Housing is increasingly considered as an essential element of health, and healthcare organizations could do more to improve housing with government incentives and financial support from Medicare and Medicaid.
Housing impacts health, and healthcare organizations have opportunities to improve housing in their communities.
Housing problems are a key determinant of health for individuals and families, Stuart Butler, PhD, wrote in an article published this month in the Journal of the American Medical Association.
"Poor living conditions can trigger such developments as respiratory problems and stress-related illness, and many falls and hospitalizations among elderly individuals result directly from unsafe housing," he wrote.
Healthcare providers are increasingly partnering with local groups and housing advocates to tackle problems such as homelessness that impact health. Butler makes four recommendations to foster and finance these partnerships.
1. Tax and other incentives
A daunting hurdle for housing partnerships that involve healthcare providers is the "wrong pocket" problem. In these partnerships, investments in housing generate savings that are allotted to healthcare budgets rather than the housing sector's bottom line.
For nonprofit hospitals, one solution to the "wrong pocket" problem is investing in housing as part of the federal community benefit tax reduction, Butler wrote.
"Partly in response to this requirement, as well as to pursue their philanthropic goals, several health systems have invested significantly in housing, such as Bon Secours in Baltimore. The treasury requirement thus serves as a partial antidote to the wrong-pocket problem by encouraging hospitals to invest in the community."
Promotion of housing investment by healthcare organizations also could be achieved through changes to the Community Health Needs Assessment for hospitals under the Patient Protection and Affordable Care Act, Butler wrote.
"Today many hospitals are unsure if they will receive CHNA credit for innovative housing investments."
2. Medicaid managed care waivers
Butler calls on the federal government to increase health-related housing spending through Medicaid managed care's Home and Community Based Services waivers.
"These waivers from federal rules allow communities to use paid social workers more broadly to provide home-based care and so avoid expensive nursing home care," he wrote.
He says federal, state, and local government could also improve safety in the homes of seniors and the infirm by supporting senior villages—nonprofit membership groups that use volunteers and staff to provide a range of home services.
3. More from Medicaid
The federal government should ease restrictions on the use of Medicaid funding for health-related housing spending, Butler says.
Particularly when there are opportunities to improve health and achieve savings, Congress should allow Medicaid spending for room, board, and capital expenses, he wrote.
4. Medicare flexibility
He says Congress should build on passage of the CHRONIC Act of 2017, which gives some Medicare Advantage health plans authority to use money for nonmedical services that boost health such as housing.
Congress could also allow Medicare managed care organizations to pay for home alterations, Butler wrote.
When performing cardiopulmonary resuscitation in a hospital bed, getting into the bed or leaning on the bed optimizes the working position.
In the hospital setting, working position such as lowering a patient's bed optimizes cardiopulmonary resuscitation (CPR), researchers say.
Using manikins in hospital beds and on the floor, the research compared clinicians' CPR performance based on depth of chest compressions. Although no difference in chest compressions was noted—both groups were too shallow—work position improved chest compression depth.
"Participants who optimized their working position for CPR (defined as jumping onto or lowering the bed) performed chest compressions with a median depth of 39mm, while participants who did not optimize their working position performed chest compressions with a median depth of 29mm," the researchers wrote.
In hospitals, most resuscitation attempts are made in a bed.
Working position boosts CPR performance, according to the researchers, who published their article in the American Journal of Emergency Medicine. The study included 108 healthcare professionals.
"Lowering the height of the bed or kneeling on the bed increases the force delivered and leads to deeper chest compression depth. Our pooled data support these findings as participants who optimized their position, by lowering the bed or jumping onto the bed, performed deeper chest compressions," the researchers wrote.
An earlier study found that a small increase in bed height to 20 cm above the knee decreased chest compression depth.
with less than a 30% chance of survival to discharge. International
resuscitation guidelines stress the importance of CPR with high-quality chest compressions with minimal interruptions," the AJEM researchers wrote.
Earlier research has found healthcare professionals often perform CPR poorly during actual cardiac arrests.
