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A Compendium of Patient Safety Concerns for 2020…and Beyond

By: David P. Lind

According to a March 2020 report by non-profit, independent organization, ECRI Institute, diagnostic errors and maternal health issues are considered to be the top two patient safety concerns for healthcare organizations. This report, however, was released prior to Covid-19 becoming the national focal point in the U.S.

ECRI’s list of the top 10 patient safety concerns was based on analysis of more than 3.2 million patient safety events recorded via the institute’s reporting program.

The list (in order) is as follows:

    1. Missed and delayed diagnosis.
    2. Maternal health across the continuum.
    3. Early recognition of behavioral health needs.
    4. Responding to and learning from device problems.
    5. Devise cleaning, disinfection and sterilization.
    6. Standardizing safety across the system.
    7. Patient matching in the Electronic Health Records.
    8. Antimicrobial stewardship.
    9. Overrides of automated dispensing cabinets – This refers to overrides to remove medications from a computerized drug storage device before pharmacists have reviewed and approved the move.
    10. Fragmentation across care settings.

11 Takeaways for the #uniteforsafecare Public Awareness Campaign

The World Health Organization designated September 17 as World Patient Safety Day to raise awareness of healthcare safety and its importance. During that virtual event, the Patient Safety Movement provided 11 takeaways on its Patient Safety Blog for the public, patients and their families to understand while seeking care:

    1. Recognize that the system is not perfect.
    2. Stay engaged in your own health care process.
    3. Recognize that your voice matters.
    4. Don’t be intimidated.
    5. Get a second opinion.
    6. Don’t be afraid to “shop around” for healthcare.
    7. Follow your gut.
    8. Double-check everything.
    9. Minority communities must be cognizant of the social disparities in patient care.
    10. Keep in mind that health workers are not to blame, the system is to blame.
    11. Remember that we’re all in this together.

The Joint Commission’s Seven Most Common Sentinel Events

Through the first half of 2020 – ending June 30 – The Joint Commission (TJC) reviewed a total of 437 sentinel events, with 85 percent being voluntarily self-reported by an accredited or certified organization. A sentinel event is a patient safety event that results in death, permanent harm, severe temporary harm or intervention required to sustain life. That total of 437 is a very low number because it is a grossly underreported by medical organizations. In fact, TJC estimates that only two percent of all sentinel events are reported.

The most common sentinel events for the first six months of this year are as follows:

    1. Care management – 165 reported events
    2. Surgical or invasive procedures – 131
    3. Unassigned events at the time of the report – 46
    4. Suicide – 41
    5. Protection events – 38
    6. Environment events – 12
    7. Product or devise – 4

New National Action Plan for Patient Safety

To combat preventable medical harm, the Institute for Healthcare Improvement (IHI) released a National Action Plan on September 17. The report, “Safer Together: A National Action Plan to Advance Patient Safety” was arranged by 27 federal agencies, safety organizations and experts, and patient and family advocates. The plan focuses on four key areas:

    1. Culture
    2. Leadership and governance
    3. Workforce safety
    4. Learning systems
Keeping patient safety front and center is critical to force-needed changes within our healthcare environment.

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Physician and Caregiver Burnout – Yet Another Epidemic

By: David P. Lind

My particular primary-care doctor has been my medical ‘counselor’ for about 25 years. I visit her at least annually for my routine physicals, but have frequently consulted with her about obtaining referrals to specialists outside her scope of practice. I see her because I have unquestionable trust in her abilities to put my interests above any other outside influences.

On numerous occasions, I have confided in her about my family medical history, specifically having lost two siblings to different cancers. Through her own tears, I have come to accept her as yet ‘another sister’ to me – my fifth! Her compassion for my well-being is both genuine and reassuring. Suffice it to say, I have the utmost admiration for the medical professionals who work diligently on a daily basis to care for patients.

Much of what I have written in the past, whether through blogs or op-ed pieces, is directed to help educate the general public about the problems (and potential solutions) of our healthcare system. Not only is the healthcare service delivery we seek local, it is also very personal, especially as it relates to the relationships we have with the doctors, nurses and other caregivers in our communities.

But what patients may not understand is the ‘backroom’ in which clinicians are required to perform their daily work. It is within this ‘black box’ of their work environment that their human frailty may become tested and subsequently exposed, negatively impacting their own mental well-being, and possibly undermining patient care.

