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The Culture of Health Care Welcome to The Culture of Healthcare: Sociotechnical Aspects: Clinicians and Technology. This is Lecture (b). The component, The Culture of Healthcare, addresses job expectations in healthcare settings, including how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace. Sociotechnical Aspects: Clinicians and Technology Welcome to The Culture of Health Care: Sociotechnical Aspects: Clinicians and Technology. This is Lecture b. The component, The Culture of Health Care, addresses job expectations in health care settings, including how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace. Lecture b This material (Comp 2 Unit 10) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

Sociotechnical Aspects: Clinicians and Technology Learning Objectives Describe the concepts of medical error and patient safety (Lectures a, b). Discuss error as an individual problem and as a system problem (Lecture a). Compare and contrast the interaction and interdependence of social and technical “resistance to change” (Lecture c). Discuss the challenges inherent with adapting work processes to new technology (Lecture c). Discuss the downside of adapting technology to work practices and why this is not desirable (Lecture c). Discuss the impact of changing sociotechnical processes on quality, efficiency, and safety (Lectures a, b). The Objectives for Sociotechnical Aspects: Clinicians and Technology are to: Describe the concepts of medical error and patient safety. Discuss error as an individual and as a system problem. Compare and contrast the interaction and interdependence of social and technical “resistance to change.” Discuss the challenges inherent with adapting work processes to new technology. Discuss the downside of adapting technology to work practices and why this is not desirable. Discuss the impact of changing sociotechnical processes on quality, efficiency, and safety. The Objectives for Sociotechnical Aspects: Clinicians and Technology are to: Describe the concepts of medical error and patient safety Discuss error as an individual problem and as a system problem Compare and contrast the interaction and interdependence of social and technical “resistance to change” Discuss the challenges inherent with adapting work processes to new technology Discuss the downside of adapting technology to work practices and why this is not desirable Discuss the impact of changing sociotechnical processes on quality, efficiency, and safety

Patient Safety Goals The National Patient Safety Goals (NPSGs) Promoted by The Joint Commission Set of regulations addressing safety issues including: Infections by antibiotic-resistant microorganisms Catheter-related bloodstream infections (CRBSIs) Surgical site infections (SSIs) This lecture will discuss patient safety. Because of the importance of patient safety, measures are being taken nationwide in order to improve patient safety in healthcare facilities in the US. The National Patient Safety Goals, or NPSGs [N-P-S-Gs], promoted by The Joint Commission, are a set of regulations that address specific safety issues in the hope of improving care on a national level. For example, these regulations include measures to reduce infections by microorganisms that are resistant to multiple antibiotics. The NPSGs address the problem of bloodstream infections related to the use of indwelling catheters or CRBSIs [C-R-B-S-eyes] and also specifically focus on reducing surgical-site infections, or SSIs [S-S-eyes]. By addressing potentially avoidable safety issues, the NPSGs aim to create a safer patient environment during the delivery of healthcare. This lecture discusses patient safety. Because of the importance of patient safety, measures are being taken nationwide in order to improve patient safety in health care facilities in the United States. The National Patient Safety Goals, or NPSGs [N-P-S-Gs], promoted by The Joint Commission, are a set of regulations that address specific safety issues in the hope of improving care on a national level. For example, these regulations include measures to reduce infections by microorganisms that are resistant to multiple antibiotics. The NPSGs address the problem of bloodstream infections related to the use of indwelling catheters, or CRBSIs [C-R-B-S-eyes] and also specifically focus on reducing surgical-site infections, or SSIs [S-S-eyes]. By addressing potentially avoidable safety issues, the NPSGs aim to create a safer patient environment during the delivery of health care.

