Patient Safety

MARCH 2018 | FUTUREOFPERSONALHEALTH.COM

Patient Safety Joe Kiani reaffirms the 2020

goal for zero preventable deaths and shares why, with the right steps, it’s well within reach.

Learn how one woman harnessed her best and worst

patient experiences to inspire an advocacy movement.

Discover how the aviation industry’s black box could

inspire wide-reaching change in health care simulation.

2 | FUTUREOFPERSONALHEALTH.COM | IN THIS ISSUE

SAFETY CIRCUIT MGMA18 Operations Apr 22-24, 2018 World Drug Safety Congress Americas 2018 Apr 10-11, 2018

3 Critical Steps on the Road to Removing Diagnostic Error

World Healthcare Congress Apr 29-May 2, 2018 AAMI 2018 Expo Jun 1-4 2018 Population Health Analytics Summit Jul 30-Aug 1, 2018 Virtual Health Care Summit Jul 30-Aug 1, 2018 SimGHOSTS 2018 USA Jul 31-Aug 3, 2018 MGMA Annual 2018 Sep 30-Oct 3, 2018 Patient Engagement and Experience Summit Sep 13-14, 2018 World Anti-Microbial Resistance Congress USA 2018 Oct 25-26, 2018

Jeffrey Brady, M.D., M.P.H. Director, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality

The patient safety landscape in 2018 is changing rapidly as public and private sector players work together to ensure safe, high-quality care for all patients. But challenges remain.

Getting the right diagnosis at the right time is essential to high-quality health care. However, a 2015 report from the Institute of Medicine entitled “Improving Diagnosis in Health Care” noted that most of us will experience at least one diagnostic error in our lifetimes. These

errors occur in all settings of care (including hospitals and medical offices), contribute to about 10 percent of patient deaths and are the leading type of paid medical malpractice claims.

A diagnostic error is defined as “the failure to establish an accurate and timely explanation of the patient’s health problem or to communicate that explanation to the patient.” When these errors occur, the unfortunate result is that you might not get the care you need when you need it, or you might get the wrong care altogether.

That’s why the Agency for Healthcare Research and Quality (AHRQ) is focusing on diagnostic safety as the next frontier in our work to improve patient safety. AHRQ has already produced a toolkit to help primary care doctors track lab test results so that important information is available when it’s needed most. We’re working to build on that toolkit, and we’re working with national experts, doctors, nurses, patients and others to capture their best ideas about what additional research and tools should be our next priority.

Here’s what’s in view on the road ahead: 1. Understanding that if you can’t measure it, you can’t improve it.

We want to help the field get better at tracking and understanding diagnostic errors and make this information available where it matters most — in the hands of those on the front lines of care. We are working with collaborators, such as the Office of the National Coordinator for Health IT in their work with the National Quality Forum to use research conducted by AHRQ and others and address measurement gaps in diagnostic accuracy.

2. Making health IT work to improve the diagnostic process.

From information gathering, to helping doctors with the decision process, to learning from errors, health IT can be a powerful tool for improving diagnosis.

For example, AHRQ-supported research is currently underway to better understand how natural language processing can be used to collect information

within a patient’s electronic health record and present it in a more user-friendly way for the care team.

3. Engaging patients and families as part of the health care team.

The popularity of patient portals and mobile health applications that collect patient-generated health data are getting patients more actively engaged in their care. These tools can also help clinicians gather information prior to diagnosis.

AHRQ is supporting research on how best to collect and utilize patient-reported outcome data to improve the quality and safety of care, better integrating the patient perspective into clinical practice in ways that make sense to everyone who needs this important information.

That’s where you come in. At your next medical appointment, prioritize a list of questions and information for your health care provider. Make the most of your visit, and help your doctor make the right diagnosis for you. n

Publisher Alexandra Flecha-Hirsch​ Business Developer Jordan Hernandez Managing Director Luciana Olson Content and Production Manager Chad Hensley Senior Designer Celia Hazard Designer Tiffany Pryor Copy Editor Emily Gawlak Production Coordinator Josh Rosman Contributors Jeffrey Brady, Kristen Castillo, Jennifer DeMeritt, Joe Kiani, Amber Logan Cover Photo Patient Safety Movement Foundation All photos are credited to Getty Images unless otherwise credited.

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INSPIRATION | MEDIAPLANET | 3

The Nightmare Experience That Turned One Woman Into a Patient Advocate Ilene Corina experienced the worst and best of health care.

Now she’s dedicated her life to helping other patients take charge.

