By Tina Hilmas, RN, BSN, MS, CPPS
Center for Patient Safety, Assistant Director
Did I get your attention? Good! We do have a problem, and it’s not the usual having to deal with Conditions of Participation (CoP) or with the ever-changing reimbursement model, but the problem is with patient care. You see, this week (March 10–16) is Patient Safety Awareness Week. This week highlights the need for everyone to increase their awareness that patients are suffering harm – ranging from mild to severe – and even death due to preventable medical errors. And patient harm doesn’t just occur in hospitals, it is occurring under our watch in home-based care.
The Institute of Medicine (IOM) came out with an initial report 20 years ago which estimated that there were approximately 98,000 deaths per year due to preventable harm. In 2016, a journal article estimated that number to be even higher, more around 250,000 deaths per year, making it the third leading cause of death. And even more importantly, there are documented patient safety events reported that show harm is coming to patients in home-based care, including falls that cause intracranial bleeds and medication errors that send patients to the emergency room. The Center for Patient Safety, as a federally designated patient safety organization (PSO), identifies over 1,800 patient safety events in the home-based care environment that demonstrate adverse events are occurring under our watch.
Have you ever heard of patient safety organizations (PSOs) before? If you answered no, I am not surprised. Even though these organizations have been around since 2008, it can be hard to define exactly what a PSO is and what services they offer. The Agency for Healthcare Research and Quality (AHRQ) website provides in-depth information on PSOs. However, simply put, PSOs collect and aggregate patient safety incidents with the goal of improving patient care. The benefit of working with a PSO is that active participation provides legal protections that are supposed to remove fear of legal liability.
This can be important because as the original IOM report noted, a large factor that is a barrier to improving patient safety is the culture of healthcare. Unfortunately, we are not very good at trying to use mistakes as learning opportunities. Think for a moment about what the response would be to the following scenario:
Your nurse goes out to do a Start of Care (SOC). While completing the SOC, the patient’s adult child bursts into the house, aggravated and angry. The patient whispers that the child has been involved with the law due to a drug problem. The police are called, the situation is resolved, and the nurse finishes the SOC. When you, as a supervisor, are reviewing the paperwork, you notice the fall risk assessment wasn’t completed and there was no assessment of the house for fall hazards. As you notice this, you get a call from the patient’s spouse stating that the patient tripped and fell over a rug and is in the Emergency Room with a broken hip. Do you:
- Call the nurse, inform her of the situation and tell her she is suspended pending investigation of the incident, and that this incident will go into her personnel file?
- Call the nurse, explain the situation, then tell her the incident is not her fault and absolve her from all responsibility?
- Call the nurse, ask her to come in and do a root cause analysis together to not only look at the situation that was present during the SOC, but also to review your agency’s policies, processes and the system that goes into completing SOCs?
My hope is that you would choose option 3. However, too many organizations fall into the category of option 1. It may seem that, of course, this is the logical answer. Nurses should know what goes into a SOC. They should know that a fall risk assessment should be completed with every admission. Let’s take this example a step further. What if the nurse who completed this SOC was your star performer? The patients like her. She always goes by the book and submits her paperwork on time. She also knows how to coordinate care and the rest of the team really likes her. But how would you respond if it was not your star performer? Let’s say this event happened to one of your borderline nurses. This nurse is always a little late with paperwork and you regularly need to monitor her. While the care she provides to her patients isn’t bad, and for the most part her patients seem to like her, she seems to do the bare minimum. Would your response be different or would you treat them the same?
I’m certain you would like to say both nurses would be treated the same, but many times this is not what happens. This type of behavior points to the culture of the organization. Yep, that’s right, culture. I know it sounds soft. Culture is not hard science and it isn’t black and white. It’s… touchy-feely stuff. I get it. However, your culture plays a huge part in the quality of care being provided to your patients.
Think about your turnover rate. How high is it? Do you do exit interviews? Do you know why employees are leaving your organization? Also, think about your Quality Assurance and Performance Improvement (QAPI) projects. How do you know you’re being successful? Do you know how your staff views the organization and it’s quality improvement projects? Do you truly know if your employees trust the organization and feel challenged/engaged to participate in quality improvement projects? Or do they think it’s just the flavor of the month and if they keep their heads down and avoid attention that things will just go back to where they feel comfortable and they won’t really have to change?
These are hard questions to answer. Many organizations send out employee engagement surveys, which are good to an extent, but they don’t really measure how your staff views the organization. The best survey would be one that measures your organization’s culture and asks staff if they believe the organization is committed to supporting it’s staff and protecting it’s patients. Lastly, the survey should be administered by a third party. This last point is very important. If your organization is one that is punitive in response to errors and the survey is administered by leadership, employees may worry that they will be identifiable based on their answers. This won’t provide the organization with a starting point to change it’s culture. You want your staff to be truthful because to be successful in quality improvement, the culture of your organization must support it.
Home-based care is faced with many challenges to maintaining patient safety that other areas of healthcare don’t face, with the main challenge being the actual environment in which healthcare is provided. But that doesn’t mean we should just shrug our shoulders and say that patient safety is a province of hospitals. It means that we need to find ways to take the lessons learned regarding patient safety from hospitals and figure out how they can be applicable to our setting. You see, our future depends on it. Home-based care is being challenged and pushed to meet the same safety and quality standards that other areas of healthcare are expected to achieve without any of the tools that were developed to help these other areas. We need to push for research regarding patient safety in our area. We need to push for ways to improve the culture of our organizations. And lastly, we need to keep patient safety and quality of care top priorities in all the care we provide.
HHQI University Offers Free Patient Safety Courses
Learn more from Tina in the following HHQI University courses which include free nursing CEUs:
- Patient Safety Culture: A Foundation for a QAPI Program
- Patient Safety: All in a Day’s Work! (2-hour virtual workshop to begin developing a patient safety Performance Improvement Project)