Editor’s note: Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.
In her professional role, Ann Gaffey is active in the American Society for Health Care Risk Management, serving on the Nominating Committee, as Chair of the Enterprise Risk Management Task Force, as a member of the Leadership Task Force, and as a Faculty member. She also services on the Advisory Council for the Coalition to Improve Diagnosis, a collaboration convened by the Society to Improve Diagnosis in Medicine. Dr. Spurlock serves as an Educational Faculty member for the American Association of Physician Leaders, a clinical and quality improvement contractor for the American Association of Physician Leaders, and as a quality improvement consultant for Valley Presbyterian Hospital.
Dr. Stephen Hines: Can you please provide a short synopsis of the current role that you play as well as the role that you played in the creation of the Making Healthcare Safer Report?
Ann Gaffey: I’m a nurse by background and my work has been centered around risk management, patient safety, and quality for about 30 years. I work primarily in the risk management arena. I was a past president of ASHRM [American Society for Healthcare Risk Management], am on the advisory taskforce for the Coalition to Improve Diagnosis, am the Vice Chair for the National Coordinating Counsel for Medication Error Reporting and Prevention, and continue to do a lot with the Coalition to Improve Diagnosis, as well as some other work with national groups around the country. I believe this work in part led to me serving the technical expert panel for this report. In my day-to-day work, I am in the trenches with risk and patient safety people at healthcare organizations across the country, so I believe I brought that lens of someone who is in the field to the TEP [Technical Expert Panel].
Dr. Bruce Spurlock: I run a small but mighty improvement organization called Cynosure Health. Most of our work is in patient safety and quality in the hospital space. We previously focused on individual organization improvement, but then we shifted to driving improvement at scale, first at the regional-statewide level and more recently at the national level. We are expanding outside of the hospital space, but that’s where the vast majority of our experience is.
SH: If someone is not familiar with the Making Healthcare Safer Report, what is your short explanation of what this report actually is?
AG: From my perspective, in comparison to the previous editions of the report, we have developed a product that makes information actionable quickly. This is of huge benefit to people in the field. The executive summaries allow readers to access the information quickly, and we’re now providing links to resources and toolkits within each chapter. What users are getting in this report is vetted research and a consensus by experts that will help those in the field implement effective improvements more efficiently. The new cross-cutting topics, such as Safety Culture, Teamwork and Communication, etc. also help to highlight the impact that these have on most of the patient safety practices that we’ve highlighted in the report. The final thing that I think is helpful is that we are identifying the setting that the patient safety practice is applicable to. For example, if I was working in a long term care facility, I could easily find the patient safety practices that will be beneficial to me and the work I’m doing.
BS: People are bombarded with information about patient safety and quality, and it’s changing so rapidly with so much new information about how we should be addressing different problems. If I’m new to this area, I wouldn’t know where to start. The report gives me a foundation, a ground floor of the science we should be doing to try to protect patients. From there, you can also get in-depth information on the topics most important to you. It is the one place where you can find all the information you need to get started from experts in patient safety.
SH: Can you both give me an example of how an experience or perspective that you had from your professional life affected how any part of the report was written?
AG: On a day-to-day basis in my work, I consider myself an end-user of this very impressive body of work. When I bring a recommendation or proposed activity forward, the report helps me efficiently understand: where this practice may be applicable, how substantive the review was, what specific outcomes I will be able to affect, and key takeaways. The lens that I believe I brought to the panel was how the end-users are thinking about patient safety practices and what can we offer them to help ensure that they get results. That helped us to evaluate the patient safety practices. Then on the other side, I am taking the team’s findings back to the field to say this is what we’re seeing is working, this is what’s not working, this is worth trying, and we’re still hoping to see more research in this area.
BS: What I work on is mainly implementation. First the practices and the evidence are developed, usually in other settings, and then we disseminate and spread those practices and try to accelerate the adoption. In all the cross-cutting activities in the report, there is now a whole section on implementation effectiveness. This is really a gap area. We know that identifying a patient safety practice doesn’t mean you can effectively use or implement it. For example, I work a lot in early detection of deterioration. When a patient deteriorates in the hospital, if we wait too long to act, we could miss the opportunity for early mitigation of a problem. Just putting sepsis early detection systems in your EHR doesn’t necessarily save lives. It is about how you implement, escalate, and do this notion of a rapid response team. So the report is a great combination of technically necessary practices and the adaptive or implementation practices that makes them effective on the outcomes of most interest.
