Checklists are a vital tool in improving healthcare safety and accountability.

At the same time, even the best system of self-regulation depends on the participation of the individuals using it. In order to aggregate and prioritize the data gathered by the system, administrators must know that the front-line workers entering the data are doing so accurately. (1)

Readiness Rounds recognizes the importance of vigilance in scrutinizing real-time data, both in achieving optimal outcomes for our clients and for our ability to determine and maintain our own best practices.

The following three keys to making the best use of hospital checklists come from direct, extensive experience in the field.

Within a healthcare organization, three key factors must be in place if a self-regulatory system is to function efficiently. The first two elements help ensure that the people submitting data to the system will do so accurately. The third concerns the way in which administrators handle the data once it has been collected. (2)

The 3 Keys to Effective Hospital Checklists

Key #1. It’s Not About Getting a High Score

A culture of safety must guard against the very natural human desire to “get a good grade.” Although it is important to recognize those individuals and departments that are consistently high-performing, administrators must resist creating a culture that encourages people to “spin” or alter data to present their own performance as being better than it really is. Administrators must also be willing to apply special scrutiny to departments that report at or near 100% accuracy.

Such numbers could be a red flag, suggesting that the data is idealized, not realized. The goal of a culture of safety is, of course, to score 100% on every checklist. Pragmatic administrators, however, recognize that this goal is unlikely to be reached even on a single checklist, except on very rare occasions. (3)

Key #2. Approach every observation as if it has failed

Those who interpret the data generated by checklists cannot assume that all data in the system is reliable. Such an assumption can be dangerously misleading. Even in the most highly developed culture of safety and teamwork, administrators must be willing to look carefully at the input they receive. Ideally, all aspects of data collection and aggregation should be reviewed independently by several safety team members on an ongoing basis.

Key #3. Celebrate Failures

The flip side of the first key, is that within a safety culture, it is critical that failures and shortcomings be treated sources of valuable feedback for improvement. Employees must feel safe from reprisal in reporting problems and adverse events and must know that their concerns will be taken seriously. Administrators must create an atmosphere in which failures generate cooperative problem-solving rather than punitive measures. Only in such an environment will individual workers be motivated to report data accurately, especially when the data illuminates a failure to meet expectations.

By creating a culture in which failures are seen as opportunities to improve, and the goal of 100% accuracy is seen as a process, not a requirement, organizations can minimize the motivation for individuals to idealize the data they submit. In addition, persistent scrutiny of all aspects of the data gathering process further ensures accuracy in reporting and planning and thus promotes continuous process improvement.

Beginning January 1, 2017, Joint Commission-accredited nursing care centers are required to “implement evidence-based practices to prevent indwelling CAUTIs.”

According to the Joint Commission, the new National Patient Safety Goal will improve patient safety and mortality and reduce the costs and lengths of stay associated with CAUTIs. New elements of performance (EPs) include:

• Educating staff and licensed independent practitioners involved in the use of indwelling urinary catheters about CAUTI and the importance of infection prevention.
• Developing written criteria, using established evidence-based guidelines, for placement of an indwelling urinary catheter.
• Following written procedures based on established evidence-based guidelines for inserting and maintaining an indwelling urinary catheter.
• Measuring and monitoring CAUTI prevention processes and outcomes in high-volume areas.

Source: The Joint Commission

Read more about the new TJC SAFER Matrix here.

How Hospital Room Design Can Prevent Falls

What does it tell you?

You can assess a fair amount about the subject: the weather, time of day, approximate age of the individual, etc. We can see that the man in the photo is lying on the ground, holding a fishing pole and his dog is caught in the fishing net. Do you know what may have brought him to this place or what may have happened leading up to it?

The answer is that, although this photo tells a story, it is merely a snapshot in time.

Now, watch the video below:

What do you know now that the photo didn’t display?

We can now tell that he caught a fish, was going to net the fish and then tripped and netted his dog instead! We now know a much more detailed story and can better assess the events leading up to his fall and dog being netted.

Let’s apply this to collecting quality and safety data in healthcare.

When we do small, infrequent data collection, it gives us just a small amount of information, perhaps only pertinent to that date and time.

But conversely, when we collect data consistently over time, we are given a much more robust and less time frame-specific picture of what is really going on.

It allows us to understand the potential causative factors that contribute to the data and therefore allows a better baseline from which to launch performance improvement efforts.

A data “snapshot” can be very useful in particular for determining prevalence.

trending that data over time to evaluate whether or not appropriate assessments and risk scales were completed for pressure ulcers.

Once the factors that contribute to the prevalence are identified, the hospital can more easily address issues that are negatively impacting their prevalence rates and improve them.

As healthcare providers, we all know that it is no fun having to work during the holidays – but realize that it is less fun being a patient in the hospital during the holidays, especially if their stay was extended by a preventable infection, such as CAUTI or CLABSI, or by a medical error.

Patient safety continues to be a public issue that affects  in this country, patients and caregivers alike.

Many of us are quite familiar with the 1999 landmark report from the Institute of Medicine (IOM): To Err is Human: Building a Safer Health System. 

