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By: Donna M. Prosser, DNP, RN, NE-BC, FACHE, BCPA, chief clinical officer at the Patient Safety Movement Foundation
Millions of Americans are harmed each year because of a preventable medical error, but most of these errors do not have to be reported so it is hard to determine the true impact. One study from the Journal of Patient Safetyestimated that medical harm costs the U.S. $19.8 billion annually on unnecessary medical expenses and lost productivity, but the financial burden is likely far higher.
Luckily, most medical harm is preventable, and the healthcare industry has spent the past two decades working to improve patient safety. Yet, there is still a great deal of work to do to create safe systems for patients and health workers. Unfortunately, most healthcare systems have not made a true commitment to become the highly reliable organizations needed to provide safer care. Highly reliable organizations, typically found in high-risk industries like aviation and nuclear power, are focused on anticipating problems before they occur to prevent errors. For health care systems, this means having the processes in place to operate for extended periods of time without error. Becoming highly reliable does not happen overnight and requires a preoccupation with safety and robust improvement systems that can address issues quickly.
Why the healthcare industry has not adopted high reliability operations
Many healthcare leaders do not realize that harm is occurring in their organizations This lack of visibility occurs for a few reasons. First, organizations tend to focus on the good data and the heartwarming success stories. Compounding this issue, reporting medical errors is not consistent and so it is hard to accurately determine how many errors nearly or actually occurred. Even more so, it can be difficult to understand how harm could occur in their organization as most health systems view their processes internally versus experience the care environment from the patient and family perspective.
How harm can financially impact a health system
Some reports have estimated that preventable medical harm costs an average of $8,000 per hospital admission or roughly 8.7 percent of total budget costs. Not only do medical errors impact a patient, but health system reimbursements hinge on performance metrics. Therefore, leaders point to improving quality and patient satisfaction scores as proof that they are safe, yet last year in the U.S., 774 hospitals were penalized by Medicare for not meeting expected quality targets. This resulted in the federal government pulling one percent of their Medicare payments over the next 12 months. Since 60 percent of most hospital revenue comes from Medicare and Medicaid, this is a significant loss for most.
Shifting to high reliability to save lives and dollars
The best way to avoid economic loss is to create highly reliable systems in healthcare. If healthcare were required to be as safe and reliable as the nuclear power and aviation industries, it could save hundreds of thousands of lives and billions of dollars each year. This does, however, require a shift in the way we think about the delivery of healthcare and requires organizations to embrace the following concepts:
- Ensure that safety is the number one priority. Understand and anticipate the safety risks for everyone in the organization, including patients, families, clinicians, staff, visitors and others. This requires an open culture of transparency and honesty in data reporting. An environment of “blame and shame” has no place in these organizations.
- Provide true patient-centered care. Involving patients and families as active, equal members of the care team is one of the best ways to improve care coordination and reduce the risk of harm. Engaging patients and families to participate in improvement work is also a great way to identify gaps that those too close to the process may not be able to see.
- Establish a culture of continuous improvement. Apply a standardized, conceptual framework for improvement, such as Plan-Do-Study-Act (PDSA) or data-driven improvement cycle (DMAIC), across the organization while also allowing flexibility in the utilization of process improvement tools and the management of internal group dynamics. Communicate all ongoing improvement work routinely so that the right hand knows what the left hand is improving, and teams are not competing for limited resources.
- Grow clinical leaders who can effectively manage and sustain change. Sustaining hard won change is one of the most difficult things for today’s leaders to accomplish. Robust leadership development programs that focus on understanding human factors and how this impacts sustainment are critical in organizations trying to become highly reliable.
Healthcare organizations that invest in creating highly reliable systems have found:
- Improved efficiency reduces overall costs and increases both staff and patient satisfaction.
- Increased patient satisfaction and quality scores result in increased Medicare reimbursement and reduced penalties.
- Increased staff satisfaction reduces turnover and vacancy rates, resulting in significant recruitment and onboarding savings.
- Implementing best practice protocols while also focusing on sustainment and education reduces error rates.
- Disclosing errors honestly and openly to patients and families reduces risk management claims and settlements.
While the time and financial investment to make the organizational changes needed might seem steep, there are many tools and resources available free of cost to health systems. Change doesn’t happen overnight but making the investment now to become highly reliable is not only good for your bottom line but also can save lives.
About the author: Donna Prosser, DNP, RN, NE-BC, FACHE, BCPA, is the chief clinical officer at the Patient Safety Movement Foundation. The Patient Safety Movement Foundation is a global non-profit with a vision to eliminate preventable patient harm and death across the globe by 2030. It provides free Actionable Patient Safety Solutions and coaching to help health systems improve their care.
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