 14 years of consulting, he has worked with more than 120 healthcare organizations in the United States, Canada, Europe, and the Far East.
On April 21 (from Paris), Capgemini announced the sale of its healthcare practice in the U.S. and Canada to Accenture. The transaction is subject to regulatory and other customary approvals and is expected to close within the next 60 to 90 days.