B

eing hospitalized or having a serious illness can be overwhelming for patients — not only because they are anxious about their health but because they don’t know how to navigate the health care system. They might not know the right questions to ask when they need information from doctors and nurses. Health care professionals, in turn, might not realize that patients have important concerns. This can lead to poor communication, mistrust and worse.

A mother’s worst nightmare Ilene Corina remembers this feeling well. “I didn’t know who to trust and was not sure if I would ever feel safe using the health care system,” she says.

Ilene had recently lost her young son after he had a routine tonsillectomy. He began throwing up blood a few days after surgery.

“Repeated trips to the emergency room were met with, ‘Don’t worry, he’s fine,’” Ilene recalls. But a week after her son’s surgery, he died.

“Who would learn from this tragic mistake of a little boy bleeding to death from getting his tonsils removed?” Ilene did.

A crash course in advocacy When she became pregnant with her third child, she was forced to learn everything she could about advocating for herself as a patient. “I was on bed rest and advocating for my unborn child.

I was told this pregnancy could not be saved, but I asked the doctors to try. Giving up wasn’t an option.”

“What is my main problem?

What do I need to do?

Why is it important for me to do this?”

professionals. She attended a conference for the National Patient Safety Foundation (NPSF) in 1999.

“This was when the first Institute of Medicine report was being released that 98,000 people die in hospitals from preventable medical errors,” she says.

Patients, families and health care professionals all want the same thing; what’s best for the patient. “We just didn’t have the same vocabulary,” Ilene explains.

The baby was born premature and spent four months in neonatal ICU. During that time, Ilene says, “I learned from his nurses about being part of the team. We worked together to care for him.”

Since then, Ilene has been on a mission to share her knowledge with other patients and medical

Giving patients a voice Ilene looked for ways to bridge that gap. She started the Pulse Center for Patient Safety Education & Advocacy, where she found that relatively simple actions — like developing door signs and chart signs for patients with special needs and disabilities — could make a difference.

Ilene has also focused on teaching patients how to take charge of communication with their doctors. “The NPSF’s ‘Ask Me 3’ is a great way to encourage patients to start the conversation. What is my main problem? What do I need to do? Why is it important for me to do this?” Necessary conversations between patients and doctors are more likely, she says, “when a patient has tools to begin the dialogue.”

Ilene and the NPSF are not alone in this effort. Indeed, the Agency for Healthcare Research and Quality reports that patients who are involved in their care get better outcomes.

Ilene notes, “It has to do with making the patient and their family more responsible for being part of the team.” ■

By Jennifer DeMeritt

4 | FUTUREOFPERSONALHEALTH.COM | SPOTLIGHT

With Determination and Action, an Ambitious Goal for 2020 Remains in Reach The founder of the Patient Safety Movement Foundation holds fast to his organization’s commitment to zero preventable patient deaths and explains why he’s confident they’ll make their goal.

Six years ago, we began the Patient Safety Movement Foundation with the audacious goal of achieving zero preventable patient deaths by 2020. Today, we are just two years away from our goal, with more than 4,600 hospitals across 44 countries committed to implementing processes that can get us to zero preventable deaths, including the free, evidence-based Action-

able Patient Safety Solutions (APSS) we’ve produced. Participating hospitals that updated their measurements reported 81,533 patient lives saved in 2017 alone. The number of lives saved in 2017 by hospitals that made the commitment to Patient Safety Movement Foundation could be as high as 212,579, with 84,172 in United States alone.

A firm deadline We’ve made progress, but we are still not at zero. I’ve said it before, and I’ll say it again: we will not move or extend the deadline. So how do we get to zero?

First, I’d like to challenge all hospitals to adopt all 16 of the Actionable Patient Safety

Solutions. The APSS are processes designed by a cross-section of the world’s leading medical experts and are proven to reduce preventable harm. Each APSS is drafted in a checklist format which enables hospitals to successfully assess and compare their own existing process, then come up with plans to make sure they are doing all of the steps. Examples include protecting patients from health care-associated infections, sepsis detection and medication error reduction.

Planning for zero The message is clear: systemic patient safety is attainable, but we can’t just hope for zero — we must plan for zero.

Technology has and continues to help clinicians accomplish major clinical breakthroughs, and most of our APSS recommend the technologies needed in the process to achieve zero preventable deaths. But we are not yet taking advantage of the available technologies enough. To reach our zero preventable deaths goal, we need medical device interoperability.

People are dying because of the lack of data sharing. Algorithms that can warn clinicians and help them with decision making can’t be used because data from medical devices and electronic medical records have historically been walled by the manufacturers. To solve this problem, we have rallied 83 medical technology companies

to sign open data pledges to help build a Patient Data Super Highway. We need more medical technology companies to make this pledge and join us in this fight.

