High Reliability and Patient Engagement

Consumer Reports recently published safety ratings for hospitals across the country (see How Safe Is Your Hospital?). As Consumer Reports explains, “The safety score combines six categories of hospital safety into a score between 1 and 100.” The six safety categories include: (1) Infections; (2) Readmissions; (3) Communication Around Medication and Discharge; (4) Double scanning; (5) Serious Complications; and (6) Mortality based on six causes. Most categories were assigned a value of 20 points, while serious complications and mortality were assigned a value of 10 points. Overall, it was good work and much-needed, as the chosen categories are all good indicators of a health system’s safety culture. While hospitals now debate the validity of the rankings, many of the indicators used to develop the Consumer Reports’ safety score are hard to deny. But two areas in particular seem to be generating a lot of conversation.

First, many are wondering if the four categories assigned twenty points each should be weighted equally. For example, does research show infection rates are equally effective in determining a hospital’s safety profile as is the overuse of diagnostic scans and the unnecessary exposure that comes from that second test? Would a patient be equally as disturbed getting scanned with and without contrast as they would developing a central line infection that kept them in the hospital eight more days on average? Both metrics are important indicators of safety, but should they carry equal weight in a composite safety score?

The second issue is the fact that a hospital’s commitment to “Patient Engagement” (e.g. number of patients on boards, safety and quality committees, team-based rounds that include the patient/family) was not included in the composite score, nor in the recent hospital grades put out by The Leapfrog Group. In fact, when the idea of including patient engagement was raised by consumers on one of the criteria selection committees, the idea was shot down.  The six categories used to compile the rankings in Consumer Reports are based on reported data and, except where limitations are pointed out by Consumers Union in the report, are hard to dispute.

Data in areas like patient engagement, transparency or reporting, however, can also be good indicators of an organization’s commitment to safety and quality. Does anyone still believe patient engagement is a not a good thing when it comes to safety and quality? Every national patient safety meeting devotes a significant portion of the curricular agenda to ways in which we can better engage and partner with patients to make care safer in our hospitals because we all know the more  engaged patients are with caregivers, the safer their care will be.  But there is a disconnect between patient engagement and many of the safety ratings, as some of the highest rated hospitals have little, if any, patient engagement while some of the most patient engaged hospitals in the country are not rated well. Why is that? We have a saying in medical education, “Assessment drives the curriculum.” If you don’t test it, students don’t think it is important (and don’t study it). When hospital boards see areas like patient engagement left out of safety scores, like students, they too come to believe it is not an important component of safety, and ignore it.

Over the last week or two, I have been referring to Maureen Bisognano’s and Charles Kenney’s recently published, Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better Health, and Lower Costs. As previously discussed, common to these innovative healthcare organizations, also highly rated on safety & quality measures, are seven characteristics, of which patient engagement is one. Yet patient engagement appears to be a glaring omission from the rating systems used by organizations like Consumer Reports and The Leapfrog Group. Why was IHI able to come to this conclusion and others have not been able to? Maybe the best scoring system for determining a hospital’s safety and value to the public would be a composite score that combines both reported metrics, like those used by Consumer Reports, with metrics that assess the common characteristics seen in high quality health systems moving towards the ‘Better Care, Better Health and Lower Costs’ of the Triple Aim? Qualities like patient engagement and transparency, for example. While many safety experts deciding what should, or should not, be included in these rating scores prefer to stay with categories that can be qualitatively measured, it is important to remember the warning by Robert Helmreich PhD and David Musson, MD, (both highly awarded experts in human factors and behavioral science in high reliability industries such as aviation and healthcare), to healthcare leaders many years ago when asked to comment on safety in our industry:

“Health care may be well advised to examine how other industries have supported such research, and how successful interventions were employed, rather than attempt to adopt specific training elements or seek validation of every component of complex and specific training programs. A random, double-blind, placebo-controlled study of the utility of team training may be virtually impossible and potentially meaningless in its results. It is important to recognize that while this study design may be the gold standard for validation in medicine, it may not be appropriate for complex socio-technical interventions.”

The traditional healthcare logic that has kept our safety vision foggy for many years may very well be preventing us from seeing the importance of patient engagement, and other important domains like transparency and organizational reporting, being used in combination with conventional metrics when determining a hospital’s safety score.