Structural Approaches to Address Issues in Patient Safety

Susan D. Moffatt-Bruce

• Publisher: Emerald Publishing Limited
• Year: 2019
• Print ISBN: 9781838670856
• eBook ISBN: 9781838670863
• Topic: Social Sciences
• Subtopic: Management
• Index: Social Sciences

This volume explores the ways in which structural changes in health care environments impact patient safety. It delves into the potential that design thinking can have when applied to organizational systems and structures, as well as the physical environment, to mitigate risks, reduce medical errors and ultimately improve the quality of care, provider well-being, and the overall patient experience. 

Much of health management empirical research has focused on the process and outcomes and then attempted to reverse engineer the structure that may reasonably explain that. This volume presents studies from the United States and Europe to demonstrate the benefits of a structure led approach. The chapters employ a variety of methods including needs assessment, consensus building, systems modelling, survey research, secondary analysis of EMR data, and qualitative methodologies. Together they provide meaningful conclusions to the question of how structural approaches in learning health care environments can be improved to create a positive impact on patient safety.

FAILURE TO RESCUE EVENT MITIGATION SYSTEM ASSESSMENT: A MIXED-METHODS APPROACH TO ANALYSIS OF COMPLEX ADAPTIVE SYSTEMS

Susan P. McGrath, PhD^a Emily Wells, MPH^b Krystal M. McGovern, MSN, RN, MBA, CCRN^c Irina Perreard, PhD^d Kathleen Stewar, BS^e Dennis McGrath, MA^f and George Blike, MD, MHCDS^g

^aDepartment of Anesthesiology, Dartmouth-Hitchcock Medical Center, USA, [email protected]

^bDepartment of Surgery, University of Michigan, USA, [email protected]

^cDartmouth-Hitchcock Medical Center, USA, [email protected]

^dDepartment of Anesthesiology, Dartmouth-Hitchcock Medical Center, USA, [email protected]

^eDartmouth-Hitchcock Medical Center, USA, [email protected]

^fConsultant to Dartmouth-Hitchcock Medical Center, USA, [email protected]

^gGeisel School of Medicine, Dartmouth College, USA, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA, [email protected]

ABSTRACT

Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.

Keywords: Systems analysis; failure to rescue; patient safety; system design; ideal rescue care system; complication management

THE OPPORTUNITY FOR SYSTEMS ANALYSIS OF PATIENT SAFETY PROGRAMS

It is widely acknowledged that health care systems are complex adaptive systems (Gravio & Patriarca, 2016; Kuziemsky, 2016), where analysis of constituent subsystems cannot easily explain the behavior of the system as a whole. Yet, as McDaniel et al. discuss (McDaniel, Driebe, & Lanham, 2013), health care delivery systems also differ from other complex adaptive systems due to the incidence and relationship between many factors, including abundant non-determinate processes and behaviors, temporal and geographic variability, and lack of effective cost-benefit models. These properties complicate the many program management and resource investment decisions entrusted to health care system leaders (Dixon-Woods, McNicol, & Martin, 2012; Swensen, Dilling, Carty, Bolton, & Harper, 2013). Planning and management of hospital-wide programs can be especially difficult, as methods typically employed for strategic planning and prioritization vary widely across health care organizations, with most attention focused on national-level and patient bedside process planning, versus institutional-level priorities (Barasa, Molyneux, English, & Cleary, 2015). Patient safety systems represent a key case in point, as they are commonly implemented across institutions and possess many of the factors that set health care systems apart from other complex adaptive systems, as described here.

The need for systems-focused practices to address health care management challenges has been acknowledged nationally (National Academy of Engineering US and Institute of Medicine US Committee on Engineering and the Health Care System, 2005; President’s Council of Advisors on Science and Technology PCAST, 2014), and as a consequence some hospitals have turned to systems engineering analysis and design domains such as systems thinking (IDEO.org, 2015; Meadows, 2008), systems engineering (Buede & Miller, 2016; Carayon et al., 2011), continuous improvement (Cudney & Agustiady, 2016; Staudter et al., 2013), and cognitive systems engineering (Rasmussen, Pejtersen, & Goodstein, 1994). These domains support investment decision-making, facilitate more deliberate prioritization, and improve performance of health care delivery systems (Bo-Linn & Pronovost, 2012; McGrath & Blike, 2015). Systems engineering approaches are human-centered design disciplines and combine qualitative and quantitative analysis, objective and subjective considerations, and theoretical and empirical approaches to improvement. The engineering toolkit contains methods and instruments that allow complex systems to be described, analyzed, understood, and optimized.

Systems approaches use a set of structured execution steps. These include identifying goals, documenting current system performance, comparing the current state to the desired state, implementing improvements/designs, and measuring performance of the new system. The benefits of standardizing such methodologies within organizations, including health care, have been demonstrated (Schilling et al., 2010), although integrated systems engineering functions within health care management are not commonplace. There is also evidence that institutions with more mature capabilities (Looy, 2014) can derive added benefit from drawing upon a variety of tools to improve understanding and decision-making, particularly in highly complex adaptive systems such as health care delivery (Yaduvanshi & Sharma, 2017). The following sections provide an illustration of the application of systems engineering methodologies to management in the context of an institutional-level health care delivery system case example.