In addition to using an effective working position, the AJEM researchers highlighted three best practices for resuscitation in the hospital setting:
Compressions must be performed at the correct depth and rate, with full recoil
Hand placement is crucial. Earlier research has found that placing the dominant hand first generates a significant improvement in chest compression depth. Other research found a quick and straightforward way to place the hands on the chest properly.
Put metrics in place to help healthcare professionals evaluate their CPR performance during training and actual cardiac arrests
Most healthcare professionals in the AJEM study overestimated the effectiveness of their chest compressions, indicating the need for performance monitoring, the researchers wrote.
"The majority reported no difficulties in achieving sufficient chest compression depth, suggesting that these participants were unaware of their sub-optimal chest compression performance."
Until there is more clarity about best practices for resuscitation in the hospital setting, the researchers give two options for CPR training:
Focus resources on simple but more frequent CPR training with a manikin on the floor
Create a more realistic training environment that emphasizes CPR working position
Compared to a control group of patients, acute heart failure patients in an emergency department's clinical pathway program had a 13.1% lower readmission rate.
Enrolling acute heart failure patients in a clinical pathway program reduces hospital readmissions from emergency departments without increasing time spent in the ED, researchers say.
The research, which was published this month in the American Journal of Emergency Medicine, found patients in an Acutely Decompensated Heart Failure Clinical Pathway (ADHFCP) program experienced a 13.1% decrease in hospital admission from the ED compared to a control group of patients.
A key element of the ADHFCP program, which was conducted at an academic medical center, was an immediate consultation with a cardiologist when participating patients presented at the ED, the researchers wrote.
"Improved communication between cardiologists and ED physicians through the establishment of an explicit pathway to coordinate the care of heart failure patients may decrease that population's likelihood of admission without increasing ED disposition times," they wrote.
The cardiologist consultations likely reduced admissions from the ED for two reasons, according to the researchers:
First, ADHFCP patients were more likely to receive diuretics than the control group of patients, and diuretics were given in higher quantities to ADHFCP patients. "These differences in care may have helped reduce the need to admit these patients," the researchers wrote.
Second, meeting with a staff cardiologist likely boosted the confidence of ED physicians to discharge ADHFCP patients, they wrote.
"Direct communication between the ED provider and the staff cardiologist frequently resulted in a guaranteed short-term clinic follow-up visit. Knowing these patients would be re-evaluated shortly after discharge increased the comfort level of the ED providers."
In addition to the cardiologist consultation, the ADHFCP program had four primary components:
Cardiology follow-up appointments a week after discharge
Primary care appointments two weeks after discharge
Follow-up telephone calls at 3, 7, 14, and 21 days after discharge
More care visits at the discretion of clinicians
Medicare's Hospital Readmission Reduction Program (HRRP), which penalizes hospitals financially for high readmission rates, includes heart failure as one of its 20 targeted conditions.
Heart failure is a prime area of concern for hospitals seeking to lower readmissions, the researchers wrote. "One of the HRRP's diagnoses of interest was congestive heart failure, which clearly merits focus for readmission reduction. Approximately 550,000 individuals are diagnosed with heart failure a year."
In addition to lowering readmissions, the researchers found that ADHFCP patients did not spend more time in the ED than the control patients.
"While the difference between the time spent between ADHFCP patients and control patients was not statistically significant, patients in the program actually spent slightly less time than controls, suggesting that the program may have even saved time in the ED," the researchers wrote.
Uncertainty plays a key role in wasteful healthcare decisions such as ordering unnecessary medical tests, and hospitalists can help address the problem in their role as educators.
Uncertainty is a primary driver of wasteful clinical care in the hospital setting, researchers say.
Even though the Choosing Wisely campaign has generated more than 500 guidelines to decrease unnecessary testing and treatment, hospitalists face many other uncertainties daily, the researchers wrote in an article published in the Annals of Internal Medicine.
"Guideline recommendations cannot possibly cover the range of decisions that hospitalists make on a daily basis. This gap leaves large areas of uncertainty that are often filled with unnecessary care," they wrote.
They say uncertainty fuels misguided decision-making about medical testing. "An unfortunate consequence of uncertainty is that it often leads to a knee-jerk reflex to 'order more tests' and, in many cases, the additional tests do not significantly reduce the uncertainty at hand."
