A Roadmap For Patient Safety and Quality Improvement

This month the Agency for Healthcare Research and Quality (AHRQ) published a new report that identifies the most promising practices for improving patient safety in U.S. hospitals.

An update to the 2001 publication Making Health Care Safer: A Critical Analysis of Patient Safety Practices, the new report reflects just how much the science of safety has advanced.

A decade ago the science was immature; researchers posited quick fixes without fully appreciating the difficulty of challenging and changing accepted behaviors and beliefs.

Today, based on years of work by patient safety researchers—including many at Johns Hopkins—hospitals are able to implement evidence-based solutions to address the most pernicious causes of preventable patient harm. According to the report, here is a list of the top 10 patient safety interventions that hospitals should adopt now.

Top 10 Recommended Patient Safety Strategies

1. Preoperative checklists and anesthesia checklists to prevent operative and postoperative events.
2. Bundles that include checklists to prevent central line-associated bloodstream infections
3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols
4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia
5. Hand hygiene
6. The do-not-use list for hazardous abbreviations
7. Multicomponent interventions to reduce pressure ulcers
8. Barrier precautions to prevent healthcare-associated infections
9. Use of real-time ultrasonography for central line placement
10. Interventions to improve prophylaxis for venous thromboembolisms

Source: Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices, AHRQ

But as The Leapfrog Group’s CEO Leah Binder points out in a Forbes.com article responding to the report, the list alone will not help hospitals solve these challenges. Although some of the strategies may sound simple enough—getting doctors and nurses to wash their hands, for example—in reality changing behaviors and work processes can be quite difficult. Increasingly hospitals are told to do more with less all while facing increasing pressure to improve performance on a growing list of quality measures.

Even with a list of sound strategies, creating a plan to implement all or even half of them may sound like a daunting task. The Armstrong Institute for Patient Safety and Quality has created a checklist to help you get started.

1. Identify priorities and assess readiness for change.
What are your organization’s strengths and weaknesses and how do those compare with best practice organizations? Conduct a risk assessment to identify four to five areas of greatest need and prioritize resources around those areas.

Before implementing any improvement efforts, assess readiness for change. If a unit’s surgical site-infection rate is double the national standard but its surgeons, nurses and technicians don’t know about the issue or understand their role in improvement, then some team education is needed before progress can be made.

2. Establish engagement and accountability at all levels of the organization.
Although leadership consensus and buy-in is an obvious and important step, it’s equally important to involve frontline staff in the process of developing solutions.

To sustain improvements, every unit and department needs an accountable patient safety champion—an individual with knowledge of the science of patient safety who is accountable for their team’s performance.

3. Communicate constantly (the good and the bad).
Frequent and transparent communication about what is and isn’t working is an important aspect of any quality improvement project. Recognize employees who speak up to prevent a mistake. Examine setbacks and failures. Regular team meetings and patient safety rounds with a senior leader are valuable venues for discussion.

Before beginning a quality improvement project, tell the story of how the organization is doing today. What is the cost of doing nothing? Build a case for change and communicate often on the journey to improvement.

4. Measure, measure, measure… and then measure some more.
One step that’s often forgotten when implementing operational changes is identifying baseline measurements. Without something tangible to gauge improvements against, it can be difficult to see the impact of invested resources.

Measure early and measure often. Share data transparently so that employees know their performance individually, and as a team and organization.

5. Learn from mistakes and commit to continuous improvement.
Quality improvement is a never-ending journey: there is always room to improve. Even when an organization achieves its goals, then the new challenge of sustaining that success arises.

Best practices must be continuously evaluated as they evolve; medicine must work with industry to develop technology and tools that better support the needs of patients and their care providers; and continued investments of staff time and education are all needed to reduce patient harm, optimize outcomes and reduce waste.

Director of the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Peter Pronovost, MD, PhD is a practicing anesthesiologist and critical care physician who is dedicated to making hospitals and health care safer for patients. Pronovost has chronicled his work in his book, Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out. His posts appear occasionally on THCB and on his own blog, Points from Pronovost.

1 reply »

  1. The problem with hospital accountability is…no one is accountable. Nurses used to be the guardian of the patient. Now they are forbidden from anything that smacks of judgement calls. This leaves the system to run on automatic pilot. As long as the system is working, then the outcome must be due to the patient simply not surviving.

    The best way to be safe is DO NOT GO TO THE HOSPITAL unless you are about to die.

    If you must go to the hospital, NEVER BE ALONE. Always have someone watching you and your care. If someone is with you it will decrease falls, med errors, misidentification. It can shorten stays by having your family know what is going on.

    In the age of the hospitalist, where a different doc or PA sees you each day your care is very fragmented in today’s hospital. Have someone keep up with the plan for you.

    It used to be your doctor. Now it is the doctor for the hospital.

    All the other measures are fine, but within 6 feet of the patient, your best chance is to have your own guard.