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Patient Safety, Engagement Relies on Crafting a Culture of Change

“You must set the goal at zero. Patient safety must be an uncompromisable core value of your organization.”

By Jennifer Bresnick

- Whether it’s the first time or the fiftieth, an inpatient admission can be an extremely frightening event for a patient. Unwell and anxious, surrounded by unfamiliar people and places, subject to invasive and uncomfortable procedures, many patients find that their usual decision-making capabilities simply shut down as they put their complete trust in the hands of healthcare professionals.

Patient safety and patient engagement

There is no doubt that these clinicians – nurses, physicians, and supporting staff – are deeply committed to the safety and wellbeing of their patients, and that no sensible, responsible caregiver would ever intentionally cause harm to another person under their care.

However, mistakes do happen, and patients are the ones who suffer most from lapses in protocols, fragmented attention spans, and technical errors

Millions of patients experience adverse events while in the hospital, including medication errors, infections, pressure ulcers, and falls.  Hundreds of thousands more will check in and never leave.

While some patient safety advocates may blame electronic health records for these deficiencies, and others might cite overwork, understaffing, and inadequate training, there’s one thing that all quality-minded stakeholders can agree upon: patient safety is a critical concern that must be addressed in a holistic, comprehensive way.

READ MORE: 21% of Patients See Medical Errors, but Providers Deny Responsibility

Improving patient safety is primarily a matter of responsibility, says Dr. James Merlino, President and Chief Medical Officer of the Strategic Consulting Division of Press Ganey.  Healthcare organizations must take on the challenge of creating a “culture of care” that encompasses every member of the care team – including patients.

By broadcasting bold patient safety goals, engaging providers, and enacting patient-centric strategies for process improvement, healthcare organizations have the opportunity to make meaningful progress in the fight to reduce preventable patient harm.

“Organizations really need to adapt a strategic objective of patient centricity,” Merlino told  “They have to get across to everyone that works in healthcare that they exist for the patient, and that their purpose is to deliver on the promises that they implicitly make with their patients: providing a safe, high-quality, human environment where the patient feels cared for.”

To do this, organizational leaders have to be sure that their staff members are not only educated about patient safety risks, but fully committed to eliminating preventable harm all together.

“You must set the goal at zero,” Merlino stated. “Patient safety must be an uncompromisable core value of your organization.”

READ MORE: EHRs, Clinical Decision Support Top 2017 Patient Safety Hazard List

“What I find in some of the organizations that we work with is that they have differing degrees of alignment around the topic.  Obviously, nobody comes to work in healthcare because they think about wanting to harm a patient.”

“But accidents do happen, because we’re human.  We just need to think about how to integrate the best possible processes into the care system, and it has to start with a commitment from leadership to model these practices and create a culture that is deeply patient-centric.”

Integrating the EHR into intuitive care strategies

Creating care processes that allow staff members to work quickly, efficiently, and safety hasn’t always been an easy task for healthcare organizations, and many have found that electronic health records make the job even tougher.

Despite the fact that the Office of the National Coordinator has cited EHRs has a major driver of a 17 percent reduction in adverse patient safety events since 2010, not everyone is convinced that the data-driven tools are as beneficial as they could be.

READ MORE: 6 EHR Patient Safety Strategies for Medication Orders, CPOE

EHRs frequently make an appearance on top healthcare hazards lists, and suffer from some fundamental flaws that may be detrimental to patient safety.  Interoperability concerns, poor device integration, puzzling interfaces prone to user errors, and unreliable health information exchange make EHRs a challenge for many organizations.

Merlino believes that EHRs are a positive development for patient care, but sympathizes with clinicians who feel unprepared to use them to their fullest potential.

“I think a lot of people just like to complain about EHRs,” he said.  “But it’s probably more related to the fact that they represent a change than anything else.  I don’t think there’s any question that the EHR has made delivery of care better.  The arguments from people who are unhappy with it usually stem from the fact that for some patients, it may take more time to document care.”

Other frustrations are rooted in poor training procedures that result in convoluted workflows or gaps in the care process – both major culprits in patient safety errors.

“My wife is an associate chief medical informatics officer,” Merlino explained, “and it’s fascinating when she tells me stories of working with physicians to help them better utilize EHRs.  The problem is that healthcare organizations are getting pretty good at teaching people how to use these systems, but they’re still really bad at helping them integrate electronic tools into their workflows.”

