The Center for Patient Safety (CPS) is excited about our new report being released this week: Healthcare Forward. While CPS began in 2005 with a focus on patient safety efforts in hospitals, our services have since expanded across the continuum of care and the new report highlights safety issues observed, not just in hospitals, but in all areas of healthcare. CPS works tirelessly to reduce preventable harm through services and programs designed to collect information around adverse events, near misses and unsafe conditions. CPS reviews contributing factors with the end goal of helping organizations provide safer, high quality care for their patients. It is based on the review of this information, combined with our expertise in the field and ongoing research in the industry, that the information in this campaign is prepared.
Healthcare is aiming for the goal of becoming a high reliability organization. The challenge for healthcare is meeting specific outcome measurements for reimbursement while continually evaluating processes. However, if healthcare is to continually provide high quality, safe, patient care across the continuum of care, the challenge must be met! The process of driving healthcare forward as a high reliability organization or business encompasses five steps. First; to be sensitive to operations (understand processes). Second; to be reluctant to accept the first explanation for an adverse events. Third; to have a preoccupation with failures. Fourth; to defer to expertise and lastly to show resilience.
Another ideal healthcare need is to hardwire the idea that patient safety isn’t a concept that should be boxed into hospital or inpatient care. Rather, patient safety should be a priority across the continuum. Patient safety should start with the patient’s home and their own health literacy and be an integrated value of all healthcare providers from hospitals, to medical offices, long term care facilities, home care providers and EMS.
Support and care for healthcare providers is another foundational component that many healthcare organizations have been missing for many years. Healthcare is looking at a current shortage of both nurses and physicians. Burnout is very real. To keep skilled professionals in healthcare organizations need to have processes and programs in place to support a provider if an error occurs that harms a patient.
Organizations also need to ensure that appropriate support and systems are in place for healthcare providers if/when they are subjected to violence in the workplace. Being the target of verbal/physical abuse or harassment should not be considered “part of the job”.
This new CPS campaign looks at how patient safety is integrated across the continuum of care. It focuses on the components that can move Healthcare Forward, principles such as communication, organizational culture, and leadership. It doesn’t matter what area of healthcare a provider works, all three components are required to move the needle in regards to patient safety. First, leaders set the example through their actions. Second, communication should be open, shared and verified; and lastly, a strong patient safety culture encourages open discussion regarding adverse events, near misses and unsafe conditions.
The new report highlights five different patient care topics and these principles play into the different topics. These topics include health literacy, opioid safety, medication reconciliation, respiratory compromise, and transition of care. Each topic includes case scenarios from different healthcare arenas and offers questions for leaders and employees of organizations to ask themselves in regards to their policies and processes. The report also contains two areas of support for healthcare providers: second victims and violence against healthcare workers. These topics also contain scenarios, but more importantly the questions posed provide a starting point for healthcare organizations to begin putting into place programs to support and retain their staff.
Patient safety isn’t isolated to inpatient care, it’s a fundamental concept of patient care and a right of every single patient. Safety is also a core component for healthcare providers. To retain qualified staff and attract new staff, organizations need to have the systems and processes in place that also support their employees. Our hope is that this report will help bring not only the fundamentals of patient safety to the forefront in all healthcare arenas, but especially the concept of a strong patient safety culture.