Dangerous Assumptions & Lack of Systems: Breakdown in Communication of Test Results

This article in the Washington Post points out a disturbing, yet unfortunately widespread, cause of medical errors: breakdown in communication of test results.

The Joint Commission addresses the issue as one of its National Patient Safety Goals for hospitals. However, systems at many hospitals and physician offices are not "airtight" enough to assure the reliable transmission of information and the delivery of safe care.

The "root cause" for this error generally comes down to one of a few common factors:

• Staff too busy with their "day-to-day" routine. 
• If the result reporting process is not well-integrated into their clinical workflow, there is a high likelihood of system failure.
• No clear process identified for handling of critical lab results.
• This is probably the "over-arching" root cause for the issue at hand. If the process for communication is not robust, not well disseminated, and not monitored, it will inevitably lead to errors. 
• Miscommunication about who in the hospital/ office is handling the communication.
• Results may get reported to a non-clinical staff member (such as a Unit Clerk or Office Manager) who is not the right individual to interpret the significance of the findings.
• Physician was not reachable despite numerous attempts.
• Sorry to say that this is probably one of the most common reasons for failure to relay critical test information, particularly in a busy hospital setting. 
• Lab techs, nurses, and other staff try to follow an "established process", but the process is doomed to repetitive failure because one of the key steps is not reliable.
• Results get communicated, but subsequent "changes to reports" are lost. 
• Unfortunately, this happens often for tests that have to be "incubated" (such as microbiology reports) or "reviewed" (such as radiology reports).
• Test results that cross clinical settings (such as hospital to provider office) are prone to getting lost. 
• Every provider and every hospital may have a different mechanism and process for communicating critical test results. This increases the complexity of the process exponentially, and makes it more prone to break down.
• When there is not "one standardized process for communication" across the local healthcare system, how do we expect individual physicians, staff, and even organizations to ensure reliability?

The system described by Dr. Eric Poon at Brigham and Womens Hospital is a constructive approach to this problem:

However, this system is mostly reliant on an electronic interface, which may not be applicable to all providers in a diversity of clinical settings. In addition to using electronic systems wisely, healthcare providers should remember the key principles of performance improvement for systematically reducing the likelihood of error in this vital clinical process:

• Undertake a root cause analysis for any specific errors at the respective institution
• Undertake a FMEA (failure modes effect analysis) to formally assess the likelihood of systems breakdown for key processes
• Ensure that a specific process is laid out and communicated widely to all staff and physicians
• Build in redundancies to ensure that an "adequate safety net" is in place to catch errors before they affect a patient
• Monitor data both on outcomes (errors reaching the patient) as well as critical steps in the process (such as success in test result handoffs)
• Report data widely to staff, physicians, leadership
• Provide feedback to staff and physicians on individual errors
• Incorporate education about process into staff orientation and ongoing training forums

"No one wants to be an Outlier" - Spine Surgeons at BIDMC Use Performance Improvement Tactics to Reduce Waste

This initiative at BIDMC to reduce waste in spine surgery is a great example of a "performance improvement system" (in this case they used Lean) to improve outcomes (in this case clinical utilization). A similar "performance improvement" approach can work in improving quality, mitigating risk, and improving patient safety.

The article identifies the following "performance improvement tactics" that should be integral components of all improvement projects:

• Examined how much they used and spent (review and monitor data)
• Questioned why each device was being being used (ask why five times)
• Studied reasons for wastage (undertake root cause analysis)
• Asked surgeons, operating room personnel, industry representatives, and nurses to help them identify waste (seek multi-disciplinary input)
• Compiled lists of who had been wasting more instruments than others (create profiles)
• Shared lists [of waste generators] with each other (create report cards)
• Awareness campaign (educate)
• Physician leadership prompted change (get support from leadership)

The key behavioral drivers that project leader, Dr. Kevin McGuire, Chief of Orthopedic Surgery, identified are "physicians are competitive in nature" and "no one wants to be an outlier". Understanding these drivers is key to understanding some of the performance improvement tools and how to deploy them effectively.

USA Today: Medicare Inspector General - "More tracking of serious errors needed"

Have to applaud this report since reporting and tracking are often the first steps towards improvement:

In an excerpt from the article - "That means that those hospitals ... don't learn from their mistakes, Inspector General Daniel Levinson writes .. No one tracks the effectiveness of policy changes or how the hospitals actually correct mistakes." 

These statements get at the real crux of the matter - serious adverse events are happening everyday throughout the nation's hospitals. However, are we learning and responding appropriately to the same in order to reduce the risk of injury for subsequent patients? 

In addition to reporting and tracking of the errors, we need robust risk mitigation and performance improvement systems to ensure that patient safety is being improved:

• Root cause analysis of these events to get to the incipient causes of the errors.
• Corrective action plans that hospitals are held accountable to in order to ensure that the root causes are mitigated.
• Failure modes and effects analyses (FMEAs) to ensure that we understand all the myriad ways systems can fail.
• Systems redesign to ensure that the culture, workflow, clinical actions, and behavior that led to the error are truly modified.
• Auditing and Monitoring of systems and outcomes to ensure that the intended changes have gone into effect.
• Real-time assessments of adverse events in order to mitigate immediate risk to the patient in front of us - in addition to retrospective analyses or prospective improvements.

