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Reflections on Safety
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Reflections on Safety is a monthly column presenting the insights of Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement (IHI). Dr. Gandhi was president and CEO of the National Patient Safety Foundation prior to its merger with IHI in May 2017.

 

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Top tags: leadership  culture  diagnostic error  patient safety  patients  public health  transparency  AHRQ  ambulatory  Health IT  IOM  workforce safety  2016 NPSF Congress  2017 Patient Safety Congress  board certification  collaboration  communication  communication and resolution  CRP  diagnosis  education  emotional harm  families  flu  health communication  health literacy  IHI  measurement  medical education  medication 

Using CANDOR to Improve Communication and Resolution in Health Care

Posted By Administration, Friday, July 15, 2016
Updated: Friday, July 15, 2016
A customizable resource from the Agency for Healthcare Research and Quality

helps facilitate vital conversations.



By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

A cornerstone of the National Patient Safety Foundation’s work involves a push for greater transparency in health care. The NPSF Lucian Leape Institute report on this topic outlines four domains where greater transparency can lead to safer care: between clinicians and patients, among clinicians, between organizations, and with the public.


At its core, transparency between clinicians and patients would demand disclosing medical errors and doing the right thing to mitigate harm when it occurs. Some health systems, such as the University of Michigan Health System, have long recognized that such practices bring benefits for all parties. Patients and families receive an explanation and understanding of what went wrong and why; clinicians involved are permitted to apologize if a mistake was made and to help patients and families heal; and the organization often benefits, because when errors are brought out into the open, solutions can be effected that prevent them from happening again.


Often called Communication and Resolution Programs (CRPs), these efforts get to an essential fact: That most patients and families do not want to punish or sue a hospital, provider, or health system. They simply want to know what happened and that the hospital and clinicians are taking steps to make sure it does not happen again to another patient or family. Financial compensation is also a part of these programs, because it is often necessary support for patients and families after a preventable event.


NPSF has partnered with the Collaborative for Accountability and Improvement to create an educational program for those interested in learning how to implement a CRP in their organization. The program was offered as a full-day immersion workshop at the NPSF Congress in May (read more about that program here).

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If you missed the complimentary
NPSF webcast,
Implementing an
Effective Communication and
Resolution Program,
listen to the replay.

 
   

During the session, Erin Grace, MHA, of the Agency for Healthcare Research and Quality (AHRQ) presented details of a new resource to help clinicians and health systems that want
to set up their own CRP. The AHRQ-developed communication and resolution process, called Communication and Optimal Resolution, or CANDOR, gives hospitals and health systems the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication
and timely resolution for patients and caregivers.


“The CANDOR process is a proactive approach that health care institutions and practitioners can use to respond in a timely, thorough, and just way to unexpected patient harm events,” Ms. Grace said.


Apologizing for errors or bad outcomes runs counter to the culture in which many health care professionals and administrators have long worked. A big fear among many health and risk management professionals is that medical malpractice claims will go up in an institution that readily admits to error. But at the University of Michigan, for example, that has not been the case.


Rick Boothman, JD, chief risk officer at University of Michigan, a long-serving member of the NPSF Board of Directors, and a leading voice at the national level for CRP programs, has spoken often about his organization’s experience. At University of Michigan, since the start of the “Michigan Model” of communication and resolution, malpractice claims have decreased, along with malpractice payments.


Says Mr. Boothman, “At its heart, CANDOR is aimed at stimulating patient safety and optimal patient care…It is only through honesty that we can identify our problems and improve. By focusing on safety improvement, the claims crisis will take care of itself.”


I encourage health professionals—and especially leaders of health care organizations—to take the time to review the CANDOR Toolkit and consider putting it into action.

Does your organization have a formal program for communication around medical errors? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.


Tags:  AHRQ  communication and resolution  CRP 

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Leadership, Culture, Communication at the Heart of Safety

Posted By Administration, Monday, June 13, 2016
The 18th Annual NPSF Patient Safety Congress emphasized the importance of psychological safety, patients and families as partners,
and greater transparency to make us safer.