Finally, patient education is essential. With a regular doctor visit lasting less than 15 minutes, it becomes critical that we use technology to arm patients, so they know the right questions to ask, understand their diagnosis and know when to come back for follow-up.

Stand with us and lead us towards zero preventable deaths by 2020. We want many more families to be able to share each new day. n

By Joe Kiani, Founder and Chairman, Patient Safety Movement Foundation

INDUSTRY PERSPECTIVE | MEDIAPLANET | 5

Health Care Experts Consider Innovations and Goals for Patient Safety Industry leaders bring their expertise to bear on the implications of technology in the patient safety space as well as immediate goals for the health care industry.

What best practices can health care personnel begin to implement today to support continuous improvement in the health care industry?

Kevin Marti, CEO Intelligent Video Solutions

Allen Berning, CEO Ambient Clinical Analytics

Kristin Hagen, C.M.S.S., C.P.H.I.M.S., Executive Director American College of Medical Scribe Specialists; American College of Clinical Documentation Outcomes

Kevin Marti: Simulation programs that go beyond basic procedural training situations and extend into aspects of leadership, patient safety and improving the overall patient experience. Our health care clients are consistently asking for more ways to capture data surrounding continuing education programs, where data can be quantified to ensure that training and safety goals are being met.

Allen Berning: With growing complexity in medical care, health care-associated infections have become more common. Patients with prolonged stays in acute care units often risk the chance of developing critical infections like sepsis.

Ambient Clinical Analytics strongly believes that the keys to improving outcomes on sepsis treatment lie in using best practices of early electronic detection and proactively monitoring the delivery of the sepsis care bundle within the 3 to 6 hour compliance window for treatment delivery.

These objectives are perfectly supported by using validated, real-time clinical decision support tools combined with a Lean Quality approach to continuous improvement of the sepsis detection and treatment processes.

Kristin Hagen: Transforming America’s health care system is

a team approach. Each physician should look beyond meeting minimum regulatory thresholds and qualifications, and instead, team up and gear up to implement new models of care that focus on improving all facets of health care, including technological, clinical, medicolegal and consumer-driven initiatives. Skilled, credentialed personal medical assistants, which are Certified Medical Scribe Specialists working alongside the licensed clinician, enables all physicians and mid-level clinicians across health care to confidently implement key patient safety standards, while evolving into 21st century medicine toward disease reversal, disease prevention and redefined wellness. The nation is ready; however, it is up to us — the people in the health care system — to use all of the resources available to us.

What technological application do you foresee making the greatest impact on improving patient outcomes?

KM: Without a doubt, video. Next level video technologies can not only improve training and continuing education programs but actually shrink time and distance when it comes to delivering outstanding patient experiences.

AB: Ambient Clinical Analytics has worked with Mayo Clinic to make an impact with its revolutionary, real-time clinical decision support system, AWARE. We see the inability of existing medical devices to detect sepsis

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early has contributed to the high rate of sepsis mortality. AWARE Sepsis DART bridges that gap by using hospital-defined sepsis detection rules to indicate if sepsis may be present or developing, and then programmatically coordinating with specified caregivers to assist them in monitoring the treatment during the first critical 3 to 6 hours of care.

KH: Much of the conversation around technology focuses on hardware, software and systems, even though the most important piece in successfully applying technology in health care is the people who use it. Certified Medical Scribe Specialists bring the U.S. health care system to new dimensions of care, filling in gaps that serve to release physicians from some of what they perceive as their greatest burdens.

Clinically documenting and implementing medical advancements of care toward improved outcomes will create the ongoing wellness, quality and safety that clinicians, insurers and consumers are looking for. Preventive medicine will create the transformation of care. Certified Medical Scribe Specialists are the only licensed individuals who carry the full credential both clinically and non-clinically, into evidence-based care and holistic models. Clinicians are afforded the autonomy to individualize care and best practices, ongoing, to meet their individual needs, regardless of specialty across the health care enterprise.

What does patient safety mean to you?

KM: Accountability and culture.

Every single patient interaction

needs to be treated with respect and personal accountability. Patients are customers, not numbers.

AB: Ambient’s solutions created by clinicians for clinicians improve patient safety. AWARE helps clinicians obtain a “smart view” of electronic health data.

Integrating with the hospital’s EMR system and bedside monitors, AWARE transforms your EHR to a bedside clinical care tool that presents relevant information — customizable for the care practice — on a single screen dashboard. This resolves information overload, which is the leading cause for cognitive medical errors. AWARE facilitates quick access to patient information at the point-ofcare, using color-coded alerts to notify clinicians of a patient’s critical medical condition and aid in interventional clinical decision-making. The platform also provides an intuitive rounding checklist that offers evidence-based indexing to focus on critical elements of patient data and care delivery.