“When you do a better job of adding the EHR to workflows that make sense, people actually like it.  It makes them more efficient, and it’s better for their practice.  More importantly, it’s doing a lot of good for patients, and that’s the most important thing.”

Partnering with patients for safety, quality, and satisfaction

But there’s a third leg to the patient safety stool, Merlino added.  Not only do executive leaders and clinicians need to increase their participation in error-reduction strategies, but patients themselves have to actively safeguard their wellbeing.

“Delivery of care is a partnership between the provider and the patient, he said. “We have to do a better job of empowering, educating, and activating patients to take a role in that partnership.”

“We need them to help us. They should be questioning what they're getting. We should educate them about things like medications – we should make sure they know the standard questions they need to ask when they’re given a new treatment.”

It may be a challenge, especially for patients who are not native English speakers, those with cognitive impairments, and safety net patients with low health literacy levels, but “the more you can develop a partnership with a patient, the safer healthcare delivery is going to be,” Merlino stressed.

“Patients have to do their homework and learn about their conditions.  It may not be possible for every patient to know everything about their illnesses – that’s why they’re in the hospital or seeing their physician – but they can certainly take advantage of resources that are available to them.”

It is becoming increasingly important for providers to be able to demonstrate that they are enabling higher levels of patient engagement, especially as value-based reimbursements, patent satisfaction, and long-term outcomes come into alignment.

In order to achieve higher levels of engagement that may catch a safety error before it causes harm, providers must be open to listening to what patients have to say, and must embrace the idea of being challenged in a positive way.

“I tell patients that they should question me, because they make me better,” Merlino said.  “They make me think, and they make me more thoughtful.  Patients are the only ones who can test whether or not their providers are communicating effectively.”

Just like EHR use, it may take a little extra time by the bedside to ensure that patients truly comprehend what their providers are saying, he said.  It is not uncommon for an exhausted patient to nod and smile and agree to everything as their physician hurries out of the room to continue her rounds, only to find out two weeks later that the patient is back in the hospital due to nonadherence.

“Providers usually believe that if we ask a patient if they have any questions and they say no, that they don't have any questions,” Merlino admitted. “But that isn’t always true.  If the clinician turns the tables and says, ‘Well, great – and just so I’m clear, please repeat your instructions back to me,’ they’ll often find out that the patient can’t repeat it, because they weren’t really listening as well as they should have been.”

“When I was in academic medicine, I used to tell my medical students to explain a treatment plan to a patient,” he recalled.  “And then I would have the student go back in and ask the patient what the plan was.  The patient usually couldn’t do it.  Of course, it depended on things like their age, or whether they were on narcotics – I’m a surgeon, so a lot of my patients were on pain medications.”

“It’s just fascinating to me how you can walk out of a patient’s room convinced that they understand everything, but they don’t.” 

There is a shared responsibility for ensuring that effective communication happens, Merlino believes. “The burden rests partly on providers to communicate more thoughtfully, more effectively, and ensure that that connection is made so the patients really understand,” he said. 

“It also rests on the patients to learn more and challenge themselves when it comes to participating in a dialogue they’ll remember and internalize.”

Enacting change by making patient safety personal

It’s important to put a human face on patient safety, Merlino said, especially since that face will, at some point, belong to each and every one of us.

“At the end of the day, we’re all patients,” he said.  “We’re all family members of patients.  This is not an impersonal issue, and it’s not just about numbers.  We tend to talk about bad outcomes by using statistics, but patients aren’t just numbers.  They’re people with lives, and families, and histories.  Any one of them could be a relation.  Any one of them could be us.”

It doesn’t cost much time or money to promote these important ideas throughout an organization, he added.  Simply taking a little more time to talk to patients, a little more effort to ensure that a shift change goes smoothly, or a few extra hours to learn more about the EHR, can make a major difference in the way providers view the importance of patient safety and patient engagement.

“The best way to build a personalized, engaged culture of safety is to tell stories about the real impact of patient safety,” Merlino concluded.  “Empower clinicians to make that connection.  If you start to put a face on this issue, it makes it very personal, and it can help to drive that change.”


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