Unnecessary testing linked to uncertainty has multiple negative impacts, they wrote.
"This seemingly innocuous search for clarity is a likely contributor to the estimated $25 billion waste related to the misuse or overuse of medical testing. Uncertainty has also been shown to result in unnecessary referrals, increased admission rates, delays in patient care, and even patient harm."
Hospitalists key players
Hospitalists are well-positioned to limit the impact of uncertainty, says Charlie Wray, DO, MS, lead author of the uncertainty article and an assistant professor at the University of California San Francisco.
Hospitalists are at the front-lines of inpatient education and teaching, which gives them a crucial role in teaching the next generation of physicians, Wray told HealthLeaders this week.
"This gives hospitalists the ability to role model and show our trainees that it's OK to not always have the exact right answer or to be uncertain of a decision."
Wray and his coauthor cited three approaches hospitalists can take to limit the impact of uncertainty:
Use the Physicians' Reaction to Uncertainty tool, which measures a clinicians' response to uncertainty. Using this tool at the beginning of a rotation can quantify uncertainty, allowing a hospitalist to acknowledge it and to discuss how uncertainty could affect testing decisions.
Use a learning tool such as SNAPPS to help clinicians express uncertainty during daily rounds. Expressing uncertainty is often frowned upon in medical culture, which places a premium on knowing the correct answer. A singled-minded focus on correct answers encourages learners to ignore uncertainty rather than finding out how to manage it.
Patient engagement and shared decision-making are essential because of patient unease over uncertainty. Discussions with patients should include acknowledging the vagaries of clinical care as well as the potential harms and benefits of tests.
Engaging patients openly and honestly is crucial because many of them have "therapeutic illusions" that overestimate the value of testing and underestimate the potential for harm, Wray says.
"I've found that when we're honest with our patients about the limitations of medicine, the therapeutic illusions they may have brought to the situation easily fade away as they come to understand what medicine can, and cannot, do for them. In having this open and patient-centric conversation, you build a report with the patients."
Wray has developed an approach for these kinds of conversations with his patients.
"I will be extremely focused on what our plan is. For instance, I will say we will do this if X happens, and we will do that if Y happens. Getting specifics, having a contingency plan, and knowing the direction of their care is always comforting to patients."
Patients at a Texas healthcare facility receive four levels of treatment from a full range of psychiatric and physical health staff.
The opening of a new pediatric behavioral health unit in Austin, Texas, represents a leap forward in mental health services for the city's children.
The Grace Grego Maxwell Mental Health Unit is located at Dell Children's Medical Center of Central Texas, and was funded in part with a $3 million matching grant from the Maxwell family of Austin.
"It's a best-practice model of care system for integrated mental health services. We provide a holistic approach to treating children with mental disorders," says Sonia Krishna, MD, a child and adolescent psychiatrist at Dell Children's.
Comprehensive care and enhanced access are keystones at the Maxwell Mental Health Unit.
Comprehensive care model
Placing the new mental health unit at Dell Children's is a key element of the facility's comprehensive care model, she says. "We will be on the same campus as physical health specialists like pediatricians, nutritionists, physical therapists, and occupational therapists."
The mental health unit features a multidisciplinary behavioral health staff of fellowship-training psychiatrists, psychiatric nurses, social workers, psychologists, and expressive therapists. "We have specialists in drama therapy, art therapy, music therapy, and recreation therapy. We also have access to a nutritionist for eating disorders and a pediatrician for any physical health complaints," Krishna says.
Part of the comprehensive care model for pediatric mental health at Dell Children's is offering four levels of care, she says. "We are not just having patients stay overnight. We also have lower levels of care where patients can receive intensive services while being embedded in their community."
These three lower levels of care are:
An outpatient clinic, Texas Child Study Center, operated in partnership with the University of Texas;
An intensive outpatient program, where patients interact with care providers for three hours after school; and
A partial hospitalization program, where children receive care during the day and then go home to their families at night, is in development.
