The Reality Shock
The new Health Grades report, "Patient Safety in American Hospitals" (Internet release; July, 2004), tells us that the hospital mortality rate from avoidable untoward events has doubled from 98,000 to 195,000 per year in the last five years. What's more astounding is that the authors indicate that their numbers may be grossly understated. Additionally, the report provides a few disturbing details:
The patient safety incident rate is about 3% of all hospitalizations (based on numbers tracked from 2000 through 2002);
The most common cause of preventable hospital deaths and catastrophic injuries are failure to rescue, pressure ulcers and post operative infections accounting for almost 60% of all patient safety incidents (PSI);
Teaching hospitals are more dangerous than non-teaching hospitals;
Medical patients are at higher risk of becoming victims of PSI's than surgery patients;
Virtually every hospital in the country is causing an average of 2 deaths per 1,000 admissions;
Although there are added costs for higher insurance premiums and legal defense, hospitals receive additional revenue as a direct result of their mistakes.
This information is now all over the media and we in the health care industry are dumbfounded. It's like waiting to breathe after getting the wind knocked out of your lungs. We have yet to witness the backlash with the onslaught of public outcry that is likely to follow.
The Current System - Observation and Punishment
While we are reeling, we need to quickly gather our wits and start figuring out how to reverse this terrible trend. Obviously, the traditional methods of clinical supervision i.e. observation and punishment have failed. The chain of command is ineffective because top executives simply cannot micromanage a hospital containing hundreds of autonomous health professionals moving continuously in every direction. For example, who has time to follow people around to see if they are washing their hands between patients or using the correct technique for needle and catheter insertions? Therefore, in the current system, notwithstanding the vast resources being spent on in-service classes, clinical overseers move from one incident report to another, meting out the appropriate penalty with reprimand (conferencing to be more politically correct), suspension or outright termination.
No Big Surprise
In truth, the new figures should not have surprised anyone because there was merely the appearance of change rather than an alteration in the reality of everyday hospital life. However, since most of us live in a commingled reality (what happens mixed up with what we would like to believe) the general consensus until last week was that most hospital leaders are responsible people who were dealing effectively with improving patient safety.
The response to the famous Institute of Medicine (IOM) report of 1999 was a flurry of activity - countless patient safety conferences, the proliferation of new organizations and the appointment of safety officers in hospitals across the country. Moreover, many health care leaders publicly expressed grave concern and a few even made an appreciable difference in their respective domains. Nevertheless, regardless of the political rhetoric, sleight of hand and sincere effort on the part of a few, the results across the board shriek failure. The report cards reveal that a huge breakdown has occurred that is just beginning to find its way into the public eye.
From Breakdown to Breakthrough - From Powerless to Powerful
On the other hand, at the end of every community breakdown there is a breakthrough waiting to happen if the leaders can recognize the need for transformation. To begin the process one needs merely to identify what's missing. Regarding our life-threatening problem, there is one essential element mislaid in the process of attempting to minimize catastrophic and deadly mistakes - empowerment. To clarify, the widespread substandard performance laid out in the Health Grades report reflects helplessness on the part of patient and provider.
For example, let's say that the patient safety officer identifies a high risk situation resulting in unexpected complications like internal bleeding, collapsed lung or infection and while working exclusively with staff, withholds the information from patients and family members. Consequently, the consumers remain powerless in their inability to recognize potential mistakes due to information deprivation, while the facility operates under the inherently feeble veil of secrecy motivated by fear of litigation. Hence, the patients continue to place their blind faith in hospital personnel who are mistrustful of them. Thus, we learn from this distinction that by empowering both the customers and care givers we can prevent most common mistakes and save hundreds of thousands of lives every year.
Evaluation, Education and Clinical Transformation
The process by which we can achieve the new empowerment is threefold:
Evaluation;
Education;
Clinical transformation.
First, we make an assessment of the different areas of the hospital for conditions that are mistake or accident prone. One example might be trauma occurring in the operating room when transferring patients from the table to the recovery room bed. Often the "heave-ho on three" method results in the patient being jostled and causes cauterized vessels to pop open resulting in dangerous internal hemorrhage.
Second, we educate the hospital staff as to the root causes of the known common errors and mishaps and share the same information with patients and/or family members. In the operating room example we would conduct classes to explore the dynamics of traumatic transfer and the delicate condition of people who had just undergone major surgery. Then we would have the nurses explain this to every patient who is scheduled for surgery during the pre-operative conference.
Third, we would empower staff and management to make changes in clinical and operational methodology. In our above hypothetical, we would recommend the use of an traumatic transfer device such as the Hoyer lift to move all post operative patients from the operating table to the gurney.
Conclusion:
The hospital industry has reached critical mass and is on the verge of implosion. The Health Grades report has clearly shown that all the conferences, meetings and lip services were not only ineffectual, but caused further deterioration to the extent that the number of lives unnecessarily lost is twice what most people thought. This means that for the last five years hospital decision makers have been touting their dedication to patient safety while no one was checking the results to discover that the quality of their care was in a tail spin ready to crash and burn.
While some executives knowingly perpetrated a charade, most, in my humble opinion simply harbored the naïve belief that a leader can improve quality of care by admonishing their department heads to pay more attention to patient safety issues. In other words, there was an across-the-board attempt to effect change without transformation and that is never going to happen. Additionally, the public failed to heed the Institute of Medicine warnings of 1999 and continued, for the most part, to place blind trust in the health care system. Put another way, the people they trusted could not trust them - a case of the feeble (suspicious providers) administering to the powerless (trusting consumers).
Now that the truth about the over-all dismal hospital performance is uncovered, hospital executives need to take immediate initiative and bring in consultants who will empower people for transformation. The right consultants will be able to speak to the listening of the hospital staff members and avoid making them wrong. Thus the front-line staff people will be empowered to accept responsibility for their actions and take a stand for patient safety. Accordingly, based on the respective frequencies of the various types of PSI's noted in the study, the logical initial focus of clinical transformation must be on all of the following:
Increasing the intensity of monitoring vital signs;
Relieving body pressure;
Improving wound healing promotion methods;
Enforcing meticulous hand washing between patients;
Maintaining sterile technique for post operative wound care;
Increasing the intensity of monitoring patients' activities.
This would truly be a major intervention for prevention!
Thomas A. Sharon, R.N., M. P. H. (Surfside, FL) became a registered nurse in 1977 and earned his masters in public health degree from New York Medical College in 1988. He has had vast experience in a variety of hospitals as a staff nurse, nursing supervisor and operational consultant He has also worked for a managed care organization as vice president for medical operations. For the past 18 years he has also been a legal consultant, advising attorneys on hundreds of cases in which hospitals have been accused of preventable errors.
Phone: 305-866-2858
Cell: 305-766-4805
This post was made using the Auto Blogging Software from WebMagnates.org This line will not appear when posts are made after activating the software to full version.
No comments:
Post a Comment