The number of hospital deaths by medical errors stunned the nation and the IOM report quickly became the catalyst that prompted the patient safety movement across healthcare.

So, 15 years later, how have we done?

Last week, the National Patient Safety Foundation (NPSF) released their report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, which focuses on how patient safety has improved since the IOM report was published and where progress still needs to be made.

patients, among countless other methods, has indeed helped to move the healthcare industry in the right direction; but it’s been slow in doing so.

Many, if not most, of these interventions and initiatives have been implemented to target specific safety issues in healthcare.

Although they have been successful in reducing some forms of patient harm, they have only had a slight effect on the overall numbers.

Why is this?

Likely it is due to the nature of these actions being reactive.

• Do you and your co-workers participate in them or are they secrets only known to the “higher-ups” or certain departments? 

• Most importantly, is the culture of patient safety a key focus for your organization – is it just occasionally talked about or is safety impressed upon every action that takes place within the hospital’s walls?

As you are settling down for the holidays with your families and friends and begin to reflect back on 2015, ask yourself: "Most importantly, is the culture of patient safety a key focus for your organization? "

To clarify, is the idea of safety impressed upon every action that takes place within the hospital's walls or just a word that is occasionally muttered when surveyors are around?

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.

This begs the question: are regulations and committees helping or hindering improvement?

Where does hospital safety stand today?

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.

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.

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.

4. Technology is often seen as the solution when it may be the problem

5. There is only time to be reactive

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?

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.

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

Mistake #1:

Lack of senior leadership buy-in

There could be many semi-legitimate reasons for nursing not getting it done (and how to solve that problem is probably another blog post or two).

One obvious issue is that if senior leadership is not engaged, then you may not have the ability to get the proper utilization of an electronic rounding tool (or any rounding process for that matter).

A few questions to consider:

• Is a safety culture in place that is embraced and pushed down from the top of the organization? Upper management must commit to a culture of safety, not just maintaining accreditation when needed.

• If, like in this scenario, the initiative is led by Quality and Accreditation, is it a well-developed department and are the right reporting mechanisms in place? (Quality reporting directly to C-suite.)

• Does leadership have a feel for the front lines?

Mistake #2:

Lack of Internal 'Marketing' Prior to Starting

Mistake #3:

Digital Rounding Not Being Used for Improvement

Checklists save lives. This key fact lies at the root of Readiness Rounds’ philosophy.

While their ability to save lives is more than enough to validate the importance of implementing checklists in healthcare industry routines, checklists also have the power to boost a provider’s accountability, ethical reputation, and accreditation.

Concerns about patient safety have been public knowledge for years. The healthcare industry’s failure to improve its safety record has led to a general loss of public trust. By making good use of checklists, hospitals can improve patient safety, earn back the public’s trust, and save lives.

A serious roadblock to establishing a checklist-based patient safety culture, is the traditional lack of accountability in healthcare.

The system’s failure to hold healthcare providers and organizations accountable for failures laid the groundwork for the current lack of public trust healthcare now faces.

In the new safety culture, patient safety advocates turn away from the traditions of the guild in which social standing and privileged knowledge shielded practitioners from accountability. annals.org/article.aspx?articleid=709376

They also reject the defensive posture of old risk management approaches in which physicians and leaders of health care organizations were advised to admit no responsibility and to defend all malpractice claims, whether or not they were justified.

Patient safety embraces organizational and personal accountability… while maintaining accountability and integrity in interactions with patients and families who have suffered avoidable adverse events. https://www.ahcipa.com/

A system of checklists not only allows hospitals to determine what went wrong and evaluate how the error occurred, it also facilitates the development of new and better procedures to prevent similar errors in the future.

As a result, in addition to apologizing, the organization can better explain to the patient and his or her family what happened, and can demonstrate in concrete terms how the organization has learned from this mistake and what it is doing to make sure it does not happen again.

Even in the face of adverse events, transparency and accountability work together to improve patient confidence in the system.

Accountability and ethics go hand in hand. A system with no accountability has no way to normalize or enforce an ethical code.

According to the AMA, accountability, patient safety, and the elimination of system-based errors are foundational ethical values in healthcare. Checklists embody the ethical commitment of healthcare organizations and help those organizations live the ethics they profess. web.stanford.edu/class/siw198q/websites/reprotech/New%20Ways%20of%20Making%20Babies/EthicVoc.htm

Accreditation is the official proof that a healthcare organization’s operations, accountability, and ethics are all functioning with sufficient reliability to provide reasonable patient safety. While accreditation can certainly be a strongly motivating factor in the adoption of checklists and safety culture, the real benefit comes in improved patient outcomes and a reduction in adverse events. jointcommission.org/

The purpose of accreditation is to push organizations to meet and maintain these goals. Checklists provide clear documentation that an organization meets the standards set by the Joint Commission. They provide evidence that the organization is aware of trouble spots and is taking appropriate measures to remedy problems. An organization using checklists to document its commitment to safety culture stands ready for the Joint Commission on a daily basis. jme.bmj.com/

Accountability, ethics, and accreditation all contribute to rebuilding public trust in the healthcare system. As safety culture takes root and checklists provide real-time data, the industry will improve patient outcomes and save lives, thereby gaining patients’ confidence. In their article, “What Exactly is Patient Safety,” Emmanuel, Berwick, et al write: Trustworthiness is essential to the concept of patient safety. The health care system designed for patient safety is trustworthy. This is not because errors will not be made and adverse events will never happen, but because the health care system holds itself accountable to applying safety sciences optimally.