Improving Patient Safety by Implementing a “Do Not Use” List In 2001, The Joint Commission issued a Sentinel Event Alert on the topic of medical abbreviations In 2002, a National Patient Safety Goal was approved that required accredited organizations to develop and implement a “do not use” list of abbreviations In 2004, The Joint Commission created its “do not use” list as part of the requirements In 2010, NPSG.02.02.01 was integrated into The Joint Commission Information Management standards Another aspect of patient safety is the implementation of a “do not use” list. In 2001, The Joint Commission issued a warning on the subject of medical abbreviations. Some medical abbreviations were confusing, and if used improperly they could cause harm to patients. It became obvious that some abbreviations could no longer be used. In 2002, The Joint Commission approved a National Patient Safety Goal requiring accredited organizations to develop and implement a list of abbreviations that they would not use. In 2004, The Joint Commission created its own “do not use list” of abbreviations as part of the requirements, and in 2010, the National Patient Safety Goal was integrated into The Joint Commission Information Management standards. By establishing a set of standards by consensus, The Joint Commission hopes to reduce the incidence of adverse events associated with the improper use of medical abbreviations. This has significant implications in the improvement of overall safety when patients are admitted to a hospital or acute care setting. Another aspect of patient safety is the implementation of a “do not use” list. In 2001, The Joint Commission issued a warning on the subject of medical abbreviations. Some medical abbreviations were confusing, and if used improperly they could cause harm to patients. It became obvious that some abbreviations could no longer be used. In 2002, The Joint Commission approved a National Patient Safety Goal requiring accredited organizations to develop and implement a list of abbreviations that they would not use. In 2004, The Joint Commission created its own “do not use list” of abbreviations as part of the requirements, and in 2010, the National Patient Safety Goal was integrated into The Joint Commission Information Management standards. By establishing a set of standards by consensus, The Joint Commission hopes to reduce the incidence of adverse events associated with the improper use of medical abbreviations. This measure has significant implications in the improvement of overall safety when patients are admitted to a hospital or acute care setting. Organizations with Joint Commission accreditation incorporate these various standards and directions from The Joint Commission in their operational processes and procedures, many of which focus on supporting patient safety and error reduction.

Infection Control as a Patient Safety Measure Examples of methodologies used to control infection in the inpatient setting Emphasis on hand hygiene Immunizing health care professionals to avoid the spread of disease Using antibiotics appropriately to reduce antibiotic resistance Identifying and appropriately isolating patients with infectious pathogens Revising training and competency assessments Using safer medications Hospital-acquired infections can be dangerous, and even fatal. Controlling infections in the hospital setting is an important patient safety measure, and many methods have been used to address this issue. One focus has been on improving hand hygiene. Clinicians have been encouraged to follow good hand-washing practices, and compliance has improved after the addition of waterless hand rubs, as opposed to using soap and water. Another method has been an emphasis on immunizing healthcare professionals to prevent the spread of disease. Using antibiotics appropriately for infected patients reduces the incidence of antibiotic overuse and the emergence of resistant microorganisms. If infectious patients are admitted to the hospital, they must be identified and isolated to control the spread of that infection in the hospital setting. Infection control also involves revising and updating training measures, improving competency assessments, and recommending suitable hand-washing procedures. Infection control is also achieved by promoting safety with respect to medications or delivery systems. For example, using single-use IV flush vials instead of multi-dose vials reduces the risk of cross-contamination or the introduction of infection into the environment. Hospital-acquired infections can be dangerous and even fatal. Controlling infections in the hospital setting is an important patient safety measure, and many methods have been used to address this issue. One focus has been on improving hand hygiene. Clinicians are encouraged to follow good hand-washing practices, and compliance has improved after the addition of waterless hand rubs as opposed to using soap and water. Another method has been an emphasis on immunizing health care professionals to prevent the spread of disease. Using antibiotics appropriately for infected patients reduces the incidence of antibiotic overuse and the emergence of resistant microorganisms. If infectious patients are admitted to the hospital, they must be identified and isolated to control the spread of that infection in the hospital setting. Infection control also involves revising and updating training measures, improving competency assessments, and recommending suitable hand-washing procedures. Infection control is one significant component addressed in providers’ policies and procedures. Infection control is also achieved by promoting safety with respect to medications or delivery systems. For example, using single-use IV flush vials instead of multidose vials reduces the risk of cross-contamination or the introduction of infection into the environment. Although focused on the hospital setting, efforts to control infections also apply to all other types of health care providers.