Caregiver Burnout

The opioid epidemic has become a large concern of our local and national conscience. But another troublesome public health crisis persists in our society, and it greatly impacts each of us, whether we know it or not – physician and caregiver burnout.

Physician and caregiver burnout have troubling symptoms, such as depression, exhaustion, dissatisfaction and a sense of failure. Losing the passion or purpose to serve others can be a powerful setback that steals the joy of practicing a noble profession. If left unaddressed, this burnout will erode the caregivers’ mental health and adversely impact patient safety.

The nurse burnout rates are reported to be between 35 and 45 percent. The burnout rates also vary by specialty. For example, specialties with the highest rates of burnout include1:

  • Urology – 54 percent
  • Neurology – 53 percent
  • Physical medicine and rehabilitation – 52 percent
  • Internal medicine – 49 percent
  • Emergency medicine – 48 percent
In fact, doctors who report burnout are twice as likely to commit a medical error. From our 2017 Iowan’s Views on Medical Errors study, Iowans reported the top cause of medical errors was from “Doctors and nurses who are overworked, stressed and tired.”

Quite understandably, when surveyed about the causes of burnout, physicians point to a plethora of bureaucratic tasks that include too much government and private insurance interference, too little pay, too many office hours, and too much time spent in front of the computer screen using electronic health records that are more about submitting the correct procedure codes to get paid by private, Medicaid and Medicare payers. Completing administrative and insurance requirements takes precious time away from providing face-to-face care to patients – perhaps twice as much time compared to treating patients.

According to an October 23, 2019 report, “Taking Action Against Burnout: A Systems Approach to Professional Well-Being,” the National Academy of Medicine (NAM) reports that 35 to 54 percent of nurses and physicians have substantial symptoms of burnout, while medical students and residents have symptoms of burnout between 45 percent and 60 percent. A recent Mayo Clinic report confirms similar findings, suggesting that 44 to 54 percent of physicians report having ‘burnout’ symptoms. A newly-released study by Medscape reported that almost half of physicians would take a pay cut to work fewer hours, and more than a quarter of physicians would give up between $20,000 and $50,000 per year in salary.

Potential Solutions to Burnout?

There is no clear consensus on what solutions will quickly ‘fix’ this growing crisis. Physicians want or favor the simplicity of administrative requirements from key payers, more relaxed insurance regulations, more stream-lined technology that allows caregivers to spend less time on computers and more time with patients. But the devil is clearly in the details.

The above-mentioned NAM report was prepared by the Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. This committee made six recommendations to serve as guidelines to help healthcare organizations design and implement systems to mitigate the factors that contribute to burnout:

  1. Create positive work environments
  2. Create positive learning environments
  3. Reduce administrative burden
  4. Enable technology solutions
  5. Provide support to clinicians and learners
  6. Invest in research (on clinician professional well-being)
Similar to the opioid epidemic, our state and country will need to become more involved to meaningfully address this particular crisis. Physician and caregiver burnout is a public health crisis that requires urgent action by healthcare organizations, state and federal governing bodies, including regulatory authorities.

Afterall, don’t we want our own doctors to be healthy, too?

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1 2017 Mayo Clinic

“Alexa, diagnose my cough” – Part 2

By: David P. Lind

Last April, I published a blog about potentially using cloud-based voice services, such as Amazon Echo (Alexa) or Google Home, to serve as artificial intelligence (AI) when seeking a healthcare diagnosis based on symptoms we experience. By merely sharing our medical symptoms with a smart-voice service, we could receive a diagnosis that is based on the latest peer-reviewed medical literature available.

As pointed out in the blog, one cautionary note about using such a tool was the ‘legal liability hurdles,’ such as being HIPAA-compliant (a U.S. health privacy law) – making sure that our private-patient information is being securely transmitted.

This particular hurdle appears to have been cleared. On April 4, the publication STAT reported that Amazon unveiled HIPAA-compliant software allowing pre-selected healthcare companies to build Alexa voice-program tools giving patients access to personalized information such as progress updates after surgery, prescription delivery notifications, in addition to learning nearby urgent care facility locations. Health firms can use Amazon’s Alexa Skill Kit to build voice programs that can create products to transmit and receive patient data.

As mentioned in STAT, “The move will embolden hospitals, insurers, and other healthcare firms to expose Alexa to more sensitive details of patients’ lives and medical conditions, and potentially embed the technology deeper into clinical settings.”