Emmanuel L, Berwick D, Conway J, et al. What exactly is patient safety? In: Advances in Patient Safety: New Directions and Alternative Approaches, Vol. 1: Assessment. The Agency for Healthcare Research and Quality. US Dept. of Health and Human Services. August 2014. Available from: ahrq.gov/downloads/pub/advances2/vol1/advances-emanuel-berwick_110.pdf

• Legionnares disease is linked to poor ventilation

• 2015 saw serious patient health issues due to building issues: sewage lead and live rates

• Currently being created: uniform guidelines for HVAC in sterile departments

• Evaluation of maintenance protocols

"Hospitals may wish to consider re-evaluating the maintenance protocols for their facilities to ensure patient safety."
Did you know:
Improvement Opportunities:

#5. Reprocessing Issues

The spread of infection due to inadequate cleaning practices associated with flexible scopes has been on the rise.
Did you know:

• Medical scopes tied to infections are on the Top 10 Health Technology Hazards list

Improvement Opportunities:

• Improve best practices for scope disinfection:

• Using the correct tools

• Following protocol

• Culturing to check for bacteria

 
#4. Sepsis

One million people a year will develop sepsis, half of which will die. This number continues to rise.
Did you know:

• 1 Million+ cases annually

• Half of which die

Improvement Opportunities:

• CMS has added sepsis management bundle to the 2016 Inpatient Prospective Payment System Final Rule

 
#3. "Super" Superbugs

Defined as "bacteria that cannot be treated using two or more antibiotics;" and "appear to be getting stronger."
Did you know:

• Superbugs are reported to appear to be getting stronger

• CMS reports a set of a certain strain - CRE is a cause for public health concern

Improvement Opportunities:

• Increase awareness on antibiotic stewardship

#2. Cyber Insecurity

Actual cases of medical devices being remotely hacked have been reported bringing harm to patients.
Did you know:

• In 2016 the FDA officially warned against the use of the Hospira Symbiq infusion system - an electronic pump susceptible to hacking

Improvement Opportunities:

• Increasing security of devices by the healthcare industry, manufacturers and the federal government

 
#1. Quality Data Transparency
"Physicians will develop a greater sense of accountability to deliver quality care." Ashish K Jha, MD
Did you know:

• Some hospitals internally display employee performance ratings

Improvement Opportunities:

• Displaying your data will increase accountability, incentivize staff, and encourage healthy competition.

 
Do any of these issues resonate with you?

Most of you are probably already aware of these patient safety issues. With more information and data analysis, we are able to increase our awareness and resources to ensure even better safety for our patients in 2016.
Readiness Rounds, as indicated above, encompasses many of the solutions needed to address and assist in solving these patient safety issues. Be sure to visit our samples checklist page and our resources page.
Feel free to contact us to discuss your patient safety concerns.

The NTSB has recalled more airbags since I wrote Part 1, even without the occurrence of additional driver injury or death.

The continuation of this blog identifies and examines a major barrier hindering improvements in the healthcare industry, based on TJC Root Cause Analysis, and outlines observations that must be made when considering solutions to make advances in patient safety at your facility.

If you haven’t had an opportunity to read Part 1 of the blog, or would just like to review the discussion, here is the link.

I would like to raise the red flag here and disclose that if you (or your facility) are

Are you skimping on safety?

Is patient (and employee) safety something that’s presented during orientation

etribution) when a potential risk to a patient is observed? How many potential events could be avoided by someone just speaking up?

How well and how often do leaders communicate with the front-line staff?

Do leaders know the names of the people that work for them and where it is

implementation and monitoring may help to kick start your hospital’s transition into a high-performance and high-reliability organization.

It’s time to stop ignoring safety in our facilities. Too many patients have been injured or killed in U.S. hospitals and there are no longer any excuses for this happening….start taking the steps to turn your organization around, before it’s too late for one of your patients.

Works Cited

(1) Axlund, W. (2016, 3 10). Readiness Rounds Blog. Retrieved from http://www.readinessrounds.com/blog: http://www.readinessrounds.com/blog/sentinel-events-and-patient-safety

(2) Douglass, F. (n.d.). Brainy Quote. Retrieved from Brainy Quote: http://www.brainyquote.com/quotes/quotes/f/frederickd101257.html

(3) The Joint Commission. (2016, 2 9). Sentinel Event Data Root Causes by Event Type: 2004 –2015. Retrieved from The Joint Commission: http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2015.pdf

(4) The Joint Commission. (2016, 2 9). Summary Data of Sentinel Events Reviewed by The Joint Commission. Retrieved from The Joint Commission: http://www.jointcommission.org/assets/1/18/2004-2015_SE_Stats_Summary.pdf