Stephanie R. Sibal, MSN, RN, HACP
ASA Monitor 05 2017, Vol.81, 40-41.
Stephanie R. Sibal, MSN, RN, HACP, is Quality Manager, Anesthesia Associates of Boise, Idaho.
Collection of data is all well and good, but improvement in patient outcomes requires the ability to turn information into action. The AQI Practice Quality Improvement Committee (PQIC) will collect and present examples of this principle so that all of us can learn from those who are doing it well. Learn more about quality improvement at www.aqihq.org/quality.aspx.
Have We Overcomplicated Patient Safety?
Medication errors, health care-associated infections, dental injuries, difficult airways … where does the list of potential adverse patient events end? All of these issues and more are faced by health care providers and specifically anesthesia providers on an almost-daily basis. Anesthesia providers continue to be at the forefront of patient safety and the avoidance of adverse events, yet they still occur and require investigation for cause and future prevention. When considering how to improve patient safety and prevent adverse events, have we overcomplicated this continuous adventure?
Patient safety has been defined by the Institute of Medicine (IOM) simply as “the prevention of harm to others” (Mitchell, 2008). This definition (and variations of it) is used throughout discussions when searching quality and patient safety resources. In addition, it is becoming more difficult to distinguish quality improvement (QI) and patient safety, as the relationship is a symbiotic one (Merry, Weller and Mitchell, 2014). Barriers such as regulatory requirements, system shortcomings (financial, lack of quality and/or accreditation resources) and overall organizational safety culture make the achievement of zero adverse events an uphill battle. Providers often get bogged down in reviews, debriefs and analyses that organizations require as follow up to an adverse outcome, which can lead to indifference to the process if there is no meaningful resolution that will improve results.
But what if it could be a simple process? Have we complicated the process of assessing quality of care as it relates to patient safety and outcomes? There are many tools in the quality improvement toolbox that focus on the prevention of adverse events or identification of the cause/potential risk of an adverse event. One of these techniques brings us back to the basics of quality and patient safety. Perhaps the use of a “Plan, Do, Study, Act” (PDSA) cycle may be the option to investigate events and potential risks (Agency for Healthcare, Research and Quality, 2013)?
Following the process of a PDSA cycle is relatively simple enough (Figure 1). First, there is the planning stage, which deals with identification of the actual event or potential risk for an adverse event occurring. This can be identified by a good catch or a near-miss that almost reached the patient. Potential adverse events are sometimes identified as a significant risk to patients and may escalate to a root cause analysis (RCA) during your planning phase. RCAs have been associated with negative or punitive action (speaking from experience here). So, it is understandable as to why that association exists.
It can be challenging for organizations to execute a successful RCA due to their own internal cultural climate and historical experience with adverse events. According to The Joint Commission (2017), “culture is a product of what is done on a consistent daily basis.” Organizations are plagued by lack of a culture of safety due not only to the barriers listed previously but also because of a lack of a just reporting culture in which providers and staff alike feel safe to report adverse events and near-misses as a way to improve care (The Joint Commission, 2017).
Second is the “Do” stage. Plans for improvement are put into motion after the identification of barriers. Also, it is essential to identify how the necessary data will be collected and validated. This phase flows into the “Study” phase where the team can analyze the data and determine whether or not the goals of the project are on track to establish the best course of action. This leads into the “Act” stage of the process in which the data are evaluated to conclude if the goal was met or not, if the plan needs to be refined and if any additional follow-up is required to hardwire best practices.
A PDSA cycle can use information from an RCA to help identify the problem and opportunities that exist. The process of following a PDSA cycle is relatively low-cost and can be completed within a short, specified timeframe, thus making it a very viable option for a QI project. For those providers looking at processes for Clinical Practice Improvement Activities (CPIA) for the Medicare Access and CHIP Reauthorization Act (MACRA) in 2017, the data and outcomes from a PDSA cycle could be useful to meet attestation requirements for approved activities. This area of Quality Payment Program (QPP) will continually challenge providers, as options for reporting remain limited for the practice of anesthesia.
This may seem like a very elementary approach to quality care and patient safety, but it has been used for many years with ascertainable results. And, yes, there are other proven methods available that may yield similar results but require more involvement from providers and the parent organization. We have all seen the results of improvement projects that get complicated very quickly: the yield is little to no result for a great deal of effort and frustration for the parties involved.
The next time you or someone in your group has an idea to improve patient safety and quality of care, remember that it’s O.K. to simplify the process and start small with a PDSA cycle. Also remember that the National Anesthesia Clinical Outcomes Registry can be a great resource for data and analysis. The Anesthesia Quality Institute’s Practice Quality Improvement Committee is committed to helping anesthesia providers understand the new QPP requirements and will continue to provide educational resources to help navigate those processes.
Plan-Do-Study-Act (PDSA) Cycle. Agency for Healthcare Research and Quality website. https://innovations.ahrq.gov/qualitytools/plan-do-study-act-pdsa-cycle. Last updated April 10, 2013. Last accessed March 14, 2017.
The Joint Commission. The essential role of leadership in developing a safety culture. Sentinel Event Alert 57. March 1, 2017. https://www.jointcommission.org/sea_issue_57/. Last accessed March 14, 2017.
Merry AF, Weller J, Mitchell SJ . Improving the quality and safety of patient care in cardiac anesthesia. J Cardiothorac Vasc Anesth. 2014;28(5):1341–1351.
Mitchell PH. Defining patient safety and quality care. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. https://ncbi.nlm.nih.gov/books/NBK2681/. Last accessed March 14, 2017.