Leading with Safety: Empower patients, families, and clinicians to think together as a care team

Guest Blog: Craig Clapper, PE, Founder and Principal Engineer, Reliability 4 life group, LLC

Everyone wants to be safe. No one wants to harm someone or be harmed themself. Patients want to be safe; families want patients to be safe; and care teams want patients to be safe. Family members, visitors, and members of the care team also want to be safe themselves. But that is not why people go to the hospital as a patient. They go to the hospital as a patient to be healed, and they expect to be healed in an environment that will provide the best chance of a good clinical outcome, while being treated with dignity throughout the process.

US healthcare is unsuccessful when it comes to keeping patients and caregivers safe. 251,000 patients die every year from errors and omissions in care – that is one patient death every 2 minutes, 6 seconds. An additional four million patients are harmed in their care every year. And the injury rates for caregivers are just as startling. In calendar year 2020, more than 600,000caregivers were injured on the job, and 389 of those caregivers died as a result of job-related illness or injury. (Read more about patient harm and workforce safety in Zero Harm.)

Defining safety in a modern care delivery system

Safety is an emergent property of complex systems like work systems for delivering patient care, it is not a part of the delivery system. Safety emerges through the interactions of the parts of the work systems, parts such as knowledge and skills of caregivers, methods, and technology. The right mix of the parts— called performance shaping factors—results in safe care. And since safety is the gateway to clinical quality and patient experience, the right mix of these performance shaping factors improves safety, quality, and experience. (Read more about this virtuous cycle in chapter 10 of The Engaged Caregiver.)

In our modern care delivery systems, the mix of performance shaping factors is not good because we have over prescribed methods. If paperwork made systems safe, healthcare would be safe by now. We have under prescribed thinking by caregivers and thinking together as care teams. In fact,40% of acts leading to serious patient harm are caregivers not thinking clearly in the moment.

Exploring technology that enables us to think together

Technology can be a huge advantage for caregivers thinking and thinking together as a care team—which includes bringing patients and their loved ones into the care team. Technology which enables thinking together is called Joint Cognitive Systems. If you have ever put a note on the refrigerator reading “get milk” then you have used a joint cognitive system to think with another person that is not physically there at the same time. Unfortunately, our door signs on patient rooms and white boards inside the rooms for patient communication are not much more sophisticated than the note on the refrigerator. The signs and boards are often unused, typically lacking in key detail, and sometimes wrong. One specific example I experienced occurred during patient rounding: the door sign read “NPO” and when asked, the nurse replied that her patient was not NPO but that someone had written that on the board in error and it was never erased.

The promise of tools such as a digital door sign or digital patient communication board is in being the first, truly functional joint cognitive system enabling caregivers to think with each other, including patient and family, as a care team. With all using the same information from the electronic healthcare record (EHR), shared situational awareness can occur. Everyone knows the plan, and we can help each other to recognize we have drifted off the plan. Dr Michael Leonard asks about caregivers and shared situational awareness –they are in the same room, but are they in the same plan of care? Enabling patients and family and caregivers to cross-check each other is one of the few magic solutions in safety. If the caregiver is 90% reliable in recalling and understanding information and the patient is or family are now also 90% reliable in recalling and understanding the same information – then together through cross-checking, they are now 99% reliable. That is a factor of ten reduction in error. (Read more in The Healthcare Quality Book, 5 Edition, chapter 5 Safety Science and High Reliability Organizing.)

Close the gaps in patient safety, clinical quality, patient experience, and efficiency

Healthcare systems in 2022 are too complex for one caregiver to navigate, and with the Covid pandemic exacerbating staff shortages, the newer nurses struggle most. Close that gap with a better mix of performance shaping factors – use technology like the Insight digital whiteboard and the Aware digital door sign to enable team thinking through a joint cognitive system.

Safety, quality, experience, and efficiency all depend on one another. Technology is the best hope for maintaining a shared mental model that will positively impact these critical areas. In a recent webinar with Vibe Health's VP of Clinical Innovation, Heather Wood, we discuss how advanced technology, such as the Vibe Health smart room platform, enables patients, their loved ones, and clinicians to think together, adjust together, and stay on a success path.

Interested in learning more? Contact us for a personal tour of the Vibe Health platform!