Quality Improvement, Collaboration Help Improve Patient Safety

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Quality Feature — December 2014

Tex Med. 2014;110(12):37-41.

By Amy Lynn Sorrel
Associate Editor

Fifteen years after the Institute of Medicine (IOM) issued its 1999 sentinel patient safety report, To Err is Human: Building a Safer Health System, physicians agree there's more work ahead. But they also say heightened awareness of the issue has sparked progress thanks to collaborative quality improvement efforts among systems, physicians, and patients, and a number of patient safety tools that have emerged as a result. 

Some of that progress stems from the fact that Medicare no longer pays for certain adverse events, like hospital-acquired conditions. 

Another way to look at it, says Texas Medical Association Council on Health Care Quality member Jan E. Patterson, MD, is through the lens of the quality of care patients receive as measured by evidence-based guidelines. She is director of the Center for Patient Safety & Health Policy at The University of Texas Health Science Center at San Antonio (UTHSCSA).

"Quality and patient safety go hand in hand, and many times things that are done to improve quality are for patients' safety," Dr. Patterson said. "So some of [the progress] is due to the fact that hospitals and physicians have implemented bundles of different evidence-based process measures we know work. And we have evidence we are progressing in those areas."

Dr. Patterson points to a 2003 New England Journal of Medicine study showing 55 percent of patients surveyed at the time had received recommended care. That figure has since jumped to 70 percent, according to a 2013 Agency for Healthcare Research and Quality (AHRQ) report

The council continues to work to make evidence-based quality and patient safety tools accessible to Texas physicians. TMA's free Choosing Wisely Continuing Medical Education (CME) Webinar Bundle also includes a host of patient safety and patient health literacy resources. Sign up for the webinar bundle

Seton Healthcare Family Chief Quality Officer Carol Wratten, MD, says it's also important to look at patient safety from the patient's perspective, and the patient safety movement presents yet another opportunity for physicians to engage their patients in their care. "Safety from the patient's perception looks a little bit different … and our [physicians'] role is to really invite patients to the table to get them to help us understand how to improve their experience and keep them safe."

Quality = Safety

Some of the biggest strides in patient safety have come from medical specialty societies' efforts to standardize practice guidelines and protocols, says Frank J. Villamaria, MD. The Temple anesthesiologist is a member and past chair of TMA's quality council and past medical director for quality at Scott & White Healthcare, now Baylor Scott & White Health.

For his specialty, for example, "any time, any place, any patient in America gets an anesthetic, the anesthesiologist is supposed to have specific monitors on the patient, and if those are not in place, you are not meeting basic standards for monitoring. So what that does is, it allows physicians to demand from hospitals and other facilities where they practice that those monitoring standards are met and they are functioning appropriately." 

Such standardization has led to collaborative efforts like Baylor Quality Alliance's initiative to help its physicians use quality metrics specific to their specialties and work toward improving upon them, Dr. Villamaria says. It also paved the way for the Choosing Wisely campaign, which uses evidence-based lists developed by medical specialty societies to call physicians' and patients' attention to potentially unnecessary tests and procedures that, if used, could harm rather than help patients.

"But there's still a whole lot that can be done with physician awareness" around patient safety, he says. "That's where physicians moving forward and being engaged in certain quality tools, like EHRs [electronic health records], can help them [increase awareness] and lower the chance of making an error."

Most of the quality measures physicians must now report through meaningful use of EHRs and the Physician Quality Reporting System (PQRS), for example, affect patient safety in one form or another because "all data is designed to show where the pitfalls are," says Christine Allen, RN. She is program manager at the TMF Health Quality Institute, the statewide quality improvement organization. (See "Partner in Quality," October 2014 Texas Medicine, pages 43-48.) 

The National Quality Strategy, as part of the Affordable Care Act, also dictates physicians and entities report on quality measures that fall within six domains, including patient safety and prevention, for instance.

There is room for improvement, however, in that health care "is still siloed, and we really need to work together to improve patient safety," Ms. Allen says. "But one of the biggest strides we've had toward decreasing fragmentation is with the [statewide quality improvement organization]," which looks at quality improvement across the continuum of care, and not just the physician or hospital component. 

Breaking Down Silos

Some health systems are working toward breaking down those silos, too, by engaging physicians and patients in safety improvements. 

"Most medical errors that occur are systems issues, so we want to design systems to make it easy to do the right thing and hard to do the wrong thing," Dr. Patterson said. For example, UTHSCSA began systemwide EHR protocols that help do away with medication errors due to misunderstood handwriting. 