Universal Protocol for Preventing Patient Harm during Surgery In 2003, the Joint Commission approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery Since 2004, protocol required for all accredited facilities Components of Universal Protocol:  Conducting a pre-procedure patient/site verification process Marking the procedure site prior to surgery Performing a pre-procedure time-out There is a small but distinct possibility that patients will be harmed during surgery. One unfortunate cause of patient harm is when surgery is inadvertently performed on the wrong site or even on the wrong patient. In 2003, The Joint Commission approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. Since 2004, this universal protocol has been required for all accredited hospitals, ambulatory care settings, and office-based surgical facilities. Components of the universal protocol include conducting a patient and site verification before the surgery, using a process that is replicable; and clearly marking the procedure site before the surgery begins. Surgical teams also perform a pre-procedure “time out” where they recheck important safety parameters and then proceed only if no issues are identified. These components, when combined in a well-defined, repeatable process, can reduce or prevent patient harm during surgery. There’s a small but distinct possibility that patients will be harmed during surgery. One unfortunate cause of patient harm is when surgery is inadvertently performed on the wrong site or even on the wrong patient. In 2003, The Joint Commission approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. Since 2004, this universal protocol has been required for all accredited hospitals, ambulatory care settings, and office-based surgical facilities. Components of the universal protocol include conducting a patient and site verification before the surgery, using a process that is replicable, and clearly marking the procedure site before the surgery begins. Surgical teams also perform a pre-procedure “time out” during which they recheck important safety parameters and then proceed only if no issues are identified. The Joint Commission continues to work toward ensuring that the right tools and resources are available to assist providers in maintaining the highest degree of patient safety possible and reducing errors. These components, when combined in a well-defined, repeatable process, can reduce or prevent patient harm during surgery.

Other Promoters of Patient Safety Patient safety promoted by organizations Example: Leapfrog Group, a voluntary program initiated by large employers and organizations of purchasers Leapfrog initiatives include the Leapfrog Hospital Survey and a number of initiatives that improve patient safety Patient safety is promoted by a number of organizations, for example, the Leapfrog Group. Leapfrog is a voluntary program that was initiated by large healthcare employers and organizations of healthcare purchasers. Leapfrog initiatives include a number of efforts to reduce medical mistakes, such as the Leapfrog Hospital Survey. Patient safety is promoted by a number of organizations—for example, the Leapfrog Group. Leapfrog is a voluntary program that was initiated by large health care employers and organizations of health care purchasers. Leapfrog initiatives include a number of efforts to reduce medical mistakes, such as the Leapfrog Hospital Survey.

Organizations of Purchasers Some Leapfrog Members Employers The Boeing Company Chrysler FedEx Corporation General Motors Corporation Goodwill Industries Central IN IBM Intel Corporation Lockheed Martin Maine State Employee Health Commission Motorola, Inc. Ohio Public Employees Retirement System Sprint Toyota UPS United Technologies Corporation Organizations of Purchasers Colorado Business Group on Health Indiana Employers Quality Health Alliance Iowa Buyers Health Alliance Lehigh Valley Business Coalition on Health Las Vegas Health Services Coalition Maine Health Management Coalition Massachusetts Healthcare Purchaser Group Nevada Healthcare Coalition New Hampshire Purchasers Group on Health New Jersey Healthcare Quality Institute New York Business Group on Health Niagara Health Quality Coalition Pacific Business Group on Health Savannah Business Group on Health South Carolina Business Coalition on Health The list of Leapfrog members is impressive. Employers include corporations such as Boeing, Chrysler, and FedEx; and organizations of purchasers include various state employers’ quality health alliances and state business groups on health.

Other Promoters of Patient Safety Continued Nonprofit organizations Example: National Quality Forum (NQF) Goals: Sets national priorities and goals Endorses national consensus standards Promotes the attainment of national goals Nonprofit organizations also promote patient safety. One example is the National Quality Forum, or NQF [N-Q-F]. The NQF sets national priorities and goals for quality performance improvement, endorses national consensus standards for measuring and reporting performance, and promotes the attainment of national goals through education programs. Members of the NQF include consumer organizations, clinicians such as physicians and nurses, hospitals, public and private purchasers, accrediting and certifying bodies, and health care research and quality improvement organizations.

