A 48-year-old woman, arrested for Driving Under the Influence, collapses in her jail cell and is pronounced dead of a pulmonary embolism after emergency transport to the nearby hospital. A lawsuit is settled by mediation and two staff members are disciplined for negligent behavior after an internal investigation.
Keeping patients safe is fundamental to our roles as correctional health professionals. Most of us entered health care to help those who are ill, injured or suffering, yet our patient care systems can get in the way, leading to patient harm instead of the quality care we intend. Thus, patient safety is a growing field within traditional health care and it is an increasing emphasis in the correctional setting. In the NCCHC 2018 Standards for Health Services, standard B-08 Patient Safety requires that facility staff implement patient safety systems to reduce risk and prevent harm to patients. Yet, most clinical sites already have quality improvement systems and risk management processes in place. How would a situation like the case above be handled differently from a patient safety perspective? While risk management programs focus on reducing legal liability and quality improvement programs respond to clinical quality issues, patient safety systems seek to reduce clinical error. This is, then, a patient-centered approach to fulfill our professional ethical obligation to do no harm (or minimize any harm) in the delivery of necessary health care. A comparison of the concepts of risk management, quality improvement and patient safety can clarify differences and support the proposition that a patient safety framework for organizing care delivery is superior because it actually is impactful on all three goals.
The purpose of risk management is to reduce the potential for organizational loss. In the case above, organizational risk managers would view the care concerns from a perspective of reducing financial loss to the organization during litigation or loss of reputation due to negative press coverage. Although risk managers seek to prevent and reduce loss in other areas such as property, financial risk, employees and medical staff privileges, a prime focus is prevention of loss related to legal claims against the clinical program. Thus, a risk management program includes claims management, contract and policy review, and regulatory and accreditation compliance functions. Risk management, then, is a financial function. By its nature, risk management primarily focuses on reducing financial loss. Reducing clinical error is a welcomed byproduct of risk management activities but not the primary motivation.
The focus of quality improvement is improvement of processes and outcomes of patient care. Quality improvement actions are often taken when a catastrophic clinical situation, such as the case above, occurs. In a Quality improvement environment, the Health Services Administrator, Medical Director and/or the Responsible Health Authority would perform a health record review to determine whether all policies and procedures were followed for this patient during her stay at the facility. Quality improvement activities seek to improve the efficiency and effectiveness of patient care and are often part of a clinical administrator’s role. Quality improvement is, then, primarily a management function. Benchmarking and best practices are used to determine goals for improvement activities. As with risk management, a secondary benefit of quality improvement activities can be the reduction of clinical error.
The primary focus of patient safety is preventing patient harm. Rather than a financial focus, as with risk management, or a management focus, as with quality improvement, a patient safety framework is patient-centered and seeks to reduce clinical error. Systems thinking, clinical process change and standardization to build in reliability of clinical processes lead to improved patient outcomes and decreased patient harm. According to the National Academy of Science’s recommendations in To Err is Human: Building a Safer Health System, patient safety programs should: (1) provide strong, clear, and visible attention to safety; implement non-punitive systems for reporting and analyzing errors within the organization; (2) incorporate well-understood safety principles, such as standardization and simplification of equipment, supplies, and processes; and (3) establish interdisciplinary (healthcare staff and custody staff) team training programs, such as simulation, that incorporate proven methods of team management. The following five principles are recommended to be used as a framework for safe healthcare provision: providing leadership; respect for human limits in the design process; promoting effective team functioning; anticipating the unexpected; and creating a learning environment. From a patient safety perspective, clinicians would use an extreme situation like the case above to evaluate the clinical systems and processes to determine gaps that led to the diagnostic and treatment decisions (or lack thereof).
A patient safety framework is patient-centered and focuses on reducing patient harm. This focus also reduces risk of litigation and improves care quality, enhancing both of these traditional functions. Do you follow a patient safety program at your facility? Please tell us about it in the comments section below.