Even though medication-associated errors affect over 7 million patients and cost more than $40 billion each year, healthcare often falls short when it comes to prioritizing patient safety. For example, in October 2021, a draft of the Department of Health and Human Services Strategic Plan FY 2022–2026 didn’t include reducing preventable harm as part of its mission to improve the quality of care. Meanwhile, other complex and adaptive industries, such as aviation and nuclear, give top precedence to safety oversight and compliance. To catch up to other sectors and actively pursue patient safety improvement, healthcare needs a straightforward framework for integrating patient safety across the continuum of care—an approach involving culture, clinical analytics, and frontline adoption of best practices.
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Healthcare industry leaders often look to other complex, adaptive systems, such as the airline and nuclear industries, to better understand their challenges and opportunities for improvement. In particular, the airline and nuclear industries require safety monitoring certifications to operate. These keen observation practices can guide healthcare as it strives to improve patient safety.
For example, the Federal Aviation Administration includes its Safety Management System certification, and the U.S. Nuclear Regulatory Commission oversees licenses, certifies, and oversees safety compliance in its industry. Meanwhile, in October 2021, a draft of the Department of Health and Human Services (HHS) Strategic Plan FY 2022–2026, fails to mention patient safety as part of its mission to improve the quality of care—even though medication-associated errors affect over 7 million patients and cost more than $40 billion each year.
Clearly, healthcare has progress to make in standardizing safety into its regular operations, as the aviation and nuclear industries do. A straightforward framework for integrating patient safety into healthcare involves culture, clinical analytics, and frontline adoption of best practices.
So, what does it take for patients and providers to thrive, like other adaptive industries, in a complex system? The answers center on three areas impacting patient safety and quality:
If a healthcare organization doesn’t have a culture that values teamwork, accountability, and an environment that encourages speaking up, it’s more likely to experience quality issues. For example, in a study of 1,341 healthcare professionals, more than half cited cultural factors—specifically, fear of no change or retaliation and fear of negative feedback or being wrong—as barriers to speaking up about patient safety and quality concerns.
With an organizational culture in which frontline staff are comfortable reporting any safety or quality concerns, health systems can more accurately track and responds to safety issues (an essential step in reducing risk). To ensure that staff are comfortable speaking up, leadership must uphold an environment of non-negotiable mutual respect for all team members.
Clinical analytics plays an important role in scalable, sustainable quality improvement. Factors driving the importance of clinical analytics include growing regulatory and performance requirements, the demand for more timely data for decision making, and the need to integrate data sources (financial, patient satisfaction, operational, etc.). Data is a vital component of patient safety and quality. But without a supportive culture, data isn’t as effective.
Analytics-driven patient safety applications can help health systems decrease rates of preventable harm by identifying and measuring adverse events and guiding interventions aimed at improvement. Organizations can leverage analytics tools to better understand patient harm at their facilities and prevent it from occurring in critical areas, including the following:
With today’s analytic platforms (e.g., the Health Catalyst Data Operating System (DOS™)) and evidence-based content (e.g., real-world data and evidence), health systems have the information and insights to operationalize standard, effective care practices. While there are unique cases and exceptions in patient care, the industry should leverage clinical analytics to allow providers to spend their time on the high-risk cases, while ensuring the delivery of quality standard care in all cases.
Established and approved evidence-based practices, while critical components of ensuring patient safety and quality of care, are only effective if health system clinicians and staff adopt them. Adoption includes educating and training frontline clinicians and healthcare workers, engaging patients, and collaborating with clinician leadership to drive best practices adoption. Evidence-based practices need to be hardwired—thoroughly engrained in frontline practices—to result in patient safety and quality improvements.
While healthcare can’t always follow other adaptive industries’ processes for navigating varying situations and challenges, health systems can help their patients and providers thrive by focusing on culture, clinical analytics, and frontline adoption of best practices. By strengthening these three areas, organizations can sustain patient safety and quality despite changes in providers, miscommunication, and other inevitable disruptions and changes.
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