The Problem of Patient Harm:  An Unwelcome “Fellow Traveler”

The incidence of patient harm has been widely documented.  A paper by Sammer et al showed that there is a relationship between “all-cause harm” outcomes and performance measures[1]Sammer, Christine et al. “Examining the Relationship of an All-Cause Harm Patient Safety Measure and Critical Performance Measures at the Frontline of Care.” Journal of patient safety vol. 16,1 … Continue reading such as: 

  • Safety culture;
  • Employee engagement; and
  • Patient experience. 

The Sammer et al study does not provide sufficient evidence to answer the following question: 

Does culture drive outcomes, or do outcomes drive culture? 

Pascal will seek to address this question in more depth in a future blog.

First Principle of Patient Harm:  Measure, before Managing

Worthwhile to point out is that most health systems, while investing substantially in process, technology, and people when it comes to employee engagement and patient experience, generally invest far less in patient safety, limiting resourcing to a safety team and select hires (e.g. medication safety), cultural intervention-oriented consulting (especially post-harm event), and implementation and maintenance of an event reporting system.  

Health systems do not measure adverse event outcomes using EHR data with clinical validation (AE Outcomes).  Consequently, the data do not exist at most health systems for the questions – such as the first posed above – with evidence.  Indeed, the field historically has relied on “proxy” adverse event outcomes data, i.e. those which are not sufficiently fine-grained, patient-specific, and validated using clinical data.

Practical Implications

Why is measuring with AE Outcomes relevant today?  Practically, doing so enables health systems to execute with more clinical effectiveness and operational efficiency on common initiatives.  Let’s just identify several leadership-oriented themes: 

  • Zero Harm Campaigns.  How can a CXO or board claim to be making progress towards “zero harm” if the primary source of insight is event reporting data, which the evidence indicates captures approximately 5% of patient harm?[2]Landrigan et al NEJM article; Classen et al GTT article; Sammer et al Harm ID article; HHS OIG 2012 report
  • Board Safety Objectives.  Without knowing with validation using clinical data what the frequency and severity of harm at a fine-grained category level using patient-specific data is, then how can management prioritize which event and pattern types to prioritize with limited resources?  They can’t, which is why – when responding to a board or CEO request for an annual safety KPI –  “proxy priorities” from external organizations such as The Joint Commission, CMS, and others are used instead of “How are my patients in my hospitals getting harmed, how frequently, and why?”
  • Common Cause Analytics.  This last point on “why” harm is happening can only be answered with accuracy if seeking to identify harm across the entire patient population with a comprehensive method that proactively surveils every patient (which, while not in scope for this blog, is more equitable, versus inequitable voluntary event reporting data).  The reason is because a solution such as Pascal VPS not only documents the AE Outcome but also the common causes and contributing factors to that harm – valuable insight that “tees” up analytics for caregivers that directs resources to the highest and best clinical use. 

Takeaways 

Takeaways include:

  1. Measurement.  Safety, risk, and quality programs – even if well intended – are flying blind without AE Outcomes.
  2. Management. Whether a campaign like “zero harm” or a targeted harm, only continuous measurement will enable us to validate that management is making progress or that an organization has not fallen in performance once a safety KPI is no longer a flavor de annum.
  3. Methodology Methodology matters.  It must be evidence-based and accurate, timely and actionable, and comprehensive and explanatory – providing valid and credible analytics and insight to caregivers in order to maximize the amount of time spent on care delivery, versus “sense-making” which is best already done in the background.

Footnotes

Footnotes
1 Sammer, Christine et al. “Examining the Relationship of an All-Cause Harm Patient Safety Measure and Critical Performance Measures at the Frontline of Care.” Journal of patient safety vol. 16,1 (2020): 110-116.
2 Landrigan et al NEJM article; Classen et al GTT article; Sammer et al Harm ID article; HHS OIG 2012 report