Hospitals are continuously bombarded with safety regulations by a number of agencies (TJC, JCAHO, etc.) put in place to improve preventable errors and death. While the focus on a safety culture is continuously increasing, important safety numbers have stagnated, not improving in a decade of time.
The time, effort and cost invested by safety and regulatory organizations is huge and their impact on hospital quality improvement efforts are direct and very influential.
It is widely accepted that the rate of preventable deaths is at least 100,000 annually.
It is also agreed that this rate has not declined in the past decade, which is astounding given the intensity and cost of quality improvement. This represents an ongoing rate of 40,000 preventable errors daily.
This should raise the question of the effectiveness of current efforts given the size, scope and cost of the organizations heading efforts.
Additionally consider that we are ranked 51st in the world for life expectancy at birth (Yes, some will argue it’s because of cultural factors. But 51st - really!?) and, of course, for healthcare cost, we rank #1. We spend nearly 50% more than any other developed nation on healthcare.
Most hospital staff continues to confuse regulatory compliance with safety and quality improvement. This is largely caused by the major regulatory compliance organizations also pushing very hard under the mantle of safety and quality improvement.
Until we can disconnect regulatory compliance completely from the improvement of care effort, there is a strong case to say any meaningful improvement is unlikely to be made and sustained.
This idea is strongly supported when it is understood that a hospital, when out of regulatory compliance for a process error, simply needs to produce evidence that it is conducting that process with 90% accuracy to be back in compliance from a regulatory perspective.
Comparatively, airlines would accept that pilots check that the fuel tank is full nine out of ten times prior to take off. This doesn’t mean that regulatory compliance checks are not important or beneficial, simply that regulatory compliance checks should be a byproduct of an improvement effort, not the destination.
Hospitals continue to ignore the basic requirement of any effective improvement process or platform. Where the airline industry adopts checklists as a standard way of conducting daily operations, hospitals at all levels conduct checklists only when there is time, and usually there is not time.
Ignoring this fundamental “basic” for high reliability leaves most hospitals working hard at improvement without the basic tool in place that is needed to drive improvement. Getting to basics requires the tools and the cultural commitment to improvement.
Ask any quality manager to tell you the agencies that they need to respond to and they will reel off a stunning list of external agencies that are consistently evaluating hospital performance. Keep in mind that time spent preparing for, accompanying and responding to external agencies is time that is not devoted to improvement.
Unlikely as it sounds, to people from outside of healthcare, there are many examples of different agencies evaluating the same item with different rules, compelling the onsite quality team to implement, support and report the same item differently to a variety of agencies.
The breadth and depth of technology deployed in hospitals is immense. Not a day goes by when hospital management is not being forced to evaluate yet another “breakthrough” technology. The question to ask may be that if we have access to such cutting edge technology, why is our preventable death rate unchanged in ten years?
This is not advocating that there are not several huge improvements that have been and will be made in technology, simply that pouring additional technologies into all areas of operations has not moved the safety needle.
The lack of stability in regulatory approaches leaves quality and frontline staff only the time to be reactive. The major regulatory agencies are constantly changing the rules.
This is not making a case for the status quo, however, quality improvement efforts in hospitals are almost always overwhelmed by the complexity and rate of change imposed on them, along with the anxiety about the consequences of not meeting the imposed requirements. As with the technology question above, if this rate of change was truly beneficial wouldn’t the safety needle be moving?
Conclusion:
In a perfect world, frontline managers would have a single set of regulatory guidelines to comply with.
Hospital leadership needs to insist that the requirements they are asked to meet by external agencies do indeed improve patient safety and quality of care, as it is proven that this has not been the case over the past decade.
Executives and quality improvement managers cannot exclusively focus on meeting regulations. A significant effort must be made to proactively check the reliability of systems and processes, and once that is accomplished, hospitals will be set out on the path to high reliability.
- Don Death, CEO
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