"We have all the levels of care in one place, which is revolutionary for central Texas. … Patients can have access to the inpatient unit, the medium levels of care, and a community-based clinic all on the same campus with the physical health doctors," Krishna says.
Easing access
Siting all pediatric behavioral services on the same campus is a leap forward for patient access in Austin, Krishna says.
The Maxwell Mental Health Unit has replaced a 24-bed pediatric behavioral health facility at Seton Shoal Creek Hospital, which is located about two miles from Dell Children's.
"Before, you went to Dell Children's to go to the emergency room. Then you would have to get in an ambulance and go across town to Seton Shoal Creek Hospital, where you would go to the inpatient unit. Then you would go to the Texas Child Study Center to get your outpatient care," she says.
Locating the new mental health unit at Dell Children's also eases access psychologically, Krishna says.
"What also makes it easier is we are located at a facility that people are used to going to for other needs. … If you have an allergy appointment, you go to the same place as for your mental health appointment. This also significantly decreases stigma."
In addition, an innovative approach to boosting patient access is adding behavioral health navigators to the Dell Children's staff.
"If you have an allergy appointment, you go to the same place as for your mental health appointment. This also significantly decreases stigma."
—Sonia Krishna, MD
"There is a dedicated phone number that is answered 24/7. Parents can call and get connected to a trained behavioral health navigator, who will ask them questions and try to determine the level of care that is most appropriate for their child," she says.
Millennials are becoming increasingly important for physician practices seeking to maintain or grow their market share.
Millennials are playing a leading role in the transformation of the practice of medicine.
"Over the past 10 years, there's been a move out of the hospital. There has been a shift away from having a big physician office at the hospital to having offices in the suburbs to make healthcare convenient. That's what the millennials require," says Louis Levitt, MD, vice president of The Centers for Advanced Orthopaedics in Bethesda, Maryland.
The baby boomer generation's predilection for primary care and hospitals is not shared by millennials, he says.
"Millennials tend to go to a clinic system—either acute care clinics or chronic care clinics—to treat acute processes before they will consider going to an orthopedist or other specialist for care," he says.
"They are very cost conscious, and clinics are less expensive for them than going to an expensive physician office," Levitt says.
For specialists, millennials have upended the traditional approach to generating referrals, Levitt says. Under the traditional approach, specialists build a reputation for excellence that, in turn, draws physician referral sources such as primary care practices.
He says millennials require more direct engagement.
"We have to go out and meet millennials in their work and play environments. They are not going to come into an office based on a relationship, and most millennials don't have primary care physicians," Levitt says.
Levitt is retooling his practice, Orthopaedic Medicine and Surgery Care Center in Washington, D.C., to cater to millennials. The practice has taken four approaches.
1. Online presence
Making a practice accessible online is essential to attract millennial patients, Levitt says.
"We make online booking a top feature in the office. Millennials don't have any patience—certainly not for hanging on a telephone line for 10 or 15 minutes waiting for someone to make an appointment. So, we have to have easy access for them to get into the office," he says.
In addition, online tools ease administrative burdens on millennials, he says. "We also use tech to allow patients to fill out forms in advance of showing up at the office."
Social media is also one of the keys to engaging millennials.
"There is a huge shift to relying on social media as a form of advertising—going right to the sites where millennials seek information and enticing them to come to your practice. You let them know they can been seen quickly," Levitt says.
2. Convenient location
To help provide easy access for millennials, Levitt's practice has opened its first satellite office in 35 years of operation.
"I have spent a great deal of time and energy avoiding doubling up on expenses and personnel with two offices. I always believed that if patients wanted to see me, they would come to my office," he says.
The new office was targeted specifically at millennials.
"This year, we opened our first ancillary office in an area around Capitol Hill in Washington, D.C., that is a growing gentrification area for the city. It's the site where all the millennials are focused. So, we felt we had to open an office there to be convenient for millennials," Levitt says.
3. Patient experience
Millennials insist on good service, Levitt says.
"If millennials spend more than 30 minutes waiting for you in the office, they will believe they had a bad healthcare experience no matter how good the healthcare delivery was during the visit," he says.
