Safer Hospital Care

Strategies for Continuous Quality Innovation, 2nd Edition

Dev Raheja

• Publisher: Productivity Press
• Year: 2019
• ISBN:
  9780429603525
• Edition: 2
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

According to the National Patient Safety Foundation, about 440, 000 deaths from hospital mistakes are expected in 2018. These mistakes are preventable, but the number of deaths has been increasing for the last two decades instead of decreasing. This book describes how to prevent deaths at very low cost and get very high return on investment (ROI).

The unique feature of this book is that it teaches the tools of innovation that anyone can master. It teaches healthcare staff how to manage innovation efficiently and quickly, because each patient life is critical. This second edition points out why the present methods are ineffective and shows how to find elegant solutions that are simple, comprehensive, and produce high return on investments.

The second edition contains all updated material with the addition of a new chapter on systems engineering for robust improvements, a practice that has been applied in most high-risk industries, such as aerospace, defense, and NASA, for years. It aims at redesigning systems to make sure right things, right coordination and right integration happens in healthcare systems.

Chapter 1

The Etiologies of Unsafe Healthcare

Medicine arose out of the primal sympathy of man with man; out of the desire to help those in sorrow, need, and sickness.

—William Osier

Introduction

“Despite some successes, I think it’s safe to say the patient-safety movement also has been a great failure,” said Lucian Leape, the father of the patient-safety movement. “No one to my knowledge has implemented all 34 protocols from the National Quality Forum,” he told thousands of nurse executives who gathered to hear him deliver one of the big-tent speeches at the 43rd Annual Meeting of the American Organization of Nurse Executives, which attracted 2,200 healthcare professionals to the Indianapolis Convention Center April 9–13, 2010 [1].

Inadequate systems, not inadequate people, usually cause accidents. People are only an element in a system, which can be defined as an integration of interfacing and interdependent entities working together to accomplish a mission. It includes facility, environment, all hospital staff, and services, including support personnel, suppliers, patients, families, and equipment.

Human errors are bound to happen in a system of many microsystems, such as a hospital. The physician treats from a list of differential diagnoses. This is the nature of the treatment process where there are conflicting symptoms, multiple symptoms, false-positive and false-negative test results, constant distractions, and insufficient information on the patient history. Even the most conscious safety professionals make mistakes. But this does not mean that errors can be ignored. They must be minimized through robust system designs and individual accountability.

Some errors may be unpreventable, but preventing a mishap is often an option. This is the core message in this book for hospital professionals who must work as a team to produce high return on investment and to deliver safer care.

Even though some progress has been made over the last decade, hospital care still needs a very significant amount of transformation. Would you go to a hospital where there is an excellent surgery department but where several medication errors take place every day? You may be surprised that this actually happens in many medical facilities and is not as rare as one might think. A simple math calculation will illustrate the seriousness. The Institute of Medicine estimated the medication error rate to be between 3% and 5% [2]. A hospital with 600 beds with about five medications per patient administers about 3,000 medications per day. Even with the most conservative estimate of 3% errors, the number of errors works out to be 90 errors per day!

Considering that the average length of stay in U.S. hospitals is between 3 and 4 days, the range of medication errors for this period works out to be between 270 and 360. In other words, nearly half of the available 600 beds could theoretically witness a medication error during an average patient stay. While this is scary and unacceptable, there is some hope. Not all these errors are linked or cause harm or reach the bedside of the patient. This is because some of these errors are intercepted before they reach the bedside, and, in some instances, the human body responds well to antidotes or other medications used to nullify their effect.

To clarify further, these errors are the sum total of all errors, such as in pharmacy (stocking, dilutions, compounding), handoffs (shift changes, doctor changes), prescriptions, intensive care units (surgical, pediatric, neonatal), general care units (oncology, HIV, palliative), emergency departments (EDs), operating room (anesthesia, antibiotics), lab testing, medication administration, electronic health records, and patient discharge. The errors that are not intercepted may result in adverse events.

Equally shocking are several other statistics. A Johns Hopkins research paper [3] shows about 40,000–80,000 patients are misdiagnosed every year. Another study [4] found that diagnostic error accounted for 17% of preventable errors in hospitalized patients, and about 9% of patients experienced a major diagnostic error that went undetected while the patient was alive. The purpose of this book is to explain why such errors happen and how to innovate elegant solutions that address the issues at a system level. Failure in healthcare is not an option.

Failure Is Not an Option

Concern for errors is a universal problem and not just limited to hospitals. Errors happen in aerospace, and even at Toyota car company, which is the world standard for quality. Like aerospace, failure is not an option in hospital care. Errors happen in larger proportions because of complexity of systems of interactions, highly variable conditions, complex handoffs, too many handoffs, very frequent emergencies, and too many opportunities for communication errors. Table 1.1 provides an idea on the rationale for how there are greater chances for errors in hospitals because of the iterative process in decision-making and care delivery. Since there is an intrinsic value in every human being, they can make extraordinary transformations in systems if they work as teams. The most important message that leadership must believe and convey is that when an error occurs, it is a process issue. The leadership must create a system of urgency to fix the process.

