Eradicating accidental patient deaths is a tall mountain to climb. But even the tallest of mountains can be overcome with data collection, analysis and purposeful execution. In pursuit of that goal, this briefing shares some insights from the data collection which we recently obtained about how CNOs and CMOs address patient safety.We acquired input through several methodologies. First, we conducted on-site interviews with CMOs and CNOs at several of the nation's leading healthcare institutions. Importantly, we have relationships with 80 percent of the top U.S. academic centers. Next, we gathered data via an online survey sent by third party researcher REACTION Data to over 1000 clinical leaders. Finally, Excel leadership, including CMO Mark Koppel, MD, and CSO Mary Baum, conducted extensive research.
The onsite CMO/CNO interviews featured the following patient safety questions, with the most common responses in italics below:
1) What patient safety areas occupy most of your focus?
Interviewees emphasized the importance of common language for team communication, specific actions (e.g. care plans) and guidelines. Clinical judgement and Rapid Response teams are viewed as the standard of care today, but probably not the ultimate and ideal solution.
2) What metrics do you use to gauge success?
The metrics most often highlighted for measuring success include: CMS Core Measures, outcomes data, number of codes and near misses—which were cited as the most common shortcoming of current surveillance systems, along with the prediction of patient deterioration.
3) How does data drive patient risk stratification, and what are the sources of that data?
Currently, the tools used most for tracking and trending patient status are MEW, NEWS, PEWS and safety guidelines.
The main sources of data for patient surveillance (in prioritized order) include: patient monitoring, EMR, algorithms and Point of Care.
4) What care units have more risk?
Med Surg units were cited as having patients that are most at risk.
5) Is FDA approval important for predictive analytics and patient surveillance?
The input reflected a 50/50 split on whether or not FDA clearance is important relative to predictive tools/algorithms.
6) What tools would you like to have (but don't)?
Many interviewees felt while there is a lot of talk about analytics, there is also a lack of clear and definitive information. They also repeatedly mentioned the need for more “actionable data." Finally, with private rooms the norm, several individuals believed video technology might somehow be utilized to better track patients.
From this data, we were able to determine four important takeaways relative to the issues surrounding patient safety and the eradication of accidental deaths:
- Clinicians rely heavily on experiential and educated judgment in a hectic environment where judgment is strained.
- No one wants or anticipates a major overhaul of the current system. Most want to pilot a phased approach that is grounded in solid research and tested in real world environments.
- Clinical leaders want to have a trusted solution partner that is rooted in honesty, candor, scientific basis and an unequivocal value proposition.
- The solution(s) need to span the care team, be intuitive, instill confidence and be measurable.
Like all continuous improvement processes, our data collection efforts will be ongoing. As such, we would appreciate getting your input on the critical subject of patient safety solutions in the comments below.