To rise to the customer service challenge, Levitt's practice has focused on the efficient use of patient time.
"We have gone to great lengths to cut down on the wait times and any other difficulties getting into the office. We are aware that we are no longer going to be judged on healthcare alone. Patients are judging based on the entire patient experience," he says.
4. Embracing change
To appeal to millennials, established physician practices must be open to new ideas and new approaches to providing care, Levitt says.
"I can't hang on to my old ways. So, when my junior partners come to me looking for help managing their email and text messaging with patients, I can't deny that we need this kind of help just because we didn't have the need before," he says.
The Arizona-based health system's new chief clinical officer is committed to sharing data with patients and curbing medical staff burnout.
Banner Health has promoted Marjorie Bessel, MD, to serve as the organization's new chief clinical officer.
Bessel, who most recently served as Banner's vice president and chief medical officer for community delivery, is succeeding John Hensing, MD. He retired last month.
At Banner, one of the unique aspects of the chief clinical officer position is direct oversight of the information technology department, Bessel says.
"IT reports up to this role, which is responsible for care delivery and making sure information flows. There is a lot of technical support to make sure all of that is happening," she says.
HealthLeaders Media spoke recently with Bessel. Following is a lightly edited transcript of that conversation.
HLM: Why do you have a passion for healthcare transparency?
Bessel: Part of it is personal. One of my brothers was diagnosed with Hodgkin's lymphoma six years ago. He does not live in Phoenix, where I live.
It was really important to both of us—him as a patient and me as a close sister—that the University of Rochester where he got care had a fabulous patient portal. My brother is an engineer and it was very important to him to know everything that was about to happen to him. He wanted to know all his data.
When you are in a situation like that, it can be overwhelming and life-altering. You want to feel that you have some control over what is happening to you. For my brother and patients like him, that control comes from access to their own data.
HLM: How did your brother's experience influence your approach to transparency at Banner?
Bessel: That portal experience was important to my brother and important for me at Banner. When I looked at what we had at Banner, I did not see the same level of transparency or sharing data with our patients. We did not have the same level of sophisticated tools to enable that to occur.
I worked on a very large change management initiative to make sure information was flowing to Banner's portal without delay and without embargoing test data. That resulted in a lot of changes to workflows all the way down to the provider level.
HLM: You also are an advocate for medical staff wellness. Give an example of a burnout initiative you have helped lead at Banner.
Bessel: I am responsible for burnout across the organization, in partnership with our chief human resources officer, Naomi Cramer. We have a balanced approach to put up programs so we can support all of our providers across the organization.
When you think about safety, the patient is front-and-center. They may have been harmed by the care that was delivered by Banner. Their friends and their family and their support network around them also suffer when an error happens.
We know there is a whole other circle of people suffering. These are second victims, and they are the people who delivered the care. It could be the nurse. It could be the pharmacist. It could be the physician, it could be a therapist, or someone else.
We are making sure that we are having excellent conversations with the patient, and with the patient's family and friends. We are also making sure we are supporting the staff involved in the event because they suffer as well.
Bessel: As humans, we all are going to make mistakes. What we experience in healthcare is when we put processes into place, when we put programs into place, when we put safeguards into place, we have drift over time from those best practices because we are human.
Because we have drift, we experience errors that programs or processes were supposed to mitigate.
Some of the solution is going back to basics, which is something we do at Banner. We have to make sure that when we put a program into place that we are consistent and focused on monitoring it.
Some of the challenges we have also are very basic. A lot of errors are related to infection such as post-operative infection. The solutions can be very basic like remembering to wash your hands.
At Banner, we are going back to revisit programs and processes that we have put into place. We are correcting drift. We are also working on the basics that all of us should do like hand washing.
The new measurement set is designed to generate valuable clinical care and outcome data without placing a crushing administrative burden on physicians and their organizations.
The American Medical Group Association has endorsed 14 metrics as a value and quality measurement set for data reporting in payer contracts.
Widespread adoption of the new measurement set would address the administrative burden and burnout associated with the current patchwork of reporting regimes, says Jerry Penso, MD, MBA, president and CEO of the AMGA.
