Interview: The Importance of Patient Safety in Healthcare

Stephanie Sargent serves as the Vice President of Product Development and Quality for SE Healthcare. In this position, Stephanie oversees the development and success of the Physician Empowerment Suite™ and other SE Healthcare programs.  

Stephanie has spent decades working in the healthcare industry in a variety of roles. She has worked as a registered nurse, three years of which she spent as a traveling nurse; the Performance Improvement Facilitator at the Medical University of South Carolina; and, most recently, as the Patient Safety Program Manager at the Medical University of South Carolina. As a certified Lean Six Sigma Black Belt, Stephanie is well-versed in improving efficiency, effectiveness, quality of care, and patient safety. In the following interview, Stephanie provides insight into how to improve patient safety.

SE Healthcare: The Institute of Medicine has defined patient safety as “the prevention of harm to patients” with emphasis placed on preventing errors, learning from errors that do occur, and building a culture of safety that integrates healthcare professionals, organizations, and patients.

It seems intuitive that patient safety would be a high priority in healthcare, but there are still numerous medical errors and adverse events daily. What are some of the factors that contribute to these lapses?

Stephanie Sargent: It is important to think of patient safety as a mindset. Frequently, people reference having a “culture of safety”, but what does that mean?  “Culture” simply means there is a collective mindset of “the way we do things here”. The focus should shift from trying to change minds to changing practices. Implementation of standard practices will necessarily shift mindsets and the culture of any work environment.

Three imperatives rise to the top for organizations to consider: The first is just culture. For people who are unfamiliar with just culture, it is a concept initially applied in the aviation industry and then later in the healthcare sector, led by David Marx, JD.

A just culture is one that evaluates the quality of an individual’s behavioral choices rather than outcomes. For example, two surgeons knowingly skip the surgical time-out. One surgeon’s case proceeds without incident while the other surgeon proceeds to operate on the wrong patient. How does the organization investigate and respond to each scenario? The behavioral choices were the same, but the outcomes were quite different.

Fortunately, reckless behavior as described in the preceding scenario is relatively rare. The vast majority of medical errors are unintentional and often the result of working within a flawed system – one that sets individuals up for mistakes. Human error, no matter the outcomes, does not place blame on the individual. Instead, the investigation is focused on the system and design improvements. Mistakes and near misses are golden opportunities for organizations to learn.

The second consideration is becoming a learning organization. Learning organizations have a system in place to collect error information, analyze root causes, implement changes to prevent recurrence, and disseminate learning. This creates a feedback loop: trust, report, learn, improve.  This relates to a third element – transparency.

Transparency is a powerful tool. Historically, quality metrics (including medical errors and adverse events) were heavily guarded and difficult to obtain for anyone other than a select few. Many organizations have moved away from this outdated model and now post quality metrics on the internal intranet for all to see. Some organizations even post their quality data in the public areas of the hospital for patients and visitors to peruse. Inspired by Brigham and Women’s Hospital posting medical errors on their public website, at a previous workplace we published select adverse events (ones most impactful for learning) in a daily electronic newsletter that went out to nearly 10,000 employees. Cc’d in the distribution was the local newspaper.  Each case led to system and procedural improvements.

SE Healthcare: You have previously worked in positions where you directed safety efforts to improve patient safety and you’re certified as a Lean Six Sigma Black Belt. You have utilized this experience to provide classroom instruction to all levels of staff and leadership. How can individuals in top level leadership positions contribute to improving patient safety and preventing incidents?

Stephanie Sargent: There are a few things that organizations can do to support a culture of safety. The first is to designate someone as a very visible champion of patient safety – including having responsibility for patient safety performance metrics in their job description. This should be a high-level, senior leader who may have the title of Chief Quality Officer or Patient Safety Officer.

Organizations also need to integrate patient safety into their pillar goals. Organizations typically use pillar goals to measure performance. Examples of pillars are growth, finance, quality, people, and service. Patient safety falls into the quality pillar. Within that pillar, organizations should develop goals around patient safety. Those goals could include reducing the number of serious safety events or healthcare acquired infections. The goals should be relevant to that organization.

Patient safety should be integrated into the mission statement. Incorporating patient safety into the mission statement provides a visible commitment to internal and external stakeholders of that organization’s commitment to safety. It communicates that patient safety is a top priority.

The organization also needs to decentralize accountability for safety. This means that even though one person – such as the Chief Quality Officer — is a visible champion for patient safety, they are not solely responsible for patient safety. A good way to implement a practice that sets the stage for a safety mindset is to create local safety champions. For instance, in a hospital setting, each nursing unit may have a dedicated safety nurse (.1 – .5 FTE) who is responsible for implementation of unit-based safety initiatives, managing investigation of events, and educating staff.

SE Healthcare: Referring to your experience in the healthcare industry, are there any instances that specifically stand out to you as lapses in patient safety? Can you discuss this event and how it could have been prevented?

Stephanie Sargent: In 2000, there was a patient at the Medical University of South Carolina named Lewis Blackman. This case was very public and monumentally changed how healthcare is delivered today. Lewis was a young kid, 15 years old, who elected for a voluntary surgery to correct a defect of the chest wall, pectus excavatum. In his days post-op, he was given Toradol, an IV painkiller. One of the known risks associated with Toradol is GI bleeding, so it is carefully administered within safe parameters. At that time, less was known about the risks in adolescents, so it was administered on a recurrent schedule to control his pain. Lewis complained of severe and increasing abdominal pain following his surgery. The nurses and physicians inadvertently misdiagnosed his pain as intestinal gas or an ileus. He died three days after his surgery of a perforated gastric ulcer that had bled ¾ of his total blood volume into his abdomen.

