Bottom Line in Patient Safety and Quality

Improving patient safety is a goal at every hospital and health system. In fact, hospital and system trustees have a fiduciary responsibility to ensure high-quality, safe patient care. First, the goals of improving quality and eliminating patient harm must be embedded into the strategic plan and planning process. Second, board-level quality committees or clinical quality committees must be engaged in the process. Most highly effective boards devote a significant part of each board meeting discussing quality and safety.

Though there is no single measure of patient safety and quality, a total patient harm rate that aggregates outcomes throughout the organization can get close to a patient safety bottom line. While hospitals and systems should continue tracking individual measures, combining those measures into one total patient harm rate provides a greater opportunity for critical discussion of organizational strategies for improvement. Key strategies to eliminate harm and improve quality are embracing transparency; engaging clinicians, patients and families; aligning goals throughout the organization; and reducing disparities.

Total Patient Harm Rate

What gets measured gets done. Hospitals and systems must have specific, measurable targets to improve quality and eliminate patient harm and, ideally, hospital performance should be tracked monthly. Patient harm areas include: adverse drug events, catheter-associated urinary tract infections, central line-associated bloodstream infections, injuries from falls, obstetrical adverse events and early-elective deliveries, pressure ulcers, surgical-site infections, venous thromboembolism and ventilator-associated events.

Boards must ensure that these metrics are aggregated into the organization’s overall patient harm composite rate. This rate allows the hospital and board to deploy major strategies to improve patient care everywhere, every time and for every patient. For example, hospitals and health care systems in the American Hospital Association and Health Research & Educational Trust Hospital Engagement Network used an “Eliminating Harm Across the Board” template to succinctly illustrate their progress toward eliminating harm by tracking the actual number of harms, spotlighting specific harm-reduction measures and sharing strategies for success.

The total patient harm rate offers other advantages. It provides a clear picture that can be used to engage trustees, senior leaders and staff. Focusing on different harm priorities helps to connect the dots so staff members don’t view the work as yet another project. Additionally, the rate can be addressed at quality, medical executive and nursing executive committees. It helps to unify different improvement activities.

Strategies to Eliminate Harm

Tracking patient harm and identifying areas of improvement force conversations about quality and patient safety at a higher level. Instead of examining one indicator and identifying trends, tracking total patient harm encourages discussion about organizationwide strategies to eliminate harm. Board-level discussions should focus on ensuring transparency; engaging clinicians, patients and families; encouraging teamwork; aligning leadership incentives; and reducing health care disparities.

Transparency. Tracking total harm provides compelling data with an emotional impact. When adverse events occur at a hospital or system, the board must respond to the patient and family and use the event as an opportunity to learn and improve. Unit leaders can post quality data in their respective areas and the hospital overall, and board members should ask front-line staff about the data. When total patient harm is reported to the board, using patient first names focuses attention on the fact that the harm happened to a person, not just a number or statistic.

Engagement and teamwork. Clinician engagement can greatly strengthen quality improvement efforts. Board members should communicate and work closely with clinical champions when setting quality and patient safety goals and priorities. Physician and nurse board members will possess the clinical competencies to understand and track improvement. In addition, collaborating with patients and families can help to build a patient-centered hospital or system. In such a system, patients and families are encouraged and supported as essential members of the health care team, and they have meaningful opportunities to serve as advisers and partners in quality improvement efforts, patient safety initiatives and health care redesign. Many high-performing organizations use patient and family care councils. These groups meet monthly or bimonthly and focus on sharing the patient perspective on new polices, facility design, quality and safety measures. These councils also can serve as a powerful voice in reviewing strategies for improvement.

Alignment. Boards must allocate resources to collect patient harm data and implement quality improvement initiatives. Trustees also must understand how overall performance and specific measures impact the organization’s financial performance.

Equity of care. Boards must review and address care disparities as a strategy to reduce harm. Patient diversity and disparities in care should be key factors when collecting the data and setting overall patient care and quality improvement goals.

Governance Checklist

Trustees can use this checklist to improve quality of care and eliminate patient harm:

1. Consider total patient harm as a bottom-line measure of patient safety.

2. Measure and monitor a total patient harm rate each month.

3. Discuss organizational strategies for improvement.

4. Be transparent on the harm rate and the improvement strategies.

5. Align leadership incentives to eliminate patient harm.

Trustees represent the community and the patient. They should be reviewing a total patient harm rate at every meeting. Measuring and eliminating harm are essential to delivering high-quality, patient-centered care — and a board’s strategic imperative. 

"Eliminating Harm, Improving Patient Care: A Trustee Guide" is available at www.hret-hen.org.

Maulik S. Joshi (mjoshi@aha.org) is associate executive vice president at the American Hospital Association and president of the Health Research & Educational Trust, Chicago. Todd C. Linden (TLinden@grmc.us) is president and CEO of Grinnell (Iowa) Regional Medical Center. Both also are members of Speakers Express, Health Forum’s speakers bureau.