"Our members told us that the burden of reporting the current quality measures was great; mainly, time to run the measures and time out of clinical practice for physicians to input the data," he says.
The AMGA, which is based in Arlington, Virginia, represents physician groups and health systems nationwide. More than 175,000 physicians practice at AMGA member organizations.
"Reporting is also a factor in physician burnout," Penso says. "That's a flaw in the current measurement system. There are too many measures, and they are not harmonized between the different insurance programs."
In 2016, Health Affairs published research that shows the costly consequences of the current reporting system. The study found that physician organizations spent $15.4 billion annually to report quality data and the average physician worked for 785 hours yearly on reporting.
The AMGA's 14 measures feature both process measures such as cancer screening and outcome measures such as hospital readmission rates:
Admissions for acute ambulatory sensitive conditions composite
HbA1C poor control
Depression screening
Diabetes eye exam
High blood pressure control
CAHPS, health status, and functional status
Breast cancer screening
Colorectal cancer screening
Cervical cancer screening
Pneumonia vaccination rate
Pediatric well-child visits through age 15 months
A task force drawn from the AMGA's 22-member Public Policy Committee used multiple criteria to select metrics for the new measurement set, Penso says. "They were aiming for a smaller set—14 to 25 measures—as their final target."
He says there were seven primary selection criteria:
Measures had to be clinically relevant and impactful on patient lives
Measures had to be evidence based, with scientific evidence of care improvement
Claims-based measures were preferred because of the ability to report from claims data
Track records were required—measures needed to demonstrate an ability to improve quality through past performance
Measures that accounted for patient experience were preferred because a patient's perception of care is an important outcome
Metrics needed to have a large enough sample size to be statistically valid for performance comparisons
The current reporting system is overkill, Penso says.
"The way many people use quality measures is for external reporting—it could be part of a value-based contract or public reporting for patients. Our point is that all of the measures that are out there do not need to be used for this purpose."
The AMGA is not seeking to replace or abolish metrics that were not included in the new measurement set, he says.
"A lot of other quality measures can be used for internal improvement. Physician groups can use our measures, then use other quality measures for internal benchmarking and internal management of performance improvement initiatives."
Taken as a whole, the new measurement set gauges not only quality but also value, Penso says.
"Quality is important to all of us, our patients, our families, and our providers. But our value measure set has other metrics that are important like utilization, cost, and patient safety."
The next steps in collecting patient experience data include gathering information in real time and aligning patient experience surveys with a healthcare organization's primary goals.
Patient experience officers are seeking to enhance the timeliness and value of the data collected from patient surveys and other sources.
Upgrades are overdue, according to a recent report from Boston-based Chilmark Research.
"Traditional patient experience survey solutions suffer from three clear shortcomings: They are too long, they capture retrospective data, and they use outdated phone- and paper-based methodologies to gather data," the report says.
The report is based on interviews of a dozen chief experience officers (CXOs), who said their most pressing need is gathering data in real time before patients leave care settings such as inpatient wards, emergency rooms, and laboratories.
"Among the CXOs interviewed, the most pressing need is insight into the patient experience at the point of care," the report says.
For more than a decade, healthcare providers have been collecting valuable patient experience data through Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys required by the Centers for Medicare & Medicaid Services. However, time lag is a major shortcoming of HCAHPS data, the report says.
"Today's CXOs increasingly need near-real-time information about patient sentiment in order to improve the care experience while someone is still in the hospital or within days (and not weeks) of discharge."
The report makes five recommendations for healthcare providers seeking to upgrade their patient experience data capabilities:
Align surveys with organizational goals: Healthcare providers often focus on two or three primary goals for improving the patient experience. Survey solution questions and answers should align with these goals and the metrics such as HCAHPS that measure progress toward meeting those goals.
Account for employee satisfaction: Burnout has cascading impacts—successively degrading care delivery, care quality, and patient experience. Employee satisfaction surveys should gauge burnout levels and enable sentiment analysis that can provide insight on curbing burnout.
Real-time capability: CXOs interviewed for this report wanted to understand how individual business lines and departments perform without waiting weeks for HCAHPS survey results.
