Much attention has been paid to safety in the hospital. Now it’s time to scrutinize physician offices as well.
Jennifer Lenoci-Edwards
Most healthcare professionals could easily provide examples of harm events in hospitals, including wrong-side surgeries, medication errors, falls, and pressure ulcers, writes Jennifer Lenoci-Edwards, patient safety director, Institute for Healthcare Improvement, in a recent IHI blog. On the other hand, listing the types of harms that happen in primary care offices – e.g., the failure to close the loop on the most serious referrals, such as patients referred for diabetes or cancer – may prove more challenging, because they are more subtle and camouflaged in daily routines, she says.
Examples include delayed diagnosis because of poor test or referral management, treatment or diagnostics that don’t follow evidence-based protocols, and omitted or inadequate medication reconciliation. Not fully understanding a patient’s needs and the barriers to their best health can also harm patients. Sometimes the results of unintended harm to patients in primary care don’t appear for years, but that doesn’t make this issue any less urgent, says Lenoci-Edwards.
Repertoire recently asked Lenoci-Edwards to share her views on patient safety in the primary care setting.
Repertoire: Please explain IHI’s Patient Safety Focus Area. What is its mission?
Jennifer Lenoci-Edwards: IHI is comprised of a small staff of dedicated people (approximately 130), a concept we call “one IHI,” and a big mission – to improve health and healthcare worldwide. For more than 25 years, we have partnered with organizations, communities, leaders, and front-line practitioners around the globe to spark bold ways to improve the health of individuals and populations. Through our initiatives, we change mindsets and teach frontline providers and managers the skills they need to enact system-level improvements that result in better care, better health, and lower costs.
IHI is organized around five Focus Areas: Patient Safety, Improvement Capability, Triple Aim, Patient and Family-Centered Care, and Quality Safety and Value. The focus areas, many of which overlap with one another, are mechanisms to help us organize our resources and efforts.
IHI is well-known for helping organizations improve safety in the acute care setting. Over the years, the principles and best practices have increasingly applied across the continuum of care to encompass ambulatory settings and office practices, skilled nursing facilities (including long-term-care residences) and home health. IHI believes that patients should be free from harm in any healthcare setting, and healthcare staff in any setting should have the tools to improve their environments to provide defect-free and person-centered care.
The core of our work in patient safety is IHI’s Framework for Clinical Excellence, created by key leaders at IHI. These include all the key components that need to be present for safety in any setting.
Repertoire: In your blog, you make the statement: “Safety doesn’t mean the same thing in primary care as it does in hospitals.” Can you elaborate on that?
Lenoci-Edwards: Here are some key things we have heard from healthcare providers in primary care:
- “The materials around patient safety do not apply to the work I do.” In a recent focus group we conducted, one participant recounted an attempt to do some training with their clinic around teamwork. The video used in the teamwork demonstration showed a team performing resuscitation on a patient. This physician said her team discounted the training because they didn’t see how the concepts applied to the outpatient setting. “Our patients don’t code, and our team said this does not apply to us,” said the physician lead. From IHI’s perspective, there are some great tools out there, but the bulk of our safety tools have been built for the acute care space.
- If you ask team members in primary care what patient safety concerns they have, they either say they don’t have any, or they have processes in place to address any potential gaps – even though, in some situations, the processes needed to close all the gaps are not fully realized. That is what I identified in my example from the blog: The pediatric practice recognized the importance of tracking referrals, but the intention for safety was not fully elucidated.
- “The metrics for safety don’t apply outside of the hospital or a procedural area.” Catheter-associated urinary tract infections, ventilator-associated pneumonias, and infection rates – these are all safety metrics, but they don’t resonate outside of the hospital.
- Safety metrics that do resonate, like closed-loop test results or referrals and access issues, are not easily extractable from current EMRs; and practices are so busy managing the full care of their patients, that if the data are not easy to retrieve and actionable, no one is utilizing the data or assessing it.
For these reasons, patient safety concepts and training and methods for getting at information to reveal gaps and harm need to be modified and made more relevant and actionable for non-hospital settings.
Repertoire: In “Six recommended ways to make primary care safer” from your blog, you seem to focus on processes more than specific practices or incidents. Would you say that’s a fair statement? And if so, is that a departure from conventional thinking about patient safety?
Lenoci-Edwards: I don’t think of it as a departure, but instead as an addition. As a clinician, I want to know what I can do today to address the safety of my patients. To date, great thinkers have evaluated the numerous system challenges contributing to preventable harms, such as weak IT, lack of leadership commitment, insufficient teamwork and patients not fully activated to commit to their own safety. As a clinician, I can’t wait for these systemwide problems to be resolved. We think that clinicians may want to fix the low-hanging fruit that is in their control, engage their teams and patients so that they can provide the safest care to their patients.
Lastly, I would say these process items are easily measured, and although we cannot make a firm association of the reliability of these processes to patient safety, we can assume that if we follow up on such things as the worrisome referral and make sure the patient sees the specialist, we are closing a patient safety gap.
Repertoire: How equipped is the typical physician practice to implement the six recommended ways? They seem to demand a lot of coordination, man-hours, etc. How can the practice institute these recommendations without taking on significantly higher costs?
Lenoci-Edwards: This is a great question. In my nursing career, I never learned about Quality Improvement. Staff and colleagues tended to take the shortest route to solving problems, deciding on a solution that would improve the latest defect, and assuming every team member would buy in. This approach was rarely sustained.
I know that many medical schools and allied health programs are now starting to embed the science of improvement in their curricula, and that is great. I believe that application of these tenets of improvement will increase the uptake and increase the chance of the concepts “sticking.” We don’t want the science of improvement to be another course that gets shelved once the semester is done.
If we could easily measure the financial impact of work-arounds, re-work, and turnover due to disempowered staff, we might see the financials that make the time to improve worthwhile. In addition, the empowerment of improvement also provides resilience for the team members. Knowing that you can identify a problem and have a shot at improving that for your team and the patient has some potential impact on employee turnover and the overall culture of your practice.
Repertoire: Reimbursement on the inpatient side penalizes hospitals for so-called “never” events. Do similar incentives/penalties – intended to promote safety – exist on the ambulatory care side, specifically, physician practices? If so, what effect are they having on patient safety in that setting? And if not, do you foresee a time when this could occur?
Lenoci-Edwards: Not that I am aware, but now with ACOs and the growth of bundled payments across entire episodes of care, we will start to see greater emphasis on the primary care and post-acute setting.
Repertoire: Who in the office should take primary responsibility for safety? Should there be a leader for this effort? And if so, who should it be?
Lenoci-Edwards: That is a question that we recently discussed with an expert panel. We are thinking that there should be multidisciplinary leaders at the clinic who walk the talk, provide support and make teams accountable for simple measures of improvement in quality, safety and patient engagement.