An Unconventional Way to Manage Risks

This book will start in an unconventional way. We will first define unsafe work in order to have an appreciation of what is safe work. The premise is that if we stop doing unsafe work, the ideas for safer care will automatically blossom. This is human nature. We will begin with a quote from Professor Harry Frankfurt of Princeton University [5]:

One of the most salient features of our culture is that there is so much bullshit. Everyone knows this. Each of us contributes his share. But we tend to take the situation for granted. Most people are rather confident of their ability to recognize bullshit and to avoid being taken in by it. So the phenomenon has not aroused much deliberate concern, nor attracted much sustained inquiry. In consequence, we have no clear understanding of what bullshit is, why there is so much of it, or what functions it serves. And we lack a conscientiously developed appreciation of what it means to us.

Table 1.1 Why the Chance of Error Is Higher in Hospitals

In my experience of more than 30 years as a consultant to the aerospace, medical device, and healthcare industries, a major source of unsafe work is Frankfurt’s description of bullshit. Again, let us be clear that it is a global phenomenon, and hospitals are simply a participant in the phenomenon. I regret the use of the word bullshit, but nothing else easily conveys the same meaning. The hope is that we will awaken to the wisdom of Harry Frankfurt and avoid huge amounts of inadequate, unsafe, and marginal work.

Defining Unsafe Work

Frankfurt admits that the term “bullshit” is loosely used and offers no clear definition. He offers an excellent example with the intent of what to do about it:

In the old days, craftsmen did not cut corners. They worked carefully, and they took care with every aspect of their work. Every part of the product was considered, and each was designed and made to be exactly as it should be. These craftsmen did not relax their thoughtful self-discipline even with respect to features of their work that would ordinarily not be visible. Although no one will notice if those features were not quite right, the craftsmen would be bothered by their consciences. So nothing was swept under the rug. Or, one might perhaps say, there was no bullshit.

If we accept this notion of craftsmanship as a foundation of safe work, we can say that any work linked to a potential harm to the patient can be an unsafe work if done without sufficient understanding or with an attitude of indifference. The attitude of indifference needs explanation. A driver speeding on a highway knows speeding is unsafe and yet he/she keeps doing it day in and day out. He/she has justification in the interest of efficiency and time. Like most of us, they believe that the chance “it will happen to me” is very small. In addition, he/she has very little guilt, because almost everyone else is doing it. Since an unsafe act is an option on a highway but not in healthcare, I want to make everyone aware of such a phenomenon. Allow me to use a new word “indifferencity” to emphasize the impact of such an act on safe care. It refers to performance without passion or “due concern,” or a performance diligently done in a substandard way. We can then say that any medical intervention done with inadequate knowledge or indifferencity can be unsafe.

Unsafe work can be defined as:

• Performance without adequate knowledge
• Performance with indifferencity

Chapter 3 is devoted to the expansion of the concept of indifferencity. It includes examples and some remedies.

How Unsafe Work Propagates Unknowingly

According to a Gallup poll nationally [6], engaged employees made up only 29% of the workforce (an engaged employee is one who is willing to go the extra mile to help the organization do the right things). The remaining employees were either not engaged (56%) or actively disengaged (15%). Sometimes they are referred to as “warm bodies” that just fill a position. Not engaged and actively disengaged employees tend to be accident prone. A vice president of human resources once said: Hire for attitude and train for skill when you can. With a great attitude you could get the requisite skills but without a great attitude it is hard.

For employees to be engaged, the organization must create interesting and meaningful work, a variety of responsibilities, capable and similarly committed colleagues, and respectful and respected managers who will welcome investment in safety as a business strategy instead of a necessary cost. A system of disengaged employees is a source of unsafe work. Richard Hackman and Greg Oldham in their book Work Redesign proposed a job design model that would motivate workers to be more engaged and improve overall organizational performance. They proposed core dimensions for evaluating the immediate work environment. These core dimensions turned out to be associated significantly with job satisfaction and a high sense of workers’ motivation. The work environment source consisted of five dimensions, namely, those of skill variety, task identity, task significance, autonomy, and feedback. Three key psychological states are produced when you focus on these five job design characteristics. Employees experienced meaningfulness of their work, responsibility for the outcomes of their work, and knowledge of the actual results of their work. These in turn increase the likelihood of positive personal and work outcomes.

Let us make this theory a bit more real with an example. The example here is of...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication Page
• Table of Contents
• Introduction
• Acknowledgement
• Author
• 1 The Etiologies of Unsafe Healthcare
• 2 Sufficient Understanding Is a Prerequisite to Safe Care
• 3 Preventing “Indifferencity” to Enhance Patient Safety
• 4 Continuous Innovation Is Better Than Continuous Improvement
• 5 Innovations Should Start with Incidence Reports
• 6 Doing More with Less Is Innovation
• 7 Reinvent Quality Management
• 8 Reinvent Risk Management
• 9 Human Errors May Be Unpreventable: Preventing Harm Is an Innovation
• 10 Managing Safety: Lessons from Aerospace
• 11 The Paradigm Pioneers
• 12 Protect Patients from Dangers in Medical Devices
• 13 Heuristics for Continuous Innovation
• 14 Aequanimitas—The Best-Known Strategy for Safe Care
• 15 Healthcare Systems Engineering, the Powerful Quality Improvement Tool
• Appendix A: The Swiss Cheese Model
• Index