Developments like this one may not be highly-visible to the casual observer, however, it might be similar to a simple mist that ultimately results in a torrential downpour, causing a Tsunami of change.  Who knows, perhaps in just a few short years, ‘Alexa’ and other cloud-based services may actually simplify our daily lives that, today, seem complex and frustratingly lost in unchartered waters.

Hold on tight for the next rush of change that will no doubt disrupt how we will eventually live.

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National Trend – Insurance Companies Investing in Affordable Housing Projects

By: David P. Lind

National Trend – Insurance Companies Investing in Affordable Housing ProjectsIn 2016, Dr. Yogi Shah and I co-wrote a blog about moving ‘upstream’ to make investments in population health, more specifically, the social determinants that impact our health. As indicated in our work, when compared to other industrialized countries, the U.S. spends disproportionately large amounts on medical services, while largely ignoring the living environment that greatly affects the health of our population. We spend considerably more for medical care, yet our outcomes compare unfavorably to those countries.

In the U.S., we have done a great job of ‘medicalizing’ our social problems. But instead of focusing on how to pay for medical care, we would be wise to re-direct our limited resources toward improving basic social determinants of health, such as education, housing, nutrition and poverty.

UnitedHealthcare, the nation’s largest health insurer, and a division of UnitedHealth Group, announced this past week that their program of investing in affordable housing projects has now surpassed $400 million. Since 2011, UnitedHealthcare has invested in 80 affordable-housing communities across 18 states with more than 4,500 new homes for individuals and families in need.

It should be noted that the shortage of affordable housing greatly impacts population health. It limits choices about where people live, often pushing lower-income families to substandard housing in unsafe, overcrowded neighborhoods with higher rates of poverty and fewer resources for healthy outdoor and exercise activities. Further, unaffordable housing can prevent people from meeting other basic needs including nutrition and healthcare.

Not to be outdone, other insurers are also making affordable housing investments. The nation’s second largest insurer, Indiana-based Anthem, has committed about $380 million developing affordable housing over the past decade. Kaiser Permanente, a California-based healthcare provider that also sells health insurance, has invested $200 million to address housing stability, homelessness and other community issues. Blue Cross and Blue Shield of Minnesota, HealthPartners and UCare, all in Minnesota, are also supporting smaller projects to do the same. I’m sure there are other insurers making similar investments elsewhere.

As we all know, healthcare payers are having difficulty controlling escalating healthcare costs. One mindset change is to look ‘upstream’ and find local priorities that are linked to poor health outcomes needing attention. According to one study brief, social determinants account for about 80 percent of health outcomes, meaning that the majority of our healthcare costs can be attributed to non-clinical factors.

Research continues to confirm that unmet social needs are associated with higher rates of hospital admissions, readmissions, and emergency room use. One prime example is that supportive housing has been shown to decrease Medicaid costs by up to 67 percent, which includes reduced emergency room visits and inpatient admissions. Such outcomes can positively impact the private-payer ledger by saving monies paid to medical providers who care for the low-income population.

Investing ‘upstream’ is a smart alternative to the avoidable problems that become more expensive ‘downstream.’ It is good to see that more insurers are also taking this approach.

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Tepid Improvement in Patient Safety Progress
But Massive Savings Are Possible

By: David P. Lind

Healthcare Cost Savings - Tip of the IcebergAs our healthcare delivery system evolves, we must reach beyond the endless discussion and distractions over who pays and how much. The cost, compliance, coverage and political discussions are no doubt important, but these are inextricably linked to the safety outcomes of medical care we expect to receive – but, in too many cases, do not.

The patient safety dialogue has been buried from the general public under many other pressing national concerns:  the general economy, global terrorist activities, general elections later this year, immigration, Middle East unrest, gun control – as well as countless other issues.

In addition to covering more Americans, the premise of the Affordable Care Act (ACA) was to initiate new care delivery models that would eventually make healthcare more affordable and achieve better outcomes. The hope is that our healthcare ‘system’ is now on the path to recovery – we just need to give the initiatives time to work.

But is it really that simple?