CASE EXAMPLE: FAILURE TO RESCUE EVENT MITIGATION SYSTEM ANALYSIS

The selected case example represents a multiyear effort undertaken at a rural academic health care organization. The primary aim of the work was to mitigate a critical patient safety risk known as failure to rescue (FTR) events, described by Silber (Silber, Williams, Krakauer, & Schwartz, 1992) as preventable deaths from complications in hospitals. Despite significant research and intervention, preventable patient safety events, including FTR, remain the third leading cause of death in the United States (Wachter, Pronovost, and Shekelle, 2013). Moreover, the proportional patient safety-related risk, and thus harm, is greatest for patients hospitalized in tertiary/quaternary medical centers that deliver highly specialized care (Downey, Hernandez-Boussard, Banka, & Morton, 2012).

Previous research related to this important patient safety area has included single and multicenter studies of hospital (Ghaferi, Osborne, Birkmeyer, & Dimick, 2010) and patient (Silber et al., 1992) characteristics that contribute to FTR events using statistical methods and chart reviews. Interventions have included rescue systems comprising rapid response and code teams that are commonly employed to reduce FTR event frequency by providing prompt response upon recognition of patient deterioration (Winters et al., 2007). Other tactics, such as algorithms to estimate patient state or risk of death (Gardner-Thorpe, Love, Wrightson, Walsh, & Keeling, 2006; Smith, Prytherch, Meredith, Schmidt, & Featherstone, 2013) and continuous patient monitoring (McGrath, Taenzer, Karon, & Blike, 2016; Weinger & Lee, 2011), have also been integrated into rescue systems to support recognition of patient deterioration. Rescue system performance and its impact on FTR has been studied by looking at outcomes (Smith, Santamaria, Faraone, Holmes, & Reid, 2017), activation criteria (Bavare, Thomas, Elliott, Morgan, & Graf, 2017), and various aspects of response team utilization (Molloy, Pratt, Tiruvoipati, Green, & Plummer, 2018). In spite of the aforementioned research, performance analysis, and high adoption rates of well-known interventions, significant opportunity for improvement remains (Gerry et al., 2017; Taenzer, Pyke, & McGrath, 2011).

The failure of conventional medical domain analysis methods to address FTR, even those that have proven effective for understanding disease states, is not surprising given the varied nature of FTR events and the typically fragmented approaches taken to address them. Unlike many other patient safety issues for which evidence-based prevention protocols have been developed, such as central line and catheter infections, the manifestation of FTR events can be highly convoluted, often involving a series of missed signals and misguided interventions that can cascade to produce a catastrophic outcome. Several of the studies cited earlier have called attention to the diversity of disciplines, skill levels, resources, and tools involved in preventing FTR events, highlighting the need to recognize FTR event mitigation as a system. Yet there is little evidence of the application of systems analysis and design methods, such as system modeling, creation of systems requirements, or system-level design, which can provide additional insights and integrated intervention approaches. With these observations in mind and recognition of the impact of FTR events, the study organization undertook systems-level effort to analyze FTR events and mitigation systems.

In the next section, an overview of the analysis goals and general approach is provided, including the rationale for employing multiple methods to understand and evaluate this complex system. Next, findings from macro-level and key leverage point analyses are described with examples to demonstrate the depth and breadth of the tools applied. The final section explains how the analysis findings were integrated into systems-level design concepts and requirements. The discussion summarizes key elements and significance of the approach, lessons learned, applicability to other health care systems, and limitations.

ANALYSIS GOALS AND ASSESSMENT APPROACH

Deepening understanding of FTR events and mitigation approaches began as an organizational priority initiative sponsored through the Quality and Patient Safety Division at the study institution. Initial meetings were held to define the scope of the effort and identify timelines and required resources. Specific aims for the work were established through this process:

• Assess the current state of the existing system and prior work to understand causal factors associated with FTR and identify key leverage points for improving FTR event mitigation system performance.
• Perform a detailed analysis of the identified key leverage points and associated failure modes and countermeasures/interventions that have been applied.
• Form the basis of system redesign by identifying fundamental characteristics of issues, applicable general design principles, and feasible interventions for local redesign.

This organization has nearly a decade of experience with formal application of various systems analysis methods, including an extensive cross-discipline Lean Six Sigma-based competency development program. There is also a track record of successful implementation and management of innovation-focused clinical operations systems with multidisciplinary teams. With this level of collaborative design and analysis capability and experience, the project team sought to give careful consideration to the methods and tools that would be most effective. Several execution principles were identified:

• extensive stakeholder involvement to elicit gaps in current systems, generate design ideas, and gain buy-in for implementation and adoption success;
• iterative analysis and design ideation phases to f...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• List of Reviewers
• Editorial Advisory Board
• About the Contributors
• Foreword
• Case Study: More Patient Safety by Design – System-based Approaches for Hospitals
• PROcess for the Design of User-Centered Environments (PRODUCE): Guiding Change in the Health Care Environment
• Systems Modeling Approach for Reducing the Risk of Healthcare-associated Infections
• Repurposing Geographic Information Systems for Routine Hospital Infection Control
• Application of Human Factors in Neonatal Intensive Care Unit Redesign
• The Mediating Role of Burnout in the Relationship between Perceived Patient-safe, Friendly Working Environment and Perceived Unsafe Performance in an Obstetric Unit
• Failure to Rescue Event Mitigation System Assessment: A Mixed-methods Approach to Analysis of Complex Adaptive Systems
• Continuous Cardiac Monitoring Policy Implementation: Three-year Sustained Decrease of Hospital Resource Utilization
• A Work Systems Analysis of Sterile Processing: Sterilization and Case Cart Preparation
• A Model for Cultivating a Culture of Continuous Learning and Improvement: An Ethnographic Report
• A Systems Approach to Design and Implementation of Patient Assessment Tools in the Inpatient Setting
• Beyond Patient Satisfaction: Optimizing the Patient Experience
• Index