Start with a Checklist

Checklists were first developed for flight crews in the 1980s with the goal of decreasing aircraft accidents.  As a part of “crew resource management,” checklists were employed to limit avoidable mistakes that are made because pilots and crews – at times – systematically deviated from normal behaviors.  Since then, global healthcare organizations have adopted these checklists as described in Atul Gawande’s bestselling book, The Checklist Manifesto. 

Adopting a Blame Free Culture

The aviation industry has gone beyond the checklist and sought to get a comprehensive understanding of and mitigation approach to safety.  The Federal Aviation Administration (“FAA”) created the Aviation Safety Reporting System, a valuable tool that allows pilots and other flight crew to report errors and accidents confidentially and without fear of reprisal. This highly endorsed tool gathered almost 100,000 reports in 2018 alone. Furthermore, there are similar programs for air traffic control, technical operations, and flight operations.

Simply put, aviation has a blame-free culture, focused more on identifying and solving the problem and less on penalizing or suing people. This allows for a clearer picture of safety challenges faced by aviation professionals.

What if we told you that a similar idea exists in the healthcare industry? 

The Patient Safety and Quality Improvement Act of 2005 authorized the Agency for Healthcare Research and Quality (AHRQ) to create the Patient Safety Organization (PSO) program. These organizations are experts at identifying the causes of threats to quality and safety and then developing interventions to prevent and mediate these issues.  Most importantly, there are significant legal protections for providers to disclose patient safety events and learn from them.  While providers were once reluctant to discuss patient safety events for fear of legal exposure, they can seek analysis from PSOs and discuss these events with peers from other institutions that are part of the PSO. Another tool is the Network of Patient Safety Databases (NPSD), similar to the Aviation Safety Reporting System, the focus is to enable learning on a national scale. Here, de-identified patient safety events are reviewed in terms of cause, outcome, and prevention of future incidents. Sadly, hospitals haven’t fully adopted the PSO program due to a lack of general awareness or understanding of the value. 

Most hospitals that work with PSOs see improved patient safety. For example, one hospital’s PSO alerted it to a malfunction with a certain medical device. This hospital and its peer institutions were able to identify the device and resolve the malfunction. PSOs provide hospitals analysis and education of patient safety in several ways:

• Root-cause analyses
• Benchmarking
• Safe Tables, a program where member hospital representatives confidentially meet and share best practices

One hospital representative said, “learning from other organizations in a safe environment has been extremely helpful. It assists us with identifying risks we may not have considered and decreases the chance of harm occurring to our patients.”

Capturing ROI from Prioritizing Patient Safety

As healthcare works to transition from fee-for-service to value-based care, patient safety is not only the ethically correct thing to do but also the financially responsible approach to adopt.   Reimbursement will increasingly be tied to a health system’s patient safety and quality metrics with programs such as Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  Health systems that are not addressing adverse events and readmission rates will see a loss in reimbursements.  Private health insurers are focusing more on this topic with quality reporting initiatives, such as Healthcare Effectiveness Data and Information Set (HEDIS).

How do we apply learnings from the aviation industry to healthcare? This example from a US-based academic medical center provides a road map, complete with ROI, for implementing a Crew Resource Management Program (CRMP). As a result of the program, Ohio State University Wexner Medical Center shifted its culture and significantly reduced adverse events, finding:

• The total number of adverse events avoided was 735, a 25.7% reduction
• Savings ranged from a conservative estimate of $12.6 million to as much as $28.0 million

CRMP presents a financially viable way to systematically organize for quality improvement. Thank you, airline industry!