Are We Getting It Right?

Patient Safety Quality Monthly

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April 27, 2010

When we talk about our culture of safety and high reliability, one mantra that is often quoted is, "Get it right the first time and every time." As we strive to improve patient safety and quality, this really makes an excellent goal at all levels, from the individual, through the department, to the organization or system, and then even nationally.

Within our own organizations, we track our measures and indicators to see how well we are doing. Last month, the Agency for Healthcare Research and Quality (AHRQ) gave us its latest report card on how well we are all doing collectively. The National Healthcare Quality Report has been published every year since 2003, and while we hope that all our facilities are above average, it is useful and interesting to look at our industry as a whole.

The report is more than 150 pages long, so I have pulled a few key points that I found interesting. The entire report is available online from AHRQ.

Let's start with the overall AHRQ summary, especially those areas related to patient safety and quality. The report stressed that:

Some areas merit urgent attention, including patient safety and health care–associated infections (HAIs). … Some of our findings are disturbing. For example, last year we reported that approximately one out of seven adult hospitalized Medicare patients experienced one or more adverse events. This year, we see problems specifically in the area of HAIs. (pp. 8,11)

What was the data showing?

Of the 33 hospital measures related to safety, 12 (36%) improved at a rate greater than 5% per year. In contrast, of the 19 hospital measures not related to safety, 16 (84%) improved at a rate greater than 5% per year. Still, more than half of safety measures showed some improvement. (p. 12)

The key message I take away from this is either it is harder to improve measures related to safety or we focus more on those things that are performance-related or are seen to have a more direct connection to the market. Probably both.

In addition, the other area requiring urgent attention was HAIs. The report stated:

It is unfortunate that HAI rates are not declining. Of all the measures in the NHQR measure set, the one worsening at the fastest rate is postoperative sepsis. The two process measures related to HAIs tracked in the NHQR, both covering timely receipt of prophylactic antibiotics for surgery, are improving steadily. However, HAI outcome measures are lagging; only one shows improvement over time while three are worsening and one shows no change. This may, in part, reflect improving detection of HAIs. (p. 6)

Better reporting always causes an increasing peak before we can pull it down. So what do I take from this? We still have a long way to go. Anytime we see an increase related to better reporting, it is concerning, because that means there are still things we have not yet seen. But always remember that in reporting, we want to see an increase in the number of reports and a decrease in the burden caused by the reported problem (severity).

Bottom line: Although we are making some important forward strides, the report clearly indicates that our patient safety and quality, when measured on a national level, still needs to urgently focus on "Getting it right the first time and every time."

Ken Rohde, Senior Consultant, April 2010

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