January / February 2006
What Really Ails Us?
Building a Comprehensive Safety Net
This is the last in a series of three articles regarding the potential to improve patient safety through the use of effective information-technology (IT) solutions.
In What Really Ails Us? Part I: Failure to Rescue and Errors of Omission (PSQH, July/August 2005), I reviewed basic causes of failure to rescue and reached several conclusions:
- Errors of omission are the primary cause of preventable mortality in the hospital.
- Clinicians need a systematic means of dealing with patient decompensation. The disjointed paper medical record doesn't provide that means.
- To improve outcomes, clinicians need IT solutions that deliver useful information, including alerts, directly to rapid response teams, supervisors, and clinicians.
In What Really Ails Us? Part II: Patient Monitoring: Finding Trouble Early (PSQH, September/October 2005), I reviewed current methods of alerting and noted that:
- When clinicians are inundated with alerts, they develop fatigue and can begin to ignore alerts or ask that these be sent only in extreme circumstances.
- Alerting tools tailored to differing hospital roles can solve this problem. Supervisors and rapid response teams need high-sensitivity tools; hands-on caregivers need less-sensitive tools.
- Displaying data in a meaningful fashion is critical. Supervisors must be able to quickly detect patients who are in need and drill down to determine what these needs are.
A Comprehensive Safety Net
Information technology is helping transform medical care by delivering powerful new tools that can help improve quality, monitor patient status, and evaluate trends in patient care. To build an effective, comprehensive safety net, however, hospitals and delivery systems first must ensure that clinical IT solutions meet the needs of clinicians.
- IT solutions must be always available to clinicians.
- Those solutions intended for clinicians must be used by clinicians.
- IT solutions must be able to monitor for compliance with best practices, retrospectively and in real time, and prompt interventions that boost compliance and outcomes.
- IT solutions must enable the organization to measure the effectiveness of best practices.
Successful Use in the Clinical Setting
That clinicians need tools that they actually use might seem a truism, yet in many hospitals and delivery systems, IT solutions intended for the clinical staff aren't selected by clinicians. Rather, the IT staff evaluates these applications for example, a clinical documentation system and/or EMR solution and makes the final selection, often based on technology considerations.
If such applications are to serve their purpose, however, hands-on caregivers must be brought into the selection process, with the clinicians' needs balanced with those of the IT staff.
Above all, clinicians require tools that provide easy, immediate access to critical data such as vital signs, fluids, and medication usage. If clinicians can't easily access, view, and update the information, they are not likely to use the software. And if the software doesn't guide users to follow best practices, its utility is further limited.
Too often, hospitals implement solutions that prove so cumbersome and unhelpful that clinicians simply avoid them, a circumstance that can lead to widespread failure to enter and view critical data in the electronic record.
Perhaps the ultimate test of a solution is whether it has an extensive record of success in the field, with clinicians using it, liking it, and achieving success with it.
Availability Is Essential
Just as clinical tools must be used by clinicians, they must be available to clinicians. In the post-9/11 world, many healthcare organizations have developed disaster-recovery and business-continuity plans intended to help them contend with storms, attacks, blackouts, and other disasters. Perhaps nowhere is the need for preparedness more evident than in the clinical setting, where fully functioning IT solutions are vital to patient safety.
If, during a power outage, electronic records are inaccessible, caregivers can't review or update information about patients' medications, allergies, and conditions. When automated monitoring-alert systems fail, current staffing levels and workflows may prove inadequate to monitor patients by traditional means.
The selection of IT solutions for the clinical environment must be informed by the need for consistent availability during disasters and system upgrade/maintenance activities. This is achievable through technology that has been designed with extensive redundancy and that offers off-site monitoring capabilities. The system must be able to detect and correct system problems and, in a disaster, prevent data loss.
Real-Time Big Pictures
In the previous articles in this series, I discussed the need for tools that monitor patient status and trigger alerts when they detect particular clinical values or conditions. The same data these tools leverage can be put to another important use determining whether clinicians are following best practices and, if not, prompting interventions that increase compliance.
For example, when administrators or clinicians seek to implement the Institute for Healthcare Improvement's campaign to save 100,000 lives by deploying initiatives such as rapid response teams or ventilator bundles, timely answers are hard to formulate, particularly if patient data are stored on paper or in disparate IT systems. In addition, trying to assess whether such efforts have been effective by consolidating and analyzing data can be labor-intensive, requiring extensive IT staff involvement. The reliability of the analyses may be open to question, as much of the data is typically entered by clerks not clinicians who work from second- or third-hand reports. Finally, by the time reports are completed, clinical data within such organizations are usually several months old.
Clinicians need a better, faster way to analyze data not only historical data, but current data as well. If an effective clinical documentation system has been implemented, and clinicians are using it systematically, the organization may be better able to deliver real-time, retrospective analyses and reports to strengthen the patient safety net immediately, not several months after problems have developed.
Armed with these tools, clinicians can readily determine whether preferred methods of care are being employed in a particular clinical unit or by particular providers in the unit. Deviations from best practices can be detected quickly and interventions undertaken before compliance issues and patient-safety problems arise. Clinicians also can rapidly identify patients who aren't responding as expected to best practices.
Measuring the Effectiveness
of Best Practices
The organization can employ the same data repository to help gauge the utility of current practices, make improvements, and determine whether these have been effective in further strengthening patient safety.
Reports on the effectiveness of current practices must be made available to those in a position to change these practices. In many hospitals, IT experts create reports, which then are presented at quarterly committee meetings. Although this represents a step forward from the past, when no evaluations were conducted, it does little to improve current practices. Real-time reports that can be run daily or weekly and accessed by the managers and clinical leaders of individual patient-care areas are essential to the continued strengthening and broadening of the patient safety net.
Making a Difference
To effect a significant, positive difference in patient safety, technology tools intended for clinicians must be used by clinicians and available to them. If these tools are to enable best practices, they should support the capture and aggregation of needed information and guide users to provide best practices. These tools also should monitor compliance, in real time and retrospectively; direct interventions to improve compliance; identify patients who are not responding as expected to best practices; and measure the effectiveness of best practices.
Richard Kremsdorf (firstname.lastname@example.org) is former CEO and president of CliniComp International in San Diego, California, which develops clinical documentation systems for hospitals, integrated delivery networks, academic medical centers, and other acute-care providers. Prior to CliniComp, Kremsdorf served as vice president, clinical information systems, at Catholic Healthcare West, a 48-hospital system, and as medical director of clinical information systems at ScrippsHealth. Most recently, he was CEO of Five Rights Consulting. He is an experienced speaker and educator and wrote the landmark publication, "Medication Safety Tools 2001-3," which defined the essential capabilities of CPOE and electronic medication administration. Kremsdorf is a graduate of the Massachusetts Institute of Technology and Albert Einstein College of Medicine and serves as a member of the Editorial Advisory Board for Patient Safety and Quality Healthcare.