If the Centers for Disease Control (CDC) were to include preventable medical errors in hospitals as a category, it would be the third leading cause of death in the U.S. – behind heart disease and cancer. Quite simply, the numbers for those seriously and fatally injured are massive. National estimates indicate that between 6.6 million to 11.5 million patients are seriously harmed in our hospitals – EACH YEAR. For those fatally harmed, the annual estimated range is 98,000 to 440,000 deaths.

Are improvements being made, and if so, by how much? The short answer is Yes, but…

The federal Agency for Healthcare Research and Quality (AHRQ) released a report in late 2015 indicating that hospitals have averted many types of preventable injuries (such as infections and medicine reactions) during the period 2011 – 2014, using 2010 as the base year. During this four-year period, officials examined 30,000 medical cases and, from this, extrapolated the number of complications that were possibly avoided. The cumulative results appear to be downright impressive: 2.1 million fewer incidents of harm, 87,000 fewer deaths and about $20 billion in healthcare savings.

No doubt, this is encouraging news. On the surface, the general public (and media) appear to have only tepid concerns about patient safety issues, most likely because the federal government, hospitals, grant-receiving medical provider collaborations, academia and other organizations are “all over” this national problem.

But these improvements only represent the proverbial ‘tip of the iceberg.’

Even Dr. Richard Kronick, director of the AHRQ, commented that these findings have yet to be fully understood and improvements most likely came from “low-hanging fruit.” In other words, these are the relatively easy problems. Problems in the past that should’ve been averted in the first place, but were not.

Loaded with curiosity, I decided to compare these improvements to national estimates of medical errors to understand how much progress was really made during this four-year period. Using the conservative estimate of 6.6 million patients harmed annually in hospitals, the 2.1 million averted conditions reported by AHRQ during the cumulative four-year period equates to an eight percent improvement. By using the high-end estimate of 11.5 million harmed patients annually, this reported improvement is under five percent. Keep in mind, that 2.1 million was a cumulative amount over four years, while the 11.5 million is EACH year.

As for preventable hospital fatalities, using the conservative 98,000 annual estimate that came from the Institute of Medicine in 1999 (which is now widely considered as being grossly low), about 22 percent of fatalities were averted. The high-end 440K estimate translates to a five percent fatality aversion.

Employers must understand that by averting preventable injuries, the potential cost savings are enormous, dwarfing the $20 billion reported by AHRQ. The cost savings per hospital-acquired condition found in the AHRQ report is almost $9,500. If we use this number, the potential annual cost savings by having all 6.6 million preventable injuries averted would be $63 billion annually. Should 11.5 million preventable injuries be averted, the savings would be estimated around $109 billion annually. This savings would translate into a sizeable benefit to communities, employers, employees and taxpayers. But this projected savings does not even approach the social costs associated with preventable medical errors.

Yes, progress in patient safety improvement is inching forward. But to move the needle beyond this anemic pace, this issue must become a top priority for the general public to force the care delivery system to be more transparent, effective, efficient and, most importantly, safe.

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What is Your Cultural ‘Pie?’

By: David P. Lind

Strawberry Rhubarb Pie

Full Disclosure: This particular strawberry rhubarb pie was NOT made by Deb.

My wife, Deb, makes a scrumptious strawberry rhubarb pie. In fact, I really think she could win a blue ribbon at the Iowa State Fair with her recipe. OK, I must admit that I am just a tad bias – but it’s true!

Carefully measured sugar, flour, salt, butter and eggs are added to freshly-harvested rhubarb and strawberries. The pie crust is prepared to ensure the quality and appearance of the pie will not be compromised. How can the tartness of rhubarb and the sweetness of sugar make this pie so delectable to one’s palate? I have come to the realization that my taste buds must be suffering some sort of culinary schizophrenia – especially when a scoop of vanilla ice cream is added on top!

Using consistent ingredients, coupled with the desire to make the same tasting pie each time is a great recipe for success. Unique and positive experiences eventually result in an ongoing trust that the pie will be equally pleasing to the palate in future interactions.

What a powerful and priceless combination – creating a positive experience for the consumer and, consequently, earning their trust.

Developing and maintaining an organizational culture designed to elicit trust is similar to baking a consistently-prepared strawberry rhubarb pie. It takes the right ingredients and level of determination and commitment to use the same tried-and-true process without compromise.

The idea for this particular blog originated after I finished reading a recently published book, “Think Big, Start Small, Move Fast.” Written by three insiders from Mayo Clinic’s Center for Innovation, this excellent book is about developing and implementing a new culture of transformative innovation for not only healthcare organizations but for any organization that desires to adapt to, and possibly disrupt, the future environments and markets in which they operate.