KH: The patient-centeredness of an evolving, value-based health care system is the key to ensuring patient safety. Patient safety encompasses all aspects of the health care evolution that empower and enable individuals to transform from being “patients” in a traditional health care system to being a “clients” in the U.S. health care system of the future. Preventive medicine recognizes the benefit and value of being a client in the health care system, not only keeping oneself well but also enabling the individual to empower others to do the same.

6 | FUTUREOFCAMPAIGNURL.COM | INNOVATION

6 Steps Hospitals Can Take to Intelligently Integrate Tech Technology has a significant impact on patient outcomes, making it more important than ever to act with caution when bringing new devices into a hospital setting.

Over the last decade, spending on health technology has increased exponentially, according to health care technology management professionals in the field. Although there is no question that implementing new technologies has the potential to help patients, it also presents potential risks.

When it comes to selecting and purchasing safe and effective health technology, there are several steps hospitals can take to assess the usability and safety of a device, according to human factors experts.

1

Determine Determine whether the device has undergone adequate usability testing in line with Food and Drug Administration guidance. This is important because incorporating feedback from device end users into the design process helps identify and mitigate potential risks before a real patient ever sees the device.

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2

Evaluate Evaluate the device in-house for user-centered design qualities, in addition to reviewing third-party evaluations.

3

Test Test the equipment in the actual physical use environment to see how clinicians use the device in real-world situations and if any red flags appear.

4

Consult Consult ANSI/AAMI HE75:2009/(R)2013, “Human factors engineering —Design of medical devices,” a standard that provides detailed guidance about design and evaluation.

5

Question Ask questions to determine whether the command input process and output sequences are well designed, such as: does the device perform the actions I wish to initiate? Does it understand my instructions? Does it deny inappropriate inputs? Does it come with adequate external or embedded instructions for use?

6

Train Provide adequate training that encourages proficient and consistent use of technology across users. Training should provide thorough attention to significant hazards and the means to mitigate them, as well as develop troubleshooting skills and provide methods for identifying error recovery actions.

By providing the makers of health technology with feedback and preparing clinicians to utilize this technology in patient care settings, hospitals can make significant strides in reducing preventable patient harm and improving outcomes associated with the use of health technology.

By Amber Logan, Director, Communications, Association for the Advancement of Medical Instrumentation

Learn why health care experts are challenging doctors and other medical providers to focus on both patient engagement and patient safety.

“If the country is ready to remake the health care system, a good place to start is by focusing on its 17,000 physician practices, which are the foundation for the system,” says Dr. Halee FischerWright, president of the Medical Group Management Association (MGMA), the premier association for professionals who lead medical

practices, which represents 40,000 medical practice administrators, executives and leaders at over 12,500 health care organizations in the United States.

Her book, “Back to Balance: The Art, Science, and Business of Medicine,” starts with the premise that health care can be something better.

She’s committed to reforming the art of medicine by utilizing technological innovations and keeping the human element of health care.

The way to initiate that change is “by getting physicians engaged

and empowered,” says Dr. Fischer-Wright. “I truly believe this is the first start and helps us to change from the ground up.”

Building a culture of care Organizational leaders can prioritize a patient-centered approach to create a culture of comprehensive care.

“We are very focused on the patient and the needs of the patient,” says Dave Gans, a national authority on medical practice operations and health systems for MGMA. While health care professionals traditionally are fixed on treating patients for their medical issues, they need to look beyond lab work, x-rays and symptoms.

Gans says patient outcomes may improve when doctors, nurses and health care administrators focus on the patient’s clinical and non-clinical needs.

“So often we lose sight of the patient,” he says. “We’re so busy taking care of the clinical elements, but there’s a personal element to health care as well.”

A patient-centered approach He believes paying attention to the personal and medical needs of patients is the difference between providing good care and the best care.

Gans and his MGMA colleagues encourage providers to ask, “What are the needs of the patient, and how can the organization meet those needs?”

For example, patients may need social and community resources, and information about palliative care. They may just want relief from their anxiety and pain, and talking to their doctor and medical providers can make them feel better. Even evaluating office procedures can be beneficial to patients and providers.

“So much of good patient care is good business care as well,” says Gans, who suggests looking at shortening patient wait times. Patients will be happy to be treated sooner, and the streamlining can optimize office resources and have a positive effect on the doctors and staff. n

By Kristen Castillo