Management guru Peter Drucker once said, "You can't manage what you don't measure." This idea is all too familiar to hospitals, especially in their patient safety improvement efforts. Unfortunately, undermeasurement of patient harm is common for U.S. hospitals.
In part two of a two-part series on all-cause harm, Becker's Healthcare caught up with Stan Pestotnik, MS, RPh, senior vice president of product development for Salt Lake City-based Health Catalyst, to learn about what hospitals can expect once they mitigate the discrepancy in all-cause harm reporting.
Editor's note: Responses have been lightly edited for length and style.
Question: If an organization improves its ability to identify and report patient harm, are there any repercussions it should expect?
Stan Pestotnik: If we parse this out, there are probably internal repercussions and a potential external repercussion.
Externally, it is well recognized by regulatory agencies — in this case CMS and AHRQ — that U.S. hospitals are not doing a good job of detecting and reporting all the harm occurring with their patient populations; the patients they serve.
Several years ago, the HHS' Office of Inspector General released a report for CMS that outlined this very thing and focused attention to the fact that hospitals primarily use a voluntary reporting-based method to report harm. When compared to an automated approach of reporting, the OIG estimates only 14 percent of actual harm occurring in healthcare clinical settings is reported. The OIG's challenge to the industry was to look to other methods — other than voluntary reporting — to report harm. This report and other studies raised attention toward the concepts of All Cause Harm detection, intervention and prevention.
Health Catalyst developed a system to help clinicians automatically detect harm and understand the causes of that harm, which provides organizations with a holistic view of the magnitude and nature of the harm occurring in work settings. We then combine that with the voluntary data hospitals have, which gives us a broader view of all-cause harm. If a hospital or organization starts to put these recommended approaches in place, they won't immediately see repercussions from CMS in penalties. I think as long as organizations are forthright with regulators that they have put these systems in place and are using more robust data to inform care and doing something about the processes leading to those harms — learning from the harm and thus preventing future harm — regulators will be understanding.
Internal repercussions are where people tend to freak out over increased rates of harm. From board of directors on down, people grow very comfortable with existing reporting systems. When you put technology or other methods in place that provide more comprehensive surveillance and detection, rates naturally go up and people start to panic. But they need to remember that they were not previously detecting all of their harm — which is why they came to Health Catalyst, to help gain visibility to their true harm rates and put strategies for improvement into clinical practice.
Once we help a health system understand that, we can begin as partners on identifying and implementing methods to improve the quality and safety of care delivered. It sounds like a straightforward message, but people need education, so they understand that they should expect this. If we find the same level of harm, that's good, but nine times out of 10 the health system will find more harm than they're reporting.
Q: How can hospital/health system leaders sustain attention toward patient harm on an ongoing versus episodic basis?
SP: This is all around the culture of an organization. There's lots of work done by experts in understanding the culture of safety. It is fascinating to me that the whole idea of a culture of safety started in the gas and oil industry back in late 1950s, early 1960s. At that time, they were drilling in the ocean, seeing all these accidents happening and trying to understand what was going on. Industry experts developed the concept term of a socio-technical approach to safety. Since the 1970s, that approach has been brought into the nuclear power industry, aviation/space exploration and now into healthcare.
One key part of culture is leadership. There is a whole science around how you assess the cultural health and safety of an organization, and it begins with hospital or health system leadership. If we cannot engage leadership and influence a safety culture throughout the organization, that is when you see organizations only look at episodic harm or whatever is the latest fad or regulatory measure. Leadership is a very important element in the world of safety.
Q: What types of investments, resources or capabilities must organizations obtain to improve patient harm identification and reporting?
SP: One way to think about making an investment is to envision three concentric circles — process, technology and culture. They all must work together and must be addressed concurrently to truly improve harm identification, intervention and prevention.
One way to invest in culture is through tools that CMS makes available to measure cultural attributes and the culture of safety in an organization. Almost every healthcare institution in this country completes those surveys with the entire employee base, and they have scores reflecting the cultural performance/understanding of safety all the way down to individual unit or service lines.
I always ask senior leaders whether they complete safety culture assessments for their organizations and if they do them every year or every two years. Then I ask them what they do with the data, since scores on attitudes of safety are correlated to a variety of clinical outcomes, employee turnover and employee dissatisfaction. That's when leaders get really surprised. We need to look at those scores and understand them at a unit level. Then, as we put in systems to identify harm, we need to track cultural attributes and simultaneously work to improve them as we better detect harm, so we can put meaningful improvements in place.
Q: For leaders, what is the "wrong" way to think about patient harm?
SP: One of the major wrong ways is a blame culture. People can focus on errors and blame others — you made this error and it led to some harm we are now responsible for. A lot of leaders have been in that frame of reference, and it creates a poisonous culture — more accurately described as a lack of psychological safety.
There needs to be psychological safety within an organization that encourages and welcomes folks speaking up regarding error, harm, etc. If your leadership is focused on blame, it will have a culture where people don't feel safe speaking up.
People go into healthcare because they are dedicated, smart and want to help others. They don't go to work every day with the intention of harming people, but they work in a very fragmented system. People want to go to work and do the right thing, yet many times they don't know what the right thing is. Data is siloed, leadership is siloed, best practices are siloed. We have working environments fraught with all kinds of land mines for them to make mistakes and errors that lead to harm. Effective leaders understand that and work diligently to knock those silos down. The data shows overwhelmingly that defragmented units have less harm and happier patients, happier employees, less turnover of workers, and less burnout as opposed to units that are fragmented with blame cultures.
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