There was a cascade of reasons that this incident occurred. Experience: The weekend coverage were residents – some only a few months out of medical school. Certainly not recognizing Lewis’ deterioration contributed to his death. Perhaps a seasoned clinician would have recognized the early signs of complications, but more likely the late signs to be sure.

Cognitive error likely played a role as well. Clinicians prematurely settled on the single (common) diagnosis of ileus, or post-op gas, and did not adjust the diagnosis despite new information that became available.

His mother spent the hours and days after Lewis’ surgery reporting to staff her fear that her son’s condition was deteriorating, but her concerns were not escalated to higher-level, attending physicians. Nor did Mrs. Blackman understand if she could raise the red flag in any other way.

After Lewis’ death, Mrs. Blackman fought to pass the Lewis Blackman Act. Key provisions of the law include:

  • Each hospital must provide a mechanism, available at all times, through which a patient may access prompt assistance for the resolution of the patient’s personal medical care concerns.
  • If at any time a patient requests that a nurse call his or her attending physician regarding the patient’s personal medical care, the nurse shall place a call to the attending physician or his or her designee to inform him or her of the patient’s concern. If the patient is able to communicate and desires to call his or her attending physician or designee, upon the patient’s request, the nurse must provide the patient with the telephone number and assist the patient in placing the call.
  • All clinical staff, clinical trainees, medical students, interns, and resident physicians of a hospital shall wear badges clearly stating their names, their departments, and their job or trainee titles. All clinical trainees, medical students, interns, and resident physicians must be explicitly identified as such on their badges. This information must be clearly visible and must be stated in terms or abbreviations reasonably understandable to the average person.

SE Healthcare: Many of the issues that arise in patient safety are preventable. How do other issues in healthcare, like physician burnout, contribute to lapses in patient safety?

The data is strong that patients who have better care experiences have better outcomes. There is a direct correlation between burnout, patient experience, and clinical outcomes.

Stephanie Sargent: Burned out physicians have lost their enthusiasm for their practice and they are physically and emotionally exhausted. I recently read an intriguing article about burnout and “moral injury”. First used to describe soldiers’ response to their actions in war, the definition of moral injury is, “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” This is an interesting take on one root cause of burnout.

In terms of scope, we know that rates of burnout are high – between 40 and 60% depending on the specialty. Physicians have been trained to ignore their own needs and put patients first. As a result, when they wear down, they generally don’t ask for help. The downstream impact is the burned-out physicians turnover at higher rates, induce turnover in teammates (because they can be difficult to work with), make more mistakes, have higher rates of claims, and suffer from worse patient satisfaction.

The data is strong that patients who have better care experiences have better outcomes. There is a direct correlation between burnout, patient experience, and clinical outcomes.

At an organizational level, it is advised that management start with measuring the scope of physician burnout. Measuring allows organizations to know where they are on the burnout continuum and it allows them the insight to act on the findings. And by the way, it’s not advisable to simply ask physicians to work on not being burned out (Do more mediation! Install lavender infusers in your office!). There are many flawed organizational processes and systems that contribute to burnout.

SE Healthcare: There has been a shift in healthcare towards patients taking a more active role in their health management. What tips do you have for patients on how they can advocate for themselves and mitigate the risk of experiencing patient safety lapses?

Stephanie Sargent: It is so interesting to see how patients have become more active in their care generationally. For example, Baby Boomers experienced a healthcare system where physicians practiced a more paternalistic-style medicine. These days, Millennials are more proactive, involved, and informed. The internet has been a huge disruptor in healthcare. There are more accessible resources than ever for consumers to become engaged. Recall that patients who are highly engaged are more likely to understand and adhere to care plans, be compliant with medications, and have better clinical outcomes.

With the Affordable Care Act and the individual mandate, many patients chose high deductible health plans. With these plans, they are taking on more of a risk for themselves because of potential increased out-of-pocket expenses. Consumers are focused on getting more value for their money. That being the case, more and more health plans are finding that they have to be transparent due to consumer demand. Patients want the most cost-effective care possible.

Consumers need to approach healthcare the same way they approach other consumers goods or services. When you shop for a product on Amazon, you take the time to compare your options and read reviews. You should shop for healthcare with the same mindset. There is a wealth of publicly reported quality data on such websites as Physician Compare and Hospital Compare. Healthcare consumers can easily “shop” for the doctor with the highest patient experience ratings or the hospital with the lowest infection rates. I’ve done this myself!

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About Author

Stephanie Sargent

As the Vice-President of Product Development & Quality, Stephanie oversees the continued development of the Physician Empowerment Suite©, and ensures the ongoing growth and success of the Suite and other related SE Healthcare programs. Stephanie is a seasoned clinical and Lean Six Sigma professional with more than 22 years of experience in health care. As a certified Lean Six Sigma Black Belt, she is skilled in identifying clinical and operational performance gaps to decrease professional liability risk, meet regulatory and accreditation requirements, improve clinical quality and patient outcomes and reduce waste and inefficiencies.

2 thoughts on “Interview: The Importance of Patient Safety in Healthcare”

  1. This is Nice Article. Patient safety is important factors for all healthcare providers. So that this is useful for all healthcare management.

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