As outlined above, many actions can be taken to improve patient safety. Unfortunately, as hospitals continue to be impacted by the recession - reductions in volumes, cut-backs in budgets, and cuts in reimbursement, patient safety staffing and patient safety systems are not as robust as they need to be.  We can mandate more monitoring, reporting, and tracking of errors, but unless we work with hospitals to develop the infrastructure required to build patient safety systems, patients will continue to be harmed by the very systems intended to help them.

Use of Checklists Could Help Improve Transplant Safety

Interesting article in the Boston Globe today about changes being made to the Lahey Clinic Transplant Program after a number of adverse events were noted in patients.

http://www.boston.com/news/science/articles/2011/10/21/lahey_clinic_revamps_transplant_program_after_kidney_failures/?page=1

Obviously hard to know from the outside all of the details of the issues and the actions taken, however, some of the writeup excerpted above alludes to changes that could be addressed by a "checklist" process, such as the simplistic sketch below:

Drs. Peter Pronovost and Atul Gawande have researched and written eloquently about the use of checklists to improve safety in healthcare. Those of us on the administrative and clinical front lines need to heed their recommendations for implementing this relatively simple tool that has the potential to prevent adverse events, improve outcomes, and improve reliability of care.

Performance Improvement Tip of the Day: Fix the Problem, and Not Just the Symptoms

Novartis CEO, Joseph Jimenez, in an interview by Adam Bryant of the New York Times talks about getting at the "root cause of a problem" rather than attempting to resolve the symptoms. This is an endeavor that needs to be pursued with greater discipline throughout healthcare. ITs tempting to think that we have identified the root cause, but we don't always exert the discipline to drive deep enough to find it. Too often we are satisfied to act - believing that action itself, or rapidity of action, or intensity of action, can suffice. Action may indeed be enough to keep regulators and overseers happy, but true improvement can only come from a deep understanding of the root issue.

One simple tool - ask "why?" five times - often helps us to persist in the diagnosis of the problem before we attempt to treat it. To illustrate:

Why1: Why did the patient with diabetic ketoacidosis die?

His condition was not recognized as severe in a timely manner.

Why2: Why was that?

Critical lab results were not called in to the right physician.

Why3: Why did that happen?

The lab followed its procedure, but there was confusion about which clinician was managing the case.

Why4: Why was there confusion?

There are no clear protocols for shared management of critically ill patients in the emergency room.

Why5: Why are there no protocols?

We haven't realized the significance of this issue before as an organization.

The inquiry can continue deeper, perhaps ultimately getting at issues of culture or leadership within an organization, however, the leaders conducting the analysis need to be clear that they are unearthing a "root cause" which if addressed will significantly reduce the likelihood of the problem recurring.

Fix the Problem, and Not Just the Symptoms

By ADAM BRYANT

Published: October 8, 2011

This interview with Joseph Jimenez, chief executive of Novartis, the pharmaceutical company, was conducted and condensed by Adam Bryant.

Marilynn K. Yee/The New York Times

Joseph Jimenez, C.E.O. of Novartis, the pharmaceutical maker, says he learned in a previous job that you can't solve a problem if you can't get to its roots.

Corner Office

Every Sunday, Adam Bryant talks with top executives about the challenges of leading and managing. In his new book, "The Corner Office" (Times Books), he analyzes the broader lessons that emerge from his interviews with more than 70 leaders. Excerpt »

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Q. What are the most important leadership lessons you’ve learned?

A. One occurred when I was a division president of another company. I was sent in to turn the division around after four years of underperformance. It was a declining business. And when I got there, I completely misdiagnosed the problem. I said: “Look. We’re missing our forecast every month. What’s wrong?” I brought in a consulting firm, and we looked at what was wrong. And the answer was that we had a bad sales and operations planning process, where salespeople, marketing people and operations people were supposed to come together and plan out the next 18 months and then forecast off of that. So I said: “O.K. We’re going to fix this. We’re going to have the consulting team come in and help us make that a better, more robust process, with more analytics.”

And it turned out it wasn’t at all about analytics. Because once we did that, and we put that new process in place, we still continued to miss forecasts. So I thought, “Something’s really wrong here.” I brought in a behavioral psychologist, and I said: “Look, either I’m misdiagnosing the problem or something’s fundamentally wrong in this organization. Come and help me figure it out.” She came in with her team and about four weeks later came back and said: “This isn’t about skills or about process. You have a fundamental behavioral issue in the organization. People aren’t telling the truth. So at all levels of the organization, they’ll come together, and they’ll say, ‘Here’s our forecast for the month.’ And they won’t believe it. They know they’re not going to hit it when they’re saying it.” The thing she taught me — and this sounds obvious — is that behavior is a function of consequence. We had to change the behavior in the organization so that people felt safe to bring bad news. And I looked in the mirror, and I realized I was part of the problem. I didn’t want to hear the bad news, either. So I had to change how I behaved, and start to thank people for bringing me bad news.

Q. That doesn’t mean letting them off the hook, though.

A. Right. It’s more a chance to say: “Hey, thank you for bringing me that news. Because you know what? There are nine months left in the year. Now we have time to do something about it. Let’s roll up our sleeves, and let’s figure out how we’re going to make it.” It was a total shift from where we had been previously. So after that experience, I always ask all of my people, and I always think to myself: “Are we really fixing the root cause of this problem, if there’s any problem? Or are we fixing the symptoms?”