MESSAGE FROM THE PRESIDENT

LET'S TALK

ABOUT SAFETY

THE BRITISH MEDICAL JOURNAL JUST PUBLISHED A META-ANALYSIS

ON PREVENTABLE HARM and it got me thinking. Harm in medical care is inevitable, but it is the preventable harm by which a system is ultimately judged. Every system, whether it is a large practice or just five practitioners, has its gaps and weaknesses, and when those holes all line up during a patient journey something untoward occurs. Most of us are familiar with the “Swiss cheese” model of adverse events. The size of the system just drives how many slices of cheese there are. To prevent harm, we need to be reactive in the identification of how processes align to allow these to happen but then proactive in the elimination of the holes in each “slice” or step of the journey.

What does safety look like today, and what will it look like in 2030? Today it means that safe care starts in a physical environment in which its citizens feel safe, a culture where an employee can speak up and feel comfortable doing so. As leaders in our practices, we need to set the example of what that looks like, allowing for open dialogue and engagement to identify problems before the holes in the Swiss cheese line up. Unfortunately, too many times folks are “siloed” in their work responsibilities and thus the holes of the Swiss cheese line up.

One of the Top 10 safety issues in the U.S. today is falls with injury. This costs our health care system billions of dollars a year and is in most cases preventable. Most of us do not think about falls at all, why is that? I believe that it is because of this very silo effect. The issue of falls has been historically owned and championed by Nursing. However, patients in our care are sedated, frail, running to the washroom or encephalopathic. What does it take to remind a patient to ring the call light to get help to the toilet as they are in a vulnerable position to be harmed? Maybe about 20 seconds, and in those seconds a patient hears that their provider cares about them and is reiterating what they have heard from their nurse, thus resulting in the conclusion that everyone is really working as a team.

Having been active on the Reduce Falls with Injury (REFINe) working group here at Mayo, I have come to appreciate how simple interventions from anyone working in roles ranging from food service to environmental service to gastroenterology consultation can impact a patient’s risk of falling. It was a deep dive into the problem that helped identify toileting as a major driver for patient fall risk; development of simple scripts one to two lines in length shared with all employees in the hospital to remind a patient not to go to the toilet unassisted is a way to get everyone on board and have them invested and own the problem as a unit. Use of consistent messaging in everything that we do is how culture is changed.

Another area in which we all engage is the intended procedure with a procedural pause. Standardizing the process reduces the number of wrong procedures, incomplete procedures and wrong patients. It includes simplification so that no one has to guess as to: 1) where pertinent information is located, 2) who needs to be involved, and 3) what information is included. Hardwiring this process will take teamwork across surgical, procedural and nursing disciplines to work together, facilitated by a leader invested in change.

U.S. News and World Report evaluation has now replaced patient safety with patient satisfaction, at least for now. However, it is critical that we continue to provide safe care in the context of ensuring patient trust. If safety in the future is tied to patient satisfaction, we need to be mindful that simple strategies like using layman’s terms to describe medical results and procedures, writing down names of medications, and setting expectations up front are some of the ways that patients are satisfied.

So then what does safety look like in 2030? As we move towards construction of a virtual platform we will be able to harness the power of Artificial Intelligence to help us answer some key questions in regards to safety that are not obvious to us now. These for gastroenterology likely include predicting who needs urgent endoscopy, who needs continued surveillance of polyps, and timing of liver transplant. Change is hard for most people, and getting buy-in for new strategies, methodologies and protocols can be difficult. Balancing what has to happen with what should happen takes finesse, understanding and passion for the issue at hand, along with clear vision of a safe future for ourselves and our patients.

“U.S. News and World Report evaluation has now replaced patient safety with patient satisfaction, at least for now. However, it is critical that we continue to provide safe care in the context of ensuring patient trust.”