SH: What would be the one thing that you recommend somebody to read from the report?
BS: If someone is brand new to patient safety, there’s a lot of new information related to diagnostic error in the report that is pretty exciting. The other area that is new and very helpful is the cross-cutting topics. You can learn some of the components of these topics and apply them in various settings. Whatever your focus is, whatever your department in an organization, or whether you have a senior leadership role or you’re on the front lines, the cross cutting topics are applicable and highly useful for you.
AG: I agree, if I were to point somebody to one place in the report it would be the cross-cutting topics. They apply regardless of the care setting you’re in and that’s what makes them so valuable for making healthcare safer. Also, there is the fact that we examined patient safety across the care delivery system. The prior reports were more hospital-focused, and we know that most care is not delivered there these days. The cross-cutting topics can have an impact regardless, even if you’re in home health, it doesn’t matter. These all play a role.
SH: What is the area of the report that you personally learned the most from, either from reviewing or contributing to?
BS: That’s hard to answer because there were a lot of little things. I would say that I spent the most time on the sections related to failure to rescue and sepsis, as I was one of the key reviewers and it’s really important to understand the nuances. Testing for CDI, CDI surveillance, antimicrobial stewardship, opioid stewardship, all those areas were touched on in a way that was very practical, including providing additional resources and links.
AG: For me, delirium was a good place to learn more. I also appreciated the work we did around opioid-related harms. Our lens around this topic has changed since the last iteration of the report because of what we know now in the industry, so I really appreciated the new content offered there. I also appreciated the discussions on the role of technology, which I think we were able to add value to. I thought that was very helpful.
SH: Were there any particular technologies in the report that address critical new or emerging issues that haven’t been addressed in past reports?
AG: I focused on technology to support medication-related harm. We have had CPOE [computerized provider order entry] for years, but as patient engagement with technology has changed, we can think about how to use algorithms and predictive tools to improve safety and give feedback to providers in both medication ordering and monitoring. I think that’s an important place to continue to focus on as we engage patients. For all of the patient safety topics, we need to think about how to maximize the use of technology.
BS: Since the last report, one of the things that has matured the most on the technology front is the use of EHRs. Since the previous report, the use of EHRs has expanded and become more mature, particularly in the hospital space. This opens up more opportunities and more challenges, such as clinical decision support, early warning systems, and how we capture data for medication management. Many of these we incorporated into the report. This area was greatly expanded and more meaningfully incorporated as a technology solution.
SH: This is a very large report, what’s your advice for someone hoping to gain the most information in the most efficient way?
BS: Importantly, it’s not meant to be a book you read from cover to cover. As a user, instead of doing a Google search on a topic where you’re going to get a 1000 hits and be lost on what to do, go to the relevant chapter/section in this report and use that as your starting point. Take advantage of the synthesis of information provided in the report and then drill down on specific areas of interest.
AG: I agree. Our messaging around how to use it will be important. I look at this report as a playbook. If I, or someone I’m working with, have a patient safety problem to solve, I’d want to start where the experts are providing the best information. When you look at the work done behind each of these patient safety areas, it’s impressive. I would also go to the chapter I need, but would also not forget about the cross-cutting topics.
SH: Which part of the report do you think may have the largest impact on patients and patient safety over the next five to ten years?
AG: I think diagnostic error is a big, important topic right now. It impacts everyone, whether you are a clinician or not, and we all have a role in decreasing diagnostic error and improving the diagnostic process.
BS: I would say the cross-cutting sections will have the longest lasting impact because, as Ann said before, they are generalized so well across different settings and topics. There are things that are really powerful in there like simulation, and clinical decision support. These are very impactful to success in implementing practices.