Qualitative data analysis: Surveys should have open-ended questions, not just yes or no queries that generate quantitative data. Patient experience data collection also should include phone calls to administrative offices and call centers.
EHR integration: Including patient experience surveys in electronic health records allows physicians or nurses to discuss surveys with patients, then administer the survey during the care episode. This approach can appeal to patients who dislike automated text or email messages.
The National Steering Committee for Patient Safety seeks to recast siloed approaches to safety, create measurable goals, and promote the total systems approach to safety.
A national coalition of healthcare organizations is seeking to jumpstart patient safety efforts.
The National Steering Committee for Patient Safety is tasked with crafting an action plan to reduce patient harm by early 2019 and generating measurable results within the next three years.
In 2016, Johns Hopkins safety experts reported that more than 250,000 deaths in the U.S. were linked to medical errors annually.
The new patient safety panel is striving to slash that mortality figure by breaking down safety siloes, creating measurable safety goals, and taking a systematic approach to improving safety.
Boston-based Institute for Healthcare Improvement (IHI) is the prime organizer of the steering committee. Twenty-four organizations are represented on the panel, including:
The scale and reach of the steering committee's membership bodes well, says Tejal Gandhi, MD, MPH, chief clinical and safety officer of IHI, and cochair of the steering committee.
"We need to percolate everything we are doing to the local level. The organizations we have pulled together all have interconnections with the frontlines," says Gandhi.
The steering committee has three primary objectives.
1. Break down safety silos
The steering committee seeks to promote coordination and cooperation among healthcare organizations, Gandhi says.
"There are many organizations working on patient safety, ranging from hospitals to health systems, primary care practices, associations, foundations, and government agencies. But what has become apparent is that there are often different agendas," she says.
A siloed approach to safety is inefficient and limits progress, she says.
"You can have two or three organizations working on similar safety topics but doing it in different ways without coordinating. The risk is that at the frontline the messaging can become complicated. One organization can want you to do five things, and another organization can want you to do another five things," she says.
To increase cooperation, the steering committee is drawing on the public health model, Gandhi says.
"As we have tackled public health issues over the years, we have had national coordination for these issues, whether it has been smoking, seat belts, or another public health issue. That kind of approach was the impetus behind the National Steering Committee," she says.
2. Create unified and measurable safety goals
A top objective of the steering committee will be selecting strategies to strengthen the foundation of patient safety such as leadership, organizational culture, and patient engagement.
"The hope is we will be able to create a national action plan with three or four significant goals related to safety that can be measured," Gandhi says.
Setting metrics will be a challenge, she says. "There has been a lot of debate about how you measure patient safety and harm; so, getting several organizations to come to a consensus on what we are going to measure and what we are going to improve is a key piece."
The steering committee's goals likely will be measured on a case-by-case basis. "There are many metrics, but the ones we choose are likely to be a combination of structure, process, and outcome measures. We will work that through for every one of the areas we pick," Gandhi says.
Leadership and culture are tempting targets for improvement.
"Leadership needs to be fully engaged in patient safety and see it as a core value for their organization. They set that vision and goal for the entire organization," she says.
Culture also is crucial for safety.
"Culture is foundational in terms of creating a culture where people feel comfortable talking about errors; and they know if they do talk about errors, they won't be punished. That culture is critical in advancing efforts for patient safety," Gandhi says.
3. Promote a systematic approach to safety
The steering committee, which held its first meeting in May, is promoting the total systems approach to healthcare safety.
The total systems approach is comprehensive rather than piecemeal, Gandhi says.
"You might have a medication error issue and a falls issue, which are important issues to address; but if you focus on them one at a time, you may improve them without achieving success across the board," she says.
Components of the total systems approach include ensuring that leaders foster a safety culture; creating centralized oversight of patient safety; addressing safety across the entire continuum of care; and partnering with patients and families.
Engaging healthcare leaders is essential to promoting the total systems approach to patient safety, Gandhi says.
"The governance and leadership of health systems need to understand the total systems approach. We are working on leadership and culture with the American College of Healthcare Executives. We are working on a project to better educate boards about total systems safety," she says.