By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

Regular readers of this column know that the National Patient Safety Foundation has been very focused in recent months on the issues of leadership and culture in health care. Our attention to these interdependent factors, which are vital to advancing patient safety, continued at the 2016 NPSF Patient Safety Congress—the Heart of Safety—held last month in Scottsdale.

Amy Edmondson, PhD, AM,
Novartis Professor of Leadership and Management at Harvard Business School and a member of the NPSF Lucian Leape Institute, led an enlightening keynote session on teaming, which she defined as “coordinating and collaborating, across boundaries, without the luxury of stable team structures.” In health care systems that operate 24 hours a day, 7 days per week, the need for effective teaming is obvious. If the team is not effective, they won’t perform at their best, and safety could be compromised.

Prof. Edmondson explained that psychological safety is essential for patient safety and is a hallmark of effective teams. Psychological safety, “a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes,” is best created by inclusive leadership. Leaders can create this kind of environment by being accessible, by proactively inviting opinions of others, and by acknowledging that they, too, are human, and subject to fallibility.

We also talked a lot this year about communication. Ben Moulton, JD, MPH, senior vice president, Informed Medical Decisions Foundation, led a panel on shared decision making, emphasizing that, often, there is no “right” course of action; the patient’s wishes are paramount in deciding upon a care plan. Among the evidence he cited was a study showing that decision aids lead to greater knowledge among patients, greater comfort with their decisions, fewer patients remaining undecided about a procedure, and fewer choosing major surgery.


Communication and resolution after medical error was the focus of one of our Immersion Workshops led by Tom Gallagher, MD, professor and associate chair, Department of Medicine, University of Washington, and Rick Boothman, JD, chief risk officer, University of Michigan Health System. During our meeting, the Agency for Healthcare Research & Quality released its Communication and Optimal Resolution (CANDOR) Toolkit, and Erin Grace, MHA, of AHRQ was on hand to discuss it with attendees. The new toolkit gives hospitals and health systems the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication and timely resolution for patients and caregivers.

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These topics were brought to life for attendees by Patty Skolnik and Beth Daley Ullem, mothers, patient advocates, and members of the NPSF Board of Advisors, who shared tragic and powerful personal stories of how their families were affected by medical harm. When it comes to engaging patients in their care and creating transparency around medical errors and adverse outcomes, the health care sector has a long way to go. But our faculty for these programs showed us what is possible and how much it truly matters.


Professional meetings are designed to provoke thought, and Kaveh Shojania, MD, director of the Centre for Quality and Improvement and Patient Safety at the University of Toronto and editor-in-chief of BMJ Quality & Safety did just that in offering his assessment of recent, important patient safety research. He discussed a range of topics, including diagnostic error, the impact that rudeness has on team performance, trends in adverse events over time, incident reporting, fall prevention, and high-risk prescribing in primary care. His suggestions that we revisit our thinking on areas such as harm measurement, falls, and safety reporting, have surely generated discussion among attendees.


We closed with a valuable keynote session led by resiliency expert Paula Davis-Laack, who inspired us with her tips for how health care professionals can beat burnout.


We were also very pleased to recognize exceptional work through the awards given at Congress. (Read about the poster awards here and other awards here.)


This year, as every year, I learned a lot from the presentations and from those I had a chance to speak to during our networking sessions. I know attendees left with practical tactics to take home to advance their patient safety activities. The feedback we receive is very important as it helps us shape the program over the years, so we are grateful to those who’ve gotten in touch as well as those who have completed the attendee survey. We are already working on next year, so stay tuned.

Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.


Tags:  2016 NPSF Congress  communication  culture  leadership 

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On More Evidence of the Toll of Medical Errors

Posted By Administration, Tuesday, May 10, 2016
Getting an accurate picture of the problem could help increase research funding for solutions.



By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

The patient safety community—and much of the medical field in general—took notice last week at publication of a new study estimating the toll of medical errors. Comparing data from a number of earlier studies, the authors calculated that more than 250,000 deaths per year stem from medical errors, making this category the third leading cause of death, behind heart disease and cancer.

