Navigating current pressures and complexities
For hospitals and health systems, the pressures associated with providing safe patient care have never been more intense. While patients are increasingly being admitted with complex diagnoses, the average length of stay is shorter. The COVID-19 pandemic has compounded the stress for bedside staff who must juggle patient care and the extra time needed to adhere to personal protective equipment protocols. Ongoing staffing shortages have further intensified these challenges.
When patient safety incidents and variances do occur, the pressure to report these events — and through reporting, learn how to prevent them — has also increased. Directives have come from not only The Centers for Medicare & Medicaid Services (CMS), but from private insurers and state mandates.
As Linda Justice, Nurse Executive at Conduent points out, “There is a growing focus throughout healthcare for shared learning. While not yet a national mandate, CMS has strongly encouraged hospitals to participate in reporting their risk events to a patient safety organization.” She says this enables healthcare leaders to see an aggregate of data from multiple organizations that they can use to analyze incidents and find root cause commonalities.
The ability to share data about patient safety events depends on healthcare organizations collecting it. Bedside and other clinical staff must report what they witness — from a patient losing her footing when walking in hospital-provided socks or a surgeon rushing through pre-operative scrubbing.
But it’s not uncommon for clinical staff to resist reporting patient safety incidents and unsafe conditions. In the bustle of a typical workday, many workers prioritize direct care tasks over documenting incidents — especially if that requires exiting the electronic health record (EHR). “They may view reporting as a waste of time, because they do not receive feedback that connects their efforts to improved patient care,” explained Justice. “They also might worry that there will be negative consequences for themselves or their colleagues — including the possibility their report will be discoverable during any litigation.”
How can healthcare organizations facilitate and motivate employee reporting of patient safety issues, despite common obstacles and concerns?
Follow a five-step technology-based approach:
1. Healthcare leaders must acknowledge their employees’ fears and develop effective processes to address them. One of the most effective ways to do this is through a technology platform that supports those processes and seamlessly integrates with healthcare-specific IT requirements.
2. Choose a system that’s easy for patient care staff to use. When a patient safety reporting interface is integrated with the electronic health record (EHR), staff can enter incidents quickly and efficiently.
- Conduent example: “Our Midas Platform can be launched from the Epic system, so clients can document a safety event in Midas without leaving their Epic charting,” Justice shared. “Thus, reporting does not disrupt their normal flow of work in the medical record; however, the safety event data is not stored within Epic.”
3. Select a system that administrators can customize in-house, in real time. Flexibility and ease-of-use are critical features valued by nursing administrators who often need to adjust data queries and customize reports.
- Conduent example: “If the hospital wants to change the type of safety information they want staff to enter or the data to pull for a report, they can make the changes themselves,” explained Justice. “That frees them to analyze high-risk situations more quickly and potentially prevent future accidents or injury.”
4. Use automated feedback to escape the “black hole” of event reporting. The best practice for all organizations trying to motivate behavior change is regular, actionable feedback. When employees submit a patient safety report and don’t receive feedback, it hinders motivation to make further reports. Some call this the “black hole” of event reporting. By contrast, when employees receive an immediate, automated thank you, they are assured the information they took the time to document is being routed to the appropriate reviewer for examination.
With the right technology, organizations can decide whether — and when — to send additional communication to each reporter based on the severity, type, location or other aspects of the reported incident.
- Conduent example: “It starts with the automated thank you for all reports,” said Justice. “The type and timing of feedback might be different for a level one trauma center than for an ambulatory surgery center. For trended events that lead to a change in practice or policy, the feedback might come quarterly, from nursing administration.” Conduent’s Midas Platform seamlessly integrates with hospital and EMR systems for regular automated feedback and allows each organization to set up communication flow and frequency based on their specific needs.
5. Protect the anonymity of reporters. When staff can report incidents anonymously, they are less inhibited to share information. The latest platforms can assign secure access to only those individuals in an organization who have a need-to-know regarding details of the event, such as the source of the patient safety condition report.
- Conduent example: “The customization capabilities in the Midas system enable the technology to be set up so the system asks only for necessary information and enables anonymity for the person submitting the report,” said Justice.
Learn how a PA medical center increased event reporting by 70% in one year.
Penn State Health, Milton S. Hershey Medical Center started a journey to advance its culture of safety back in 2015. In the first year after implementing the Midas Platform, the medical center’s event reporting increased 70% to 14,000 reported events. Over the next three years, that number increased to 25,000 annual events — a 206% increase since inception.
Listen to this podcast episode to hear how this healthcare system worked through the “black hole” of event reporting supported by the Midas Platform and its partners at Conduent.
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