Other Promoters of Patient Safety Continued 2 Consumer organizations Example: Consumer Reports Rates hospitals, cardiac surgical groups, treatments, natural medicines Multiple methodologies for rating Performance data Patient ratings Consumer organizations such as Consumer Reports also help to promote patient safety. Consumer Reports has released comparative data on hospitals, cardiac surgical groups, treatments, and even natural medicines. This organization uses multiple methods to generate its ratings. For example, it uses performance data from the Society of Thoracic Surgeons to rate cardiac surgeons. In another example, it uses patient ratings based on a federal government survey called the Hospital Consumer Assessment of Healthcare Providers and Systems Survey, also known as the HCAHPS [aytch-kaps] survey, to rate hospitals.

Patient Ratings of Hospitals HCAHPS questions ask about Communication Pain control Assistance Cleanliness and quietness Medication and discharge information Whether the patient would recommend the hospital to family and friends The patients’ overall rating of their experience In the HCAHPS survey that allows patients to rate hospitals, questions ask about communication with doctors and nurses, whether patients received pain control when needed, and the cleanliness and quietness of rooms. Patients are asked whether they received information about new medications and discharge instructions. They are also asked whether they would recommend the hospital to family and friends and are encouraged to provide an overall rating of their experience. When consumers become involved by providing ratings of hospitals, they assist other patients to make sensible choices and may play a role in promoting patient safety.

Sociotechnical Aspects: Clinicians and Technology Summary – Lecture b Patient safety is promoted by using enhancements in technology coupled with improvements in how people work This sociotechnical process is assisted by agencies such as The Joint Commission Organizations such as the Leapfrog Group, the National Quality Forum, and consumer organizations promote patient safety This concludes Lecture b of Sociotechnical Aspects: Clinicians and Technology. In summary, patient safety is promoted through enhancements in technology and improvements in how people work. This sociotechnical process is assisted by agencies such as The Joint Commission, which has promoted regulations to address safety issues such as surgical-site infections and catheter-related bloodstream infections. The Joint Commission has also taken steps to reduce errors associated with inappropriate medical abbreviations. Infection control in the inpatient setting is an important aspect of patient safety, and multiple strategies are applied to achieve this goal. Organizations such as the Leapfrog Group and the National Quality Forum promote patient safety, as do consumer organizations. Patient ratings of hospitals are an important facet in determining quality of care.

Sociotechnical Aspects: Clinicians and Technology References – Lecture b Ebright, P. (2014). Culture of safety part one: Moving beyond blame. University of California. MERLOT. Retrieved from https://www.merlot.org/merlot/materials.htm%3Bjsessionid= F7A1AA5120282BC1123A261CCB3EEEDC?pageSize=&page=10&userId=19195 Fonarow, G., Abraham, W., Albert, N. M., et al. (2007). Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA, 297, 61–70. Fowles, J. B., & Commonwealth Fund. (2008). Performance measures using electronic health records: Five case studies. Washington, DC: Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=685103 Institute of Medicine. (2000). To err is human: Building a safer health system. National Academies Press. Retrieved from http://books.nap.edu/openbook.php?isbn=0309068371 The Joint Commission. (n.d.). Universal protocol poster. Retrieved from http://www.jointcommission.org/assets/1/18/UP_Poster.pdf The Joint Commission. (2009). Measuring hand hygiene adherence: Overcoming the challenges. Retrieved from http://www.jointcommission.org/assets/1/18/hh_monograph.pdf. The Joint Commission. (2015). Facts about the do not use list of abbreviations. Retrieved from http://www.jointcommission.org/facts_about_do_not_use_list/ Landon, B., Normand, S., Blumenthal, D., & Daley, J. (2003). Physician clinical performance assessment: Prospects and barriers. JAMA, 290, 1183–1189. No audio.

Sociotechnical Aspects: Clinicians and Technology References – Lecture b Continued Leape, L. L. (1994). Error in medicine. JAMA, 272(23),1851–1857. Lindenauer, P., Remus, D., Roman, S., et al. (2007). Public reporting and pay for performance in hospital quality improvement. New England Journal of Medicine, 356, 486–496. Lynn, J., & Baily, M., et al. (2007). The ethics of using quality improvement methods in healthcare. Annals of Internal Medicine, 146, 666–673. No audio. Health IT Workforce Curriculum Version 4.0

The Culture of Health Care Sociotechnical Aspects: Clinicians and Technology Lecture b This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. No audio. Health IT Workforce Curriculum Version 4.0