Speaking for the National Patient Safety Foundation, I can say I am not shocked by the numbers suggested by this analysis. Although there have been some criticisms of the new paper’s methodology—mainly that the comparative studies were done on small sample sizes and are just being extrapolated to identify the national numbers—I applaud the authors for increasing public attention on an issue with which health professionals, as well as many patients and families, are all too familiar.

One of the authors’ main arguments is that medical error is not being adequately measured because it is not considered a cause of death on death certificates. They suggest, “…death certificates could contain an extra field asking whether a preventable complication stemming from the patient’s medical care contributed to the death.” If there were an ICD code for medical error, the authors propose, the CDC would be able to track deaths from that cause the way they track mortality from other causes.

While it is absolutely true that medical error is not currently adequately measured, adding “medical error” to death certificates is not as simple as it sounds; often the person completing the death certificate may not know if the death was preventable. Even when error is suspected, it often takes time to investigate and identify underlying causes.

In discussing the new study, Dr. Martin Makary, the lead author, pointed out that the numbers reported by the CDC are important because they help set the national research agenda. This is why NPSF, in our recent report Free From Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, called for federal agencies to create a portfolio of national standard patient safety process and outcome metrics across the care continuum and to retire invalid measures that are not useful or meaningful.

Better measures nationally for all medical errors will help to truly capture the extent of harm. Better measurement will also help identify research needs and increase leadership prioritization of these issues. It is time for us to begin addressing medical errors as we do other serious public health crises—with robust measurement, scientific analysis, and collaborative approaches to solutions that can reduce the toll on patient, families, and the health care workforce.

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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.


Tags:  measurement  public health 

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Helping To Ensure the Safe Use of Copy and Paste

Posted By Administration, Friday, April 15, 2016
Updated: Friday, April 15, 2016

The Partnership for Health IT Patient Safety has released its first set of guidelines

to help correct unintended consequences of health information technology.



By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

The use of health information technology (IT) has increased dramatically over the past decade, and has helped to improve patient safety through practices such as electronic prescribing. Yet as many of us have seen, health IT can bring with it unintended consequences, some of which pose new risks to patient safety.

 

Ensuring that technology is safe and optimized to improve patient safety is among the recommendations of the National Patient Safety Foundation’s most recent report, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, and health IT in particular is a key area of activity.

 

NPSF is a member of the Partnership for Health IT Patient Safety, a multistakeholder group convened by ECRI Institute’s Patient Safety Organization (PSO) in 2013. Other members include health care providers, health IT vendors, academic researchers, patient safety organizations, and professional societies. Through the collection, analysis, and sharing of health IT data and information, the partnership seeks to inform the national strategy for health IT patient safety, provide useful recommendations for all stakeholders, and in identify ways that health IT can be used to improve patient safety.

 

I serve on the partnership’s expert advisory panel and had the honor of chairing one of the first workgroups, addressing “copy and paste” functionality in health IT systems. Earlier this year, the partnership released the workgroup’s recommendations as part of a publicly available resource, Heath IT Safe Practices: Toolkit for the Safe Use of Copy and Paste.

 

Copying and pasting with the medical record is a widespread practice. Studies of varying disciplines in diverse settings indicate anywhere from 5% to 90% of notes contain copy and pasted text. This practice can improve documentation efficiency and completeness, but also represents a significant risk, as clinicians may unknowingly populate the record with old, inaccurate, or excessive information.

 

Our workgroup focused specifically on functionality and how to use it to increase, not detract from, patient safety. Our task was to define copy and paste, review the literature, and review events reported to ECRI Institute’s PSO. We also talked about vendor functionalities and looked at best practices of some exemplary organizations before finalizing the recommendations. The ECRI team and the workgroup did a terrific job of synthesizing the results of these deliberations.

 

Broadly, our recommendations cover four areas, most of which entail action by both health IT vendors and provider organizations:

 

Recommendation A: Provide a mechanism to make copy and paste material easily identifiable.

It’s crucial for clinicians to be able to easily identify text that has been copied and pasted so they can more easily verify its accuracy and review it for needed edits. This potentially can be achieved by use of a split screen or different formats (for example, use of italics) for copied material.

