Pursuing High-Reliability in Healthcare

By E.W. Tibbs

As a longtime healthcare Chief Executive Officer who began my career as a registered nurse, my passion has always been to take great care of people, both patients and caregivers. In doing so, I lead with my heart and care deeply about not hurting people.

How we accomplished this in the organizations where I have served is through disciplined process improvement and by investing in our people.  We applied methodologies such as LEAN and focused on eliminating variation and waste.

We picked a manageable number of the most important metrics (not more than 5-7 at a time) to work on, not because we weren’t good at them, but because we believed in reaching absolute zero defects/harm. Our ultimate goal was to rid our health system and community from the terrible experience of harm.

I remember starting the journey to zero harm, there were people that seemed to think the goal was too lofty. Ensuring that every harm event was humanized with the patient or caregiver's name quickly brought significance to every fraction of a percentage point.  The answer is simply; we don’t want to hurt anybody. We relentlessly pursue perfection in the care we deliver to the patients we are privileged to serve, and we celebrate progress along the way.

One misconception on the journey to healthcare high-reliability is that achieving higher quality is more expensive. The opposite is true; costs go down as does variation.   Measuring and reducing harm in healthcare produces real clinical value for the community and helps the organization financially. It is a win-win situation.

So, let’s first define what we’re talking about: What is harm?  To me, harm is any avoidable variable/variation that prevents or delays a patient from recovering as quickly and to the most optimal level of health possible.

Nobody gets out of bed in the morning and says ‘I’m going to hurt somebody today.” That is certainly not what any of us want as healthcare professionals. We need to acknowledge that the opportunity for harm is there every day.  Healthcare is a dangerous venture.

Harm can come to our patients in a variety of ways.  I’ve seen firsthand how harm can affect a patient and their family’s life. I’ve been part of the caregiver team that has delivered the harm. As a CEO, I have sat down with that patient or family and discussed how we are going to do our best to make it right. It’s not a pleasant experience for anyone involved.

Many of the ways that patients are harmed in a medical setting can be prevented or avoided. Wrong-site surgeries still occur in healthcare, as do medication events, whether that’s the wrong medication or the wrong dosage. Surgical errors, lack of timely intervention and missed diagnoses; these are all things we can reduce if we remain vigilant and keep the reduction of harm a priority.

Another form of harm is violence in the workplace. It’s a sad truth that violence between patients and caregivers is a common reality in healthcare. With the right training, caregivers can spot the signs of violence early and use better techniques to diffuse the situation.

Infections are a common form of harm in hospitals as well and one we constantly battle. Catheter associated urinary tract infections, central line-associated bloodstream infections and C-Diff are all forms of harm that bedside caregivers should keep top of mind. 

Harm can also come in the form of preventable injuries such as a fall.  Falls are a common occurrence with older patients. For a long time, one of my goals was to prevent all falls. As I saw members of my family age, it was clear they were going to fall.  My focus shifted from preventing all falls to preventing serious or debilitating injuries from the fall.   

To prevent harm, you must define it and measure it. We’ve got to benchmark and set measurable goals. Most importantly, we have to go to the front lines, to the people who do the work and get their help to refine care processes so we can eliminate what is getting in the way.

If you’ve studied LEAN methodologies, it’s all about going to the work, empowering the frontline caregivers, coming up with best practices and systematically deploying that best practice across the organization or industry.  This systematic deployment is an essential part of the processes to ensure we don’t hurt people.

While doing so, it’s important to measure and celebrate progress on the journey to reach absolute zero harm. If you can successfully do this, your organization will see many benefits through tangible value and trust equity. In the community, knowing they can count on your organization to provide high-quality care absent of harm, creates trust and loyalty. These patients know they can go to their local health system or hospital and they’re going to be safe.

Eliminating harm also has a real effect on an organization’s bottom line. Let’s face it: Medical errors are expensive to the health system because they have to be fixed. Harm is expensive to the patient because they have longer recovery times. Nobody wins. As you eliminate harm, costs go down, while productivity and efficiency are enhanced. In today’s healthcare industry, organizations are likely to be better paid by federal, state and private payers for high-quality care.

In the slide below are a few real-world examples of how reducing harm can have a positive effect on the bottom line. Though the names have been removed, these numbers reflect how a real health system was able to save millions by applying these goals and eliminating harm.

If you produce quality outcomes and cut your readmissions, you can see in the slide that the organizations can avoid the costs of penalties by as much as 3% of annual revenue. In turn, if you can eliminate hospital-acquired infections, that is another 1% penalty removed from your operating costs. That swing resulted in $4M a year in this real-world example. Multiply that by thousands of organizations across the country, and you see quickly how much savings can be achieved to the industry as a whole by eliminating harm.

We all know the reality of healthcare today means very tight margins. There is a razor-thin line between thriving and barely surviving in this industry. If you can apply these methodologies and make reducing harm a priority, you will not only bolster your annual financial performance and build your organization, you will also become the most trusted and preferred healthcare provider in your community.

Most importantly, you will reduce the avoidable experience of hurting someone’s mother or father, sister or brother…and that is why we were called to provide care in the first place.

When patients come to us, they are already in a vulnerable state. They just endured a procedure, they are sick, they are scared - whatever their situation may be. Then we take their clothes, put them in an unfamiliar situation and give them medications that alter their mental and physical functioning. It can be a frightening place.

That’s why it’s important to remember our patients’ situations because they are at their most vulnerable and need our help. Every time I went into a room as a Registered Nurse or as an executive, the three things I tried to remember that the patient wanted were: don’t hurt me, care about me and make me better.

If you keep it that simple, no matter if you are the CEO or board member, physician or nurse, environmental services or dietary, it will keep you centered on who we serve. We’re there to serve patients and their families. As an organization, we owe it to our patients to work every day to provide a safe and reliable environment that allows our caregivers to be their best. 

That is our mission and our journey to reducing harm.