Monday, November 9, 2020

Setting the Bar for Healthcare: Patient Care Goals from the Joint Commission

Joint Commission HQ
The need for a more effective safety culture (SC) in the field of healthcare is acute: every year tens of thousands of patients are injured or unnecessarily die while in U.S. hospitals. The scope of the problem became widely known known with the publication of “To Err is Human: Building a Safer Health System”* in 2000. This report included two key observations: (1) the cause of the injuries and deaths is not bad people in health care, rather the people are working in bad systems that need to be made safer and (2) legitimate liability concerns discourage the reporting of errors, which means less feedback to the system and less learning from mistakes.

It's 20 years later. Is the healthcare system safer than it was in 2000? Yes. Is safety performance at a satisfactory level? No.

For evidence, we need look no further than a Nov. 18, 2019 blog post** byDr. Mark Chassin, president and CEO of the Joint Commission (JC), the entity responsible for establishing standards for healthcare functions and patient care, and evaluating, accrediting, and certifying healthcare organizations based on their compliance with the standards.

Dr. Chassin summarized the current situation as follows: “The health care industry has directed a substantial amount of time, effort, and resources at solving the problems, and we have seen some progress. That progress has typically occurred one project at a time, with hard-working quality professionals applying a “one-size-fits-all” best practice to address each problem. The resulting improvements have been pretty modest, difficult to sustain, and even more difficult to spread.”

Going forward, he says the industry can make substantial progress by committing to zero harm, overhauling the organizational culture, and utilizing proven process improvement techniques. He singles out the aviation and nuclear power industries for having similar commitments.

But achieving substantial, sustained improvement is a big lift. To get a feel for how big, let's look at the 2020 goals and strategies the JC has established for patient care in hospitals, in other words, where the performance bar is set today.*** We will try to inform your own judgment about their scope and sufficiency by comparing them with corresponding activities in the nuclear power industry.

1. Identify patients correctly by using at least two ways to identify them.

This is a major challenge in a hospital where many patients are entering and leaving the system every day, being transferred to and from different departments, and being treated by multiple individuals who have different roles and ranks, and are treating patients at different levels of intensity for different periods of time. There is really no analogue in the closed, controlled personnel environment of a power plant.

2. Improve staff communication by getting important test results to the right staff person on time.

This should be a familiar challenge to people in any organization, including a power plant, where functions may exist in different organizational silos with their own procedures, vocabulary, and priorities.

3. Use medicines safely by labeling medicines that are not labeled, taking extra care with patients on blood thinners, and managing patients' medicine records for accuracy, completeness, and possible interactions.

This is similar to requirements to accurately label, control, and manage the use of all chemicals used in an industrial facility.

4. Use alarms safely by ensuring that alarms on medical equipment are heard and responded to on time.

In a hospital, it is a problem when multiple alarms are going off at the same time, with differing degrees of urgency for personnel attention and response. In power plants, operators have been known to turn off alarms that are reporting too many false positives. These situations call out for operating and maintenance standards and practices that ensure all activated alarms are valid and deserving of a response.

5. Prevent infection by adhering to Centers for Disease Control or World Health Organization hand cleaning guidelines.

The aim is to keep bad bugs from circulating. Compare this prctice to the myriad procedures, personnel, and equipment dedicated to ensuring nuclear power plant radioactivity is kept in an identified, controlled, and secure environment.

6. Identify patient safety risks by reducing the risk for suicide.

Compare this with the wellness, fitness for duty, and behavioral observation programs at every nuclear power plant.

7. Prevent mistakes in surgery by making sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body, and pausing before the surgery to make sure that a mistake is not being made.

This is similar to tailgate meetings before maintenance activities and using the STAR (Stop-Think-Act-Review) approach before and during work. Think of the potential for error in mirror-image plants; people are bi-lateral but subject to the similar risks.

Our Perspective

The JC's set of goals is thin gruel to show after 20 years. In our view, efforts to date reflect two major shortcomings: a lack of progress in defining and strengthening SC, and a lack of any shared understanding of what the relevant system consists of, how it functions, and how to improve it.

Safety Culture

Our July 31, 2020 post on When We Do Harm by Dr. Danielle Ofri discussed the key attributes for a strong healthcare SC, i.e., one where the probability of errors is much lower than it is today. In Ofri's view, the primary cultural attribute for reducing errors is a willingness of individuals to assume ownership and get the necessary things done, even if it's not in their specific job description, amid a diffusion of responsibility in their task environment. Secondly, all members of the organization, regardless of status, should have the ability (or duty even) to point out problems and errors without fear of retribution. The culture should regard reporting an adverse event as a routine and ordinary task. Third, organizational leaders, including but not limited to senior managers, must encourage criticism, forbid scapegoating, and not allow hierarchy and egos to overrule what is right and true. There should be deference to proven expertise and widely held authority to say “stop” when problems become apparent.

The Healthcare System

The healthcare system includes the providers, the supporting infrastructure, external environmental factors, e.g., regulators and insurance companies, the patients and their families, and all the interrelationships and dynamics between these components. An important dynamic is feedback, where the quality and quantity of output from one component influences performance in other system components. System dynamics create homeostasis, fluctuations, and all levels of performance from superior to failure. Other organizational variables, e.g., management decision-making practices and priorities, and the compensation scheme, provide context for system functioning. For more on system attributes, please see our Oct.9, 2019 post or click the healthcare label.

Bottom line: Compare the JC's efforts with the vast array of safety and SC-related policies, procedures, practices, activities, and dedicated personnel in your workplace. Healthcare has a long way to go.

* Institute of Medicine (L.T. Kohn et al), “To Err Is Human: Building a Safer Health System” (Washington, D.C.: The National Academies Press) 2000. Retrieved Nov. 5, 2020.

** M. Chassin, “To Err is Human: The Next 20 Years,” blog post (Nov. 18, 2019).  Retrieved Nov. 1, 2020.

*** The Joint Commission, “2020Hospital National Patient Safety Goals,” simplified version (July, 2020). Retrieved Nov. 1, 2020.

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