SH: For a report like this, there are some hard choices made about where to focus. Ten years from now, if AHRQ is producing a new report, what will the new issues where there wasn’t quite enough evidence for this edition?
AG: I think we should look at the impact of global supply chain disruption on patient safety. For example, after hurricane Maria and the resulting drug shortages. While not a failure of a hospital process, these nevertheless were a risk or potential risk that impacted patient safety significantly. I think our lens needs to shift as we think about an enterprise approach to reducing harm. This includes: the right leadership structure to assist with funding safety activities, the right human capital resources, and also preparing for things like significant supply change disruption or human capital disruption such as with an employee shortage. All of that affects patient safety. Another new area that we have not touched on is the behavioral health area, and we know how important that is, and how our resources are hurting there.
BS: I’d say two things. Ten years from now I expect to have much more in the ambulatory safety space. We are still grappling with how to do ambulatory safety well because we don’t have a great understanding of it. We think that the magnitude is big, but that maybe the severity isn’t. We also don’t understand the connection between hospitals and the ambulatory space and that’s going to be a big topic to work through in the next five to ten years. The next one is the potential opportunity to use AI and to capture information much more efficiently through electronic health records. This has improved dramatically from the last report, but it’s going to be orders of magnitude more mature as we accelerate along this pathway.
It’s also interesting to think about if we’re going to abandon some practices because they failed. Thinking back to “To Err is Human,” one of the big things it talked about was creating a patient safety organization where you have report all the errors. We thought that was going to be the answer, but later figured out it was not the best approach.
SH: Any speculation as to which practices may be removed in the future?
AG: I was reflecting back on the first IOM report and the first Making Healthcare Safer Report and looking at the things that we are still talking about and grappling with. For example, with regards to retained foreign bodies and wrong site surgeries, I remember thinking when the WHO checklist came out that finally the whole world can agree on one thing. We need to do checklists! But we’re still working hard to get that right 100 percent of the time. So I can see an advantage to digging more deeply into some of the cross cutting topics to get us closer to eliminating error. For example, do we need to still look at wrong site surgery? A lot of that comes down to having the right leadership to hold people accountable for activities. It’s a different way of approaching the challenge, and an opportunity. If we can focus on leadership that holds people accountable, in theory, some of these patient safety events should be minimized.
BS: It’s also interesting to think about some things that may go away because they do work rather than don’t work! For example, the infection-related activities are very effective and we’re seeing massive reductions of HAI. There is this great desire to get the rate to 0, but in ten years we will say that we’ve achieved 98% of the improvement that were going to get. I think we may see a success story like this removed from the report in ten years and we can stop “focusing” on certain areas.
SH: What would you say about the report that would make people download it, get it, and use it in a way that you both have been describing?
AG: I would say to take advantage of the work conducted by not only a team of technical experts, but research experts that have been able to mine the best data available and identify the most efficient and effective practices to help you improve patient safety.
BS: This is a must-have book for your bookshelf in your office for every patient safety expert who wants to be successful. You’re going to turn to it often to see where the state of the art is, and then go deeper from there to be successful in specific areas. Additionally, if you want to be successful in reducing harm and addressing patent safety, time is limited. The most efficient and effective way to do it is to turn first to the report and go from there. It is a time saving tool for you to be able to be effective in your work.
AG: I agree with Bruce, I think that is really a key point, because again people in the field are already overburdened and trying to make improvements. There are already a lot of demands on people’s times, fewer resources, but it’s important to maintain the urgency around the problems that were identified 20 years ago in the IOM report. Giving people a tool like this will help sustain that effort. It is very important for people in the field who are doing this work.
SH: Is there anything else related to the report that you would like to call attention to, anything else that you would like to bring up that we haven’t touched on yet?
BS: I’m going to echo something that Ann said earlier, I think that the delirium piece is undervalued and underrepresented in healthcare in general and it’s a profound problem. We don’t even know how serious it is. This is something that we are just starting to get our arms around, and we should spend more time on it in the future.
AG: Let us not forget the value this report has across all care settings. It does a great job of touching on care settings where we are not getting patient safety practices quite right, like ambulatory, long-term care, and home health. This will have a lot of value.