The Building Blocks of Better Care, 10 Years In the Making

This post is being cross-published today as part of The Blog of the Interdisciplinary Nursing Quality Research Initiative's commemoration of the 10th anniversary of To Err is Human.  You can find this contribution and other posts in two week series here.

Shortly after the second IOM report Crossing the Quality Chasm was published in 2001, Don Berwick authored a "users manual," a short document that clearly identified four broad stakeholder interests: the experience of patients; the functioning of the units where care is provided; the larger organizations in which direct care units reside; and the forces (policy, payment, regulatory, accreditation) that shape the performance of these organizations. Berwick described the model as necessarily hierarchical with the experience of the patient on top and other interests aligned to improve the health and functioning of the patients.

Berwick was probably wise to suggest that we begin crossing the quality chasm by holding on to the hierarchy. After all, no one understands hierarchies better than those who give and receive healthcare. By turning the hierarchy upside down, Berwick gave it a disruptive twist, one that helped re-establish the primacy of the care experience (and the outcomes attained) to the business of healthcare.

But I think Berwick was on to something better when he talked about the patient's experience being "true north." It's a construct that acknowledges the importance of the patient experience while seating all stakeholders around a common cause. 

The image of all stakeholders sharing space at the table works for me, especially since a decade's worth of study of system design and performance-shaping factors is dismantling the notion that strict hierarchies serve the interests of safety.

Ten years ago, the relationship between safety and strict deference to hierarchies—and other "soft" markers of dynamics that shape human performance—was not appreciated.  Cooperation, civility, and effective teamwork were seen as "nice to have's," the kind of behavior leaders might foster using sources like All I Really Need to Know I Learned in Kindergarten. Largely seen as social lubricants, behavior-based risk reduction strategies were given low priority in an increasingly technical healthcare domain.

A decade of studying what actually makes high-consequence industries reliable has sent healthcare stakeholders back to some foundational behavior-based learning. It turns out that things like speaking clearly, repeating words to be certain they have been understood; taking turns; using "inside" voices; and getting plenty of rest matter when individuals rely on complex processes to deliver intended outcomes. (Even "time-outs" have made a comeback!)

A series of recognizable standards and expectations are now visible on the frontlines of care. The Joint Commission’s National Patient Safety Goals is the most readily identifiable. But even more important to further progress are the larger studies and best practice recommendations linking elements of organizational culture to improvements in patient safety. Measures that support these relationships are plentiful, easy to locate, and increasingly integrated into forces that shape the performance of organizations.

The emergence of patient safety as a distinct discipline means the study of safety-sensitive processes and measures in healthcare now rests upon a conceptual framework, one that allows stakeholders to understand the science informing compliance measures in a way not possible before To Err is Human. We're poised to know, with increasing precision, not only who should be at the table but if what's being served is any good. 

Ten years spent building a table that so much rests upon is probably not too long. 

Happy Meals in healthcare: Not the Top Chef edition

Measuring quality and safety in healthcare is a process currently in the "Happy Meal" stage of development.

Packages like The Joint Commission's "Core Measures" target a small number of high-frequency, reasonably well understood disease processes, then measure how well people treated in hospitals receive standard, evidenced-based interventions. At their best, core measures mean people with conditions like congestive heart failure and community acquired pneumonia receive the care most likely needed to treat their condition and reduce the risk of complications whether they're in Denver, CO or Dahlonega, GA. Kind of like a #2 Value Meal is the same burger, fries, and Coke everywhere you go.

The Joint Commission's National Patient Safety Goals (NPSG) are another set of menu items. These measures identify error-prone places in systems used to deliver care, then specify practices individuals, teams, and organizations should take to minimize the risk of harm-causing errors. Many emerging norms, like "read back and verify" (used when high-stakes information is transmitted verbally) and fall prevention programs, are driven by NPSGs.

Accreditation bodies use performance on these standards when evaluating an organization's quality. So do payors (including Medicare, Medicaid, and a host of private insurers) with reimbursement schedules increasingly tied to performance. Consumers are seeing evidence of them, too. As I travel around the country, I notice remarkably similar billboards announcing awards received by local hospitals for their performance in highly visible measures of care.

This is a huge step forward in defining expected outcomes and making the processes used to achieve them more transparent. (It's worth remembering that until the IOM report To Err is Human was published 10 years ago, the possibility that patients were harmed as a result of seeking care was not discussed, let alone quantified or seen as the threat to public health that it is.)

I've been a registered nurse for nearly 25 years. And before that, a waitress. So I can tell you from experience that a boxed lunch is not the worst thing that can come of a kitchen.

Current measures and methods for measuring quality are imperfect. They're stymied by a host of confounding variables, but the science of measuring what's good, bad, and ugly in healthcare will mature. Being able to see what's on the menu is a good first step, but Happy Meals aren't satisfying and they're not enough to sustain us over time.

Can you hear me? Can you hear me now?

Welcome to the ongoing celebration of Nurses Week 2009, honoring nurses and nursing sensibilities. Today, it's all about hearing, and the good things that hearing makes easier, like listening and communicating.

Talking "patient safety" with nurses is like preaching to the choir, with the choir finally getting access to sheet music.

A few words about the valuable roles nurses play in making patients safe:




Finally, a look at standards and emerging best practices:

And a small musical tribute that says just a little bit about the important work you do:

Feel free to use the comments section to add suggestions to round out the playlist of songs celebrating nurses. Flo & Bo struck out in several genres, notably country and hip-hop. But hey, it's your party, you can cry if you want to.