Trading Checklists for a System's Approach to Quality Improvement

June 5, 2018 David Bach & Anjali Arya

Dr. Don Berwick once said, "The concept of safety as a box-checking enterprise, where we start and finish, is lethal to patients of the future." 

Berwick said this as part of an urgent recommendation to healthcare providers to be less reductive in their approach to patient safety and quality and to instead take a more systematic approach. 

For an adaptive industry, defaulting to restrictive tick boxes on checklists can prevent progress. Healthcare is not so easily templated. Not only that, but taking an reductive approach can be misleading - just as one hospital's checklist may not fit another, no two patient safety and quality journeys are the same. 

So how can hospitals and health systems get insights into risks, prevent patient harm and develop intervention protocols more effectively? 

What can safety learn from quality?   

Currently, we all define safety differently. Across organizations safety may be distinguished by varying practices, programs and policies. But at the end of the day, the concept of safety in healthcare is unified under one common goal: keeping patients free from harm.  

Now, most organizations use adverse events as a measurement for safety. However, adverse events data is often too broad to be the benchmark for what safety means. Broad scope of measurements does not provide a clear direction for improvement and corrective action processes. Processes that often require changes.  

Quality is improvement science – which has suggested protocols, recommended frameworks and actions to pursue. Though there is synergy between quality and safety as disciplines, safety can take inspiration from quality to build adaptive frameworks. This is also reflective in the industry today. Most organizations are making the connection between two traditionally separate disciplines.  

We often hear about the need to have SMART goals to measure appropriately. Organizations are now having a greater push for measuring what truly matters to them. Dulling out the noise to focus on outcomes that provide learning opportunities and areas for improvement.  

It's time to think of quality and safety as one.  

Taking the system's approach 

The Institute of Medicine published a paper called Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After to ERR Is Human. The paper provided a list of recommendations and a comprehensive strategy to reduce medical errors.  

The basic premise being that one cannot focus on individual elements, but instead, focus on what is needed for the system as a whole. But what does this mean for the existing challenges of patient safety? 

Before paving the path for improvement, we acknowledge and identify what the challenge is. Quality and patient safety teams understand that the healthcare system is complex. Systems thinking is a way to understand that the problems that we deal with, are difficult, vexing - but also to understand that this complexity isn’t necessarily a bad thing. It’s a mindset shift where you appreciate ambiguity and complexity, and understand that as a system, it's made up of many elements and dependencies.  

As hospitals embrace more of a learning culture, individuals get the ability to enhance their capabilities to create what they want to create and make it be influential. The onus then is on organizations to adapt and learn over time about how to view the problem of patient safety. 

Doing more with your data

Now that we have acknowledged that the system is complex and that different factors can contribute to improving patient safety and quality, let's take a look at how we can utilize the information we have and put things into action. 

Organizations have common goals. They are interested in finding out what happened or fixing underlying problems or weaknesses to reach their quality and safety improvement goals. By taking a systems approach, quality and patient safety teams should be able to connect the five little, all-important questions – what, when, who, where and how.   

Asking these questions provides you the metrics, gives more details on reported incidents, and allows teams to use the information gathered for improvement purposes. Having this context not only provides clarity to the challenge at hand but also gives teams a starting point to work towards crafting a SMART goal as well as a way to achieve that goal.  

Metrics in themselves only provide a small portion of the full story. Often times, metrics alone fail to provide the necessary context as to how to improve on a said experience. Organizations can use opportunities to get input from staff and patients, map safety experiences through the eyes of the patient and providers and dig deeper into the problem as they look for ways of improvement.  

Building the relationship between safety and quality 

Organizations are now starting to utilize technology to continue to bridge the gap between safety and quality. Technologies are aiding in better data discovery, access to multi-structured data, and with smarter capabilities can help us move further and uncover relationships that we don’t necessarily see.  

By better leveraging the data collected, organizations can extend their reporting capabilities into actionable items allowing for a better use of the data. To better integrate the patient safety initiatives at your organization, we must build the synergy between quality and safety to have a positive shift in culture and have a measurable impact.   

To learn more about the role technology has to play in taking a systems approach check out our quality improvement resources or see our patient safety software in action

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