8 STEPS FOR DESIGNING SAFER PROCESSES FOR RURAL HEALTHCARE
Safety, the art of avoiding injuries to patients from care that is intended to help, should be a major consideration in the process of administering healthcare. When considering your practice, you might think of it structurally, considering all its individual components (the building, the people, etc.), or in terms of outcomes, the end results of your work (patient recovery, satisfaction, or readmission to name a few). But, when trying to improve your practice, the most efficacious way of thinking is procedurally, considering how you provide your services. Consider each part of your care pathway as a step in a larger process; for example, first a patient is admitted, after that they might be triaged, and then they might be treated (each of these can be thought in terms of sub-steps but let’s keep it simple). At each of these steps, there is a possibility of an error and the ability to, with proper planning, mitigate or prevent those errors. This document details 8 steps that your practice can take to make your patients safer and so improve the quality of care. Each of the steps has an infinite number of implementations, so careful consideration of your practice’s needs will be critical in discerning how to incorporate these. In this, we will consider the goal of each step and some case studies that have actualized those goals.
1. INCORPORATE HUMAN FACTORS KNOWLEDGE INTO TRAINING
Human factors refer to the practices of considering and accounting for human based errors with procedures. In terms of healthcare, implementing human factors is built around improving interactions between health systems and all stakeholders (patients/providers/etc.). The following section will detail a few applications of human factors in health settings; it’s important to note that these do not constitute an exhaustive list, consulting with safety experts might be appropriate for your practice depending on your needs.
An explanation of the principles leading to safer healthcare processes can be found at https://psnet.ahrq.gov/primers/primer/20/human-factors-engineering.
A detailed review of human factors in medicine can be found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3057365/.
A report by the Joint Commission identified human factor considerations and procedures ranging in reliability and ease of adoption at https://www.jointcommission.org/assets/1/6/HumanFactorsThe_Source.pdf.
- Forcing Functions: functions or physical stops that prevent harmful actions; for example, a regulator that prevents incompatible gases from being used or a lockable syringe disposal.
- Computerized Automation: automating procedural steps, like the delivery of correct medication dosage over time, can reduce the burden on your care staff and error rates among easily checkable tasks.
- Human-Machine Redundancy: requiring human checks on machines at critical junctions, for example visually inspecting medication and scanning bar codes, works in tandem with computerized automation to mitigate machine errors.
- Checklists: an important way tool for many health practices, checklists encode a structure to routine task that can mitigate. Working closely with your provider staff will help determine how what procedures would benefit from standardization and which procedures might be error prone in delivery. The creation of checklists is a complex subject that requires careful consideration by your provider team.
- Forced Pause: an enforced ‘time out’ before non-time sensitive procedures to double check patient information and procedural concerns.
- Reminders: building into your electronic health record system decision aides that ‘remind’ care providers of potentially adverse effects for example of combing two or more medications.
Human factors development is a complex, multi-disciplinary field that to properly implement in your practice requires purposeful consideration of your practice’s unique culture and procedures.
2. DESIGN TECHNOLOGY AND PROCEDURES WITH END USERS IN MIND, PLANNING FOR FAILURES
Your technology systems should be designed with your providers in mind. For the most part, this means the simpler the better since medical providers are not necessarily computer experts. This recommendation has to do with everything in your practice from your Electronic Health Records (EHR) to the way your providers interact with technology. Here your practice would want to consult with medical device experts to ensure you are up to the most current standards of health technology. Three simple steps can help with implementing new technology
- Identifying areas of concern: listening to your provider team will help you identify and target areas in your current system that can cause defects.
- Partnering with a technology vendor: after identifying areas of need within your practice, identify a vendor with products to help your meet those needs.
- Usability testing: before fully rolling out new technology, working with your provider staff to determine the ‘fit’ of the technology will improve your adoption.
3. DECREASE COMPLEXITY BY REDUCING THE NUMBER OF STEPS
Considering the care you provide as series of sequential steps helps you and your provider to do a few thing. First, it structures your understanding of your processes. Understanding how your care is provided (1) makes training easier, (2) identifies standards within your care delivery, and (3) yields reproducible processes. Second, armed with this understanding, you can work with your provider team to identify points of redundancy and inefficiency. Looking for areas where your workforce spends the most times will help understand inefficient parts of your process. For instance, are providers spending a significant amount of time entering and reentering information into the electronic health record? Are they spending much time looking for medical supplies? Talking with your team will help you design a more efficient care environment.
4. ENSURE ALL SAFETY INITIATIVES ADDRESS PREVENTION, DETECTION, AND MITIGATION
Ensuring safety can be thought of as a series of three goals: preventing errors from happening, detecting errors, and mitigating the consequences of errors when they occur. Each of these must be accounted for when implementing safety initiatives.
- Prevention: making use of the steps identified within this document will help prevent errors as well as working to keep your team aware of any changes in policy or practice components.
- Detection: developing a culture that allows for mistakes to easily be reported decreases the chances of non-detection and will help detect errors in a timely manner.
- Mitigation: ensuring that errors that do occur have contingency plans and are limited in severity is crucial for any healthcare setting. This step requires the creation (and constant revision) of not only contingency plans but also trainings that keep your workforce aware and up to date with current standards.
Detailed analysis: https://catalyst.nejm.org/what-is-risk-management-in-healthcare/
5. STANDARDIZE PROCESS, TOOLS, TECHNOLOGY AND EQUIPMENT
Standardizing different aspects of your care will increase your team’s comfort with those aspects. A few examples of this include, determining a consistent patient intake procedure, using the same computer system at each workstation, or designing patient rooms with the same furniture. Some resources that will help you with this can be found at: https://www.pressganey.com/blog/standardization-of-the-health-care-environment and http://www.ihi.org/resources/Pages/Changes/StandardizeRoomsEquipmentPatientFlowandInformationFlow.aspx.
6. LABEL MEDICATIONS AND SOLUTIONS CLEARLY FOR EACH INDIVIDUAL DOSE, INCLUDING BOTH GENERIC AND TRADE NAMES
An easy step that when combined with (7) reduces errors in medication and ensure the right type and quantity of medication is given to the right patient.
7. USE BAR CODING
A relatively old, simple, and ubiquitous technology can work to manage stock medication and clinical supplies and to keep track of patients and lab specimens and surgical instrumentation. Barcoding is one of the easiest steps that can be adopted to efficiently manage your practice. A detailed approach to adopting barcoding for medication is given by the Agency for Healthcare Research and Quality at https://healthit.ahrq.gov/ahrq-funded-projects/emerging-lessons/bar-coded-medication-administration.
8. MAKE THINGS DIFFICULT THAT SHOULD BE DIFFICULT
Healthcare is difficult; each year billions of dollars and man hours are poured into care, and in many ways that’s a good thing. Making processes intensive requires users to engage with them. When reforming your practice, simplification is important and necessary, but oversimplifying can increase error rates by making human tasks automatic and therefore thoughtless. Some tasks should require extensive provider engagement and cannot be automated, an example of this might be the changing an IV bag to ensure all connections are properly in place. Not everything can or should be optimized for time or workload efficiency, instead the imperative is to carefully recognize the aspects of your practice that will require time and energy and plan accordingly around those.