From Governance to Management:  A New Era for Patient Safety & Quality, and New Best Practices

Implementing an advanced electronic healthcare record (EHR) system does not deliver safety and quality for patients — just the data for doing so 

Annals of Internal Medicine recently published an article, “Measuring Patient Safety in Real-time:  An Essential Method for Effectively Improving the Safety of Care.”  The co-authors, Dr. David Classen, Fran Griffin, and Dr. Don Berwick, base their piece on the fundamental changes brought to healthcare by the combination of health IT and patient safety. Overall, they lay out a roadmap for boards of directors and healthcare leaders on patient safety and quality.

This guidance is not just for early adopters and high performances but for “all hospitals” [and equally applicable to outpatient].  In short, the piece reminds leaders of the landmark report of Institute of Medicine (IOM) [now the National Academy of Medicine], “Health IT and Patient Safety,” which recommended that hospitals and health systems use EHR data to measure and improve safety.

Indeed, as co-author Dr. Don Berwick — the globally acknowledged founder of the modern patient safety and quality movement — makes clear in the accompanying video (below), the piece is intended to be…

“…a plea to take the electronic health record…and look at it as a tool, a lens, through which to study and assess overall safety…We propose that, at least at the first step, a way to do that would be to automate the Global Trigger Tool…to use the EHR as a window on safety and care.”

Dr. Don Berwick on the Automated GTT:  The “First Step” Towards Real-time Patient Safety

Patient Safety & Quality Management:  A Review of the Essentials

The Goals are the Same But Traditional Tools are No Longer Enough

Before going any further, let’s first set the stage by recalling — when it comes to patient safety — what the responsibility of the board and management is.  In short, alongside compliance obligations, it is to ensure that the organization is:

1. Detecting patient harm to answer the question, “Where is care not safe?”

2. Measuring harm over time to answer the question, “Are patients getting safer?”

3. Demonstrating institutional capacity to answer the question, “Are care teams avoiding harm and improving as efficiently and effectively as possible?”

If the organization is unable to accomplish any of the three requirements, there is an obligation to figure out why and then be responsible for implemented changes.  Traditional tools of event reporting, billing systems, and even advanced EHRs do not allow us to answer these questions effectively.  Let’s unpack why.

Patient Safety In Real-time:  Why Now and How to Get There

The Problem of Harm 15 Years Later:  Still Pervasive But Now Viable Solution Available

In the article, “Measuring Patient Safety in Real Time:  An Essential Method for Effectively Improving the Safety of Care,” recently published in the Annals of Internal Medicine by Dr. David Classen, Fran Griffin, and Dr. Donald Berwick, the co-authors strongly advocate to using real time EHR triggers to measure and improve patient safety.  Why have these global experts weighed in now?

First, widespread preventable injury to hospitalized patients persists more than 15 years after the IOM report, “To Err is Human,” brought it to international attention. In fact, medical error was recently cited as the third leading cause of death in U.S. hospitalized patients. This magnitude of harm will likely remain unchanged until it is measured effectively and consistently by every hospital, as many have called for.

Second, several leading health care organizations have demonstrated the ability to measure all causes of harm in real time in the whole inpatient population, allowing for more robust measurement and actionable intervention to reduce or mitigate harm. Real-time clinical surveillance not only provides a full-hospital population approach to patient safety but also can help to predict which patients might experience harm and when, supporting prevention before harm occurs:

“Surveillance for harm in the electronic record using the leading commercial EHR vendors’ products can be affordable, sustainable, and actionable….Building on what has been learned from the use of triggers in the past 15 years and leveraging the EHR is a reliable approach to measuring all causes of harm in all hospitalized patients, with minimal resources and in a time frame that allows for concurrent mitigation and prevention.”

Third, the U.S. regulators announced their intent to develop a new electronic hospital safety measure using EHR data.  This is expected to replace the current coding/claims based PSI-90, which is tied to reimbursement by both public and private payors.  Hospitals are well advised to start preparing now for a significant change in safety- and quality-related payments.

Summary Findings:  What To Do

In it Dr. Classen (an inventor of electronic adverse event detection), Ms. Griffin (a top clinical expert in patient safety), and Dr. Berwick (widely acknowledged to be the key founder of the modern patient safety and quality movement) articulate the following key points:

  • Triggers Find More Harm.  Research has demonstrated trigger-based adverse event detection to identify more than 90% of harm in hospitalized patients, versus less than 10% by billing data and less than 5% by voluntary event reporting, the current field standard
  • Boards Should Use EHR Data for Patient Safety.  Despite electronic healthcare record (EHR) penetration having reached 96% of U.S. hospitals, health systems are not using EHR data to measure, monitor, and manage safety
  • Concurrent Harm Identification & Reduction.  Building on 15 years of trigger development and learning, using EHR triggers can support “a reliable approach to measuring all causes of harm in all hospitalized patients…that allows for concurrent mitigation and prevention.”
  • Leading Systems Already Have Demonstrated Viability.  Leading health systems such as Adventist Health System, Baylor Scott & White Health, Dignity Health, Kaiser Permanente, Providence Health & Services, and Cook Children’s Health Care System have used automated EHR triggers with success
  • “CFO-grade” Patient Safety Business Cases.  Surveillance for harm using EHR triggers on health IT data can be “affordable, sustainable, and actionable,” providing a population-wide approach to patient safety, just as it has in the area of infection control — in fact, using EHR data delivers “CFO-grade” business cases for patient safety
  • Regulators Already Moving on Electronic All-cause Harm.  CMS recently announced publicly the development of a new EHR-based patient safety measure using electronic approach, which aligns with all of the above

A Call To Action:

The co-authors conclude with a call to action, namely that all hospitals should use their EHR data to measure, monitor, and manage their patient safety efforts.  In the accompanying video, Dr. Berwick implores,

“We need healthcare systems to demand it.  We need hospitals and boards of trustees and leaders in hospitals, for starters, to say we need to know what the overall levels are in our organization….”

Indeed, EHR triggers properly implemented in an automated all-cause harm management system not only has been proven to work, but leading health systems are reporting that – just as Dr. Berwick explains above – EHR trigger based systems provide a unique “lenses” into their care, enabling learning not available in any other health IT system.

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