According to former Mayo CEO Dr. Glenn Forbes, a desired culture must be imbedded into the DNA of the ENTIRE organization. “If you’ve communicated a value but you haven’t driven it into the policy, into the decision making, into the allocation of resources, and ultimately into the culture of the organization, then it’s just words.”

Of all health care organizations, one would think that Mayo could rest on their laurels and continue down the path of excellent care to their patients. After all, Mayo is all about the effective care experience for their patients. Simply put, Mayo practices that the patient comes first – at all times.

It started 150 years ago with William Worrall Mayo and his two sons, Will and Charlie. It continues today because of the consistent ingredients the organization has passed down generation-to-generation, with the same passion to serve each patient today and tomorrow. Similar to the pie, each slice is consistently processed and delivered. Each bite allows the customer to trust that the next slice will be no different.

Mayo continues to search for new ways to accentuate their tried-and-true culture so that they will be prepared to address the needs of the future. This never-ending quest serves as a great lesson for other organizations, both inside and outside of healthcare. When the public sees and feels that the organizational values are consistently customer-centric and baked within the culture of that organization, trust will inevitably endure.

So what beliefs, values and behaviors are reflected in your organization? What are the desired attitudes and behaviors that you wish to seek in the people you hire? Does your organization desire creativity, safety, collaboration or innovation?

Whatever the desired culture is for your organization, hopefully it is a positive one that permeates beyond the workplace setting and soundly resonates with the public.

Just like Deb’s strawberry rhubarb pie!

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Searching for the Medical ‘Black Box’

By: David P. Lind

A black leather briefcase with words The Big Reveal inside as aWould hospital employees choose to receive medical care from their own hospital? Wouldn’t you want to know how hospital employees truthfully rated their own hospital’s safety culture?

Yep, me too!

The Agency for Healthcare Research and Quality (AHRQ) released their Hospital Survey on Patient Safety Culture results. This survey is very important for many reasons. One key reason is that these results correlate to infection rates and patient outcomes.

When you think about it, who better to ask about quality of service within a hospital than the frontline worker themselves – staff, nurses, technicians, etc.? In fact, when noted physician, Marty Makary and his staff performed a joint study with risk management firm Pascal Metrics, they found “hospitals that scored well on the staff survey had lower rates of surgical complications and other important patient outcomes.” (Marty Makary, MD, “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care.”, Page 28)

Unfortunately, the results from the AHRQ survey are not meant for public consumption. They are meant only to be viewed by participating hospital administrators and the government. You see, this type of survey is not mandatory. In fact, U.S. hospitals participate in these surveys with the condition the results remain out of the public eye. Because hospital competition can be fierce within certain markets, reputations can be marred by having a low safety score – which adversely affects hospital revenue. Unlike the missing black box from Malaysian Flight 370, it appears this ‘black box’ of critical survey results is meant to remain hidden.

After learning of the 2014 AHRQ survey release, I quickly found that only 653 hospitals around the country participated in this non-mandatory survey (representing about 13 percent of approximately 5,000 hospitals in the U.S.). A miniscule 55 hospitals responded from 11 states within the region where Iowa was placed. The report from AHRQ does not list the participating hospitals, for reasons mentioned earlier. After a few email inquiries, I was able to learn that only 28 Iowa hospitals participated in this survey in 2012 and a paltry 9 hospitals in 2014 (Iowa has 118 community hospitals).

In all fairness, other research firms such as Pascal Metrics, also perform these studies. But once again, we have little knowledge on which Iowa hospitals participate and how often – let alone the results that come from these reports.

Dr. Makary’s view on lack of transparency for safety culture surveys is spot on:
“While I sympathize with hospitals who feel threatened by transparency of safety-culture results, I sympathize more with misled patients….In short, data transparency, properly weighted, would empower patients to make informed decisions about where they should spend their health care dollar.”

Compared to other developed countries, U.S. citizens pay world-class prices to our hospitals, but, in return, we receive little or no transparency on what matters most to us – our safety – and, in some cases, our lives.

This topic should be of great interest to employers when initiating (and leading) discussions with the healthcare provider community. Payers are entitled to know what they are paying for and, what the contents of the black box reveal.

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