- When a patient visits a hospital, she has the expectation that she will be treated with empathy, respect, and clinical excellence. At the core of each of these elements is the understanding that she will be safe. But all too often, the promise of patient safety isn’t upheld.
Adverse patient safety events and medical errors are the third leading cause of death in the United States, according to a 2016 report in the British Medical Journal. A separate 2017 survey from NORC at the University of Chicago and the IHI/NPSF Lucian Leape Institute found that 21 percent of patients experience a medical error.
To be fair, the US has seen a decline in adverse patient safety events in recent years. A 2016 report from HHS and the Agency for Healthcare Research and Quality (AHRQ) showed that between 2010 to 2015, approximately 125,000 fewer patients died due to avoidable hospital-acquired conditions than in years previous.
But just because fewer patients are experiencing preventable patient safety events does not mean that the job is done, according to Gary Yates, MD, a strategic consulting partner at Press Ganey and patient safety expert. Healthcare organizations must strive for zero preventable patient safety events because patient safety is a foundational element of a positive patient experience.
“Patient safety is fundamental to the promise we make to patients,” Yates told PatientEngagementHIT.com in an interview. “We like to think of the patient experience as being the convergence of quality, safety, and the experience of care.”
“When patients come for care, they expect that harm won't come to themselves or their loved one,” Yates continued. “They expect us to deliver the highest technical quality care, and they also expect us to treat them with dignity and respect, and that care givers will approach them with empathy and understanding. Safety is a fundamental component of the overall patient experience.”
In fact, patient safety is so important that it tends to take up most of patient mindshare. Even when a health system delivers technically excellent and emotionally supportive care, one preventable harm can mar the entire patient experience. The patient will likely not remember any of the positive qualities of the healthcare encounter.
Healthcare organizations must set patient safety as a top priority. This will require an all-in commitment across hospital leadership and staff, Yates said.
“In order to prevent harm, in order to really make progress towards the goal of zero harm for patients, it requires an organizational commitment,” he explained. “That commitment includes a tightly aligned board, senior operational leaders, and senior physician leaders, all committing to what some would consider an audacious goal, but the right goal, which is a goal of zero harm to patients.”
That strong leadership, paired with a culture of safety, can help deliver on the goal to eradicate preventable patient harms, Yates said. Once organization leadership has bought into the goal of true patient safety, it is important that they include patients in obtaining that goal. After all, patients have a significant role to play in supporting patient safety efforts.
“The organization needs to invite patients and families into the conversation to help create an environment where they can truly be partners,” Yates stated. “Organizations can provide education on ways that patients can participate and encourage them to speak up, understanding that some patients and families may be reticent to speak up or ask questions to providers.”
Healthcare organizations are inviting patients and families to serve on patient advisory councils (PACs) more and more, Yates sad. Patient and family stakeholders are also being asked to sit on operational committees and some board committees. This is an essential part of integrating the patient voice into hospital improvement efforts.
Although patient and family advisory councils are becoming increasingly common in healthcare, there are some hospitals that have not jumped on board.
“Some hospitals and health systems are still reticent to robustly include the voice of the patient,” Yates pointed out. “There may be concerns that input from the patients might be a distraction for the organization. There may be concerns about confidentiality. There may be concerns just because it's a change.”
However, those hospitals participating in PACs outweigh those who may be excluding patient sentiment. The insurgence of PACs in clinical and organization improvement are setting a good example for hospitals just beginning to consult the patient voice.
“The good news is that there are organizations that have successfully implemented initiatives such as patient advisory committees and are continuing to push the envelope,” Yates asserted. “There's a wealth of experience in how to select patients and families for participation on operational and board committees, how to vet potential members, and how to onboard and educate them so that they are effective in their role and the organization's comfortable with their role.”
Having a patient in the room is essential for changing the culture of safety. Healthcare organizations cannot properly serve the patient if leadership does not know how the patient wants to be served and which processes could best bring comfort to the patient. Understanding how patients and families need to see patient safety initiatives implemented is key to making programs successful.
“The conversation is just different when a patient is in the room,” Yates noted, quoting his peer Jim Conway, who previously served as the COO of Dana-Farber Cancer Institute.
Incorporating the patient into patient safety initiative goes beyond organizational improvements. Clinicians themselves need to be more inviting and allow the patient to participate in their own care. A patient who is engaged in care can serve as another check on patient safety protocol. This relationship works best when the patient is empowered to participate in care.
“One of the challenges to creating a true culture of safety in healthcare is dealing with the hierarchy gradient,” Yates said. “A hierarchy gradient exists when, in any relationship, one individual perceives themselves to be in a lower position of power than another individual. When the power gradient is large, then it's unlikely that the person who perceives themselves as being on the lower end will be willing to speak up.”
Patients often perceive themselves on the lower end of that hierarchy gradient, and healthcare organizations are working to change that. The same strategies organizations employ to create clinical teamwork – communication, care coordination – can help integrate the patient as a part of that care team, Yates said.
The onus is on the clinicians to create a welcoming environment in which a patient feels she can participate in her own care and her own safety.
It could be difficult for a patient to ask a provider if he’s washed his hands before an exam. Clinical team members need to create a culture that gives the patient the confidence to do so.
How a care team interacts with the patient, greets her, demonstrates empathy, invites her to ask questions, or invites her to comment on aspects of clinical care are all important things to do, Yates said.
Healthcare organizations can also use various signage to reinforce that notion.
Ultimately, the provider needs to reach out to the patient and incorporate her into the care them. Clinicians who educate their patients, give them context to participate in clinical decisions, and treat their patients as members of the care team will help create a culture of health.
“One of the best ways to manage the authority gradient and minimize power distance is when the party that's perceived as being in the higher power position invites others to participate and welcomes questions,” Yates explained. “It helps to set the tone and helps to create an environment where individuals are more likely to contribute.”
Although organizations should be working toward zero preventable patient harms, there will be missteps along the way, Yates acknowledged. Most healthcare organizations see some adverse patient safety events annually. The key is understanding how to interact with the patient following one of those adverse events.
“It's important for hospitals and health systems to do a good job with disclosure and apologize as appropriate,” Yates advised. “Establishing an atmosphere where we're transparent with patients when things go wrong is critical.”
Transparency is not only important for engaging patients and doing right by them when something does go wrong; it’s also important for the purposes of overhauling the culture of safety, Yates said. Being apologetic when appropriate is important for the patient-provider relationship and also important for clinical quality improvement.
“It allows for us to engage patients in helping us understand how we can improve going forward,” Yates concluded. “Being honest with the patient about what happened, apologizing as appropriate, and communicating with them about actions that are taken helps to assure patients that the underlying causes of what might have affected that patient or her loved ones is something that the organization is addressing to prevent it from happening to another patient.”