 

Recommendation B: Ensure that the provenance of copy and paste material is readily available.

Clinicians need to be able to figure out fairly easily where the copied material originated, which helps verify its accuracy and appropriateness. One example of a potential solution is for information about the copied material to “hover” over it when it is being accessed.

 

Recommendation C: Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste.
One of the benefits of copy and paste functionality is that it is a quick and efficient way to document complex information – especially if the information does not change much over time. Clinicians are of course responsible for the content and accuracy of their notes, but in the midst of a busy schedule, the safety risks may elude them. Ongoing education and training are needed about the best ways to optimize its use, and the toolkit provides examples of this kind of education.

 

Recommendation D: Ensure that copy and paste practices are regularly monitored, measured, and assessed.
Health care provider organizations and vendors need to work together to create audit tools and audit policies to monitor the use of copy and paste by providers. By auditing use, they can help ensure the integrity of the clinical record, as well as the quality and safety of care, and gather information on what type of data are commonly copied and pasted, in order to potentially create new solutions or tools. Examples of audit measures and policies are also in the toolkit.

 

I encourage all those involved in health care and in health IT to download the toolkit and consider implementation of the recommendations.

Have you experienced unintended consequences of copy and paste? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.


Tags:  Health IT 

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Going Global on Patient Safety

Posted By Administration, Wednesday, March 23, 2016

This month’s Patient Safety Global Action Summit should inspire us all to come together

to advance patient safety.


By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

Earlier this month I had the privilege of attending the Patient Safety Global Action Summit in London. Co-hosted by the health ministers of England and Germany, the meeting brought together health officials of many countries, including England, Scotland, Switzerland, Germany, Saudi Arabia, and Japan, to name a few, as well as leaders of health care organizations and non-governmental organizations such as the World Health Organization, the National Patient Safety Foundation, and others.

 

Health leaders from the U.S. who spoke at the meeting included Dr. Don Berwick, president emeritus of the Institute for Healthcare Improvement and former administrator of the Centers for Medicare and Medicaid Services; Dr. Gary Kaplan, president and CEO of Virginia Mason Health System and a long-serving member of the NPSF Board of Directors and the NPSF Lucian Leape Institute; and Dr. Atul Gawande, surgeon and best-selling author.

 

As one of the participants noted in a commentary, a goal of the meeting was to begin a “global drive to reduce errors, improve care, and save lives.” It was truly inspiring to see international interest and real commitment from so many countries.

 

In advance of the meeting, researchers based at Imperial College London and affiliated with England's National Health Service produced a report called Patient Safety 2030. The panel I participated in at the meeting specifically addressed one part of this report: The Patient Safety Toolbox for the Next 15 Years.

 

If that sounds familiar, it may be because there is remarkable synergy between the NHS report and the NPSF report, Free from Harm: Accelerating Patient Safety Fifteen Years after To Err Is Human, which NPSF published last December. Both reports put a strong emphasis on leadership, education and training, more centralized and coordinated oversight of patient safety, data and measurement, technology and digital health, and the need for research into implementation science and learning from other fields.

 

In discussing the toolkit needed to advance patient safety from now until 2030, the panel I took part in called for greater understanding of how behavior change happens. How do we get people to practice hand hygiene or use checklists consistently? Lessons we learn from behavioral economics, psychology, and neuroscience can help us understand how human beings behave in certain circumstances and how we make decisions. This knowledge, in turn, can help us identify the most effective ways of implementing known safety interventions.

 

I left the Patient Safety Global Action Summit energized by how much can be achieved when various stakeholders come together. It was particularly gratifying to follow up that experience with Patient Safety Awareness Week, and to see and hear what so many are doing here in the U.S. and abroad to help advance safe care.

 

The themes discussed in Free from Harm and Patient Safety 2030 are clearly resonating with clinicians, leaders, patients, and advocacy organizations. We need to keep this momentum going, to involve policy makers and all stakeholders, until we get to the stage where “Every day is patient safety day.”


What are the top patient safety issues in your organization? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.


Tags:  collaboration  stakeholders 

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