But her group also takes those lessons learned as opportunities to help educate and train physicians on how they can implement similar patient safety principles at the practice level. 

Through a Clinical Safety and Effectiveness Course Dr. Patterson helped design, physicians and clinical staff get an overview of the IOM's six dimensions of care. (See "Patient Safety Principles.") They also learn to apply those principles to improve care using a variety of quality tools and measures. Several other UT health science centers are adopting the course, and physicians can get credit for CME, and in some cases, Maintenance of Certification Part 4. For more information, visit http://uthscsa.edu/cpshp

Pearsall family physician Jose Sosa, MD, took the course as part of an outreach program conducted by the Area Health Education Collaborative to help rural primary care physicians in South Texas use their medical records systems to track and improve adult immunization rates. 

The solo practitioner thought his rates were quite good because he knew he had ordered immunizations for his older patients and had given them a referral to H-E-B, Walmart, or another local pharmacy to get them. After learning how to extract data from his EHR system, however, Dr. Sosa found that, in fact, "I wasn't sure how to make sure they actually got it [the immunization]." 

Through the project, he learned how to improve clinic flows and documentation to prompt him and his staff to ask patients for their immunization history, particularly if they hadn't visited in a while. Now, when H-E-B sends Dr. Sosa a notice that a patient received a vaccine, it arrives directly in his EHR system, and he immediately transmits it to the patient's file. 

Dr. Sosa applies the same strategies to improve adherence among his diabetes patients. He also uses his EHR system to reconcile his patients' medications and to print and discuss their treatment plans with them. 

"The education and the preventive services we promote themselves are a form of patient safety," he said. 

The Patient Perspective

That kind of patient engagement is critical to improving patient safety, says Dr. Wratten. 

The Choosing Wisely campaign, for example, helps facilitate such interaction by encouraging physicians and patients to discuss their care, including the benefits and harms of certain treatments. 

"Patient safety is one of the main focuses of Choosing Wisely to reduce harm from things we [physicians] shouldn't be doing. Over the past few years, as Choosing Wisely started, on the physicians' side, we've taken that responsibility," she said.

But Dr. Wratten adds patients themselves can play a role in helping to fix the system, and their perspective can help further discussions like those promoted by Choosing Wisely

She points to a surge of grassroots patient advocacy organizations, like the National Patient Safety Foundation, that have emerged out of the patient safety movement and prompted partnerships between systems and patients. Seton's parent organization, Ascension Health, for example, partners in a national campaign — the Centers' for Medicare & Medicaid Services' Partnership for Patients — to reduce medical errors through standardization and patient and family engagement. 

Seton also is pilot-testing a patient guide developed by a local family who lost a relative due to a medical error. The Batz Guide helps patients understand their surgical care with a series of questions to ask health professionals, prompts to share their medical history, and worksheets to keep track of their treatment and medications, for example. Johns Hopkins Medicine and the Empowered Patient Coalition developed similar tools to help patients prepare for surgery and doctor visits. (See "Patient Safety Resources.") 

Seton implemented the Batz Guide in conjunction with a new preadmission clinic that prepares patients for elective surgery, with the goals of improving patients' perception of quality, reducing complications and costs, and increasing recovery and return-to-home rates.

Dr. Wratten acknowledges that initially there was some "resistance from clinic staff and physicians to a tool that empowers patients to ask more questions … because it's going to take too much time, bring up too much, and slow me down." 

But six months into the experiment, the clinic has helped reduce hospital stays by roughly half a day, and Dr. Wratten says the Batz tool "is helping both patients and staff understand what patients need to keep themselves safe and make sure that everyone is understanding what they can do to optimize the patients' experience."

For example, early use of the tool has helped identify issues in the clinic that could have become significant problems, such as undiagnosed sleep apnea. Clinic staff notified patients to bring their breathing devices to the hospital with them, "and there's been a lot more awareness within the health care team of the problems associated with that diagnosis in people who are going to be on narcotics," Dr. Wratten said. "We've also identified patients with previous difficulty with the use of narcotics in other surgeries. That knowledge has helped the health care team avoid that complication with the second surgery." 

San Antonio obstetrician-gynecologist Charles Holshouser, MD, is the brother of Louise H. Batz, whose death sparked development of the guide. Besides activating patients in their medical care, he says an additional benefit of the tool has been "the collaboration of the health care providers involved in building the guide," which included medical, nursing, and administrative staff at facilities across Texas. Seton is one of them. 

"It's that kind of communication that helps keep everyone focused on the issue of patient safety," Dr. Holshouser said. "The patient is the reason we are here, so the patient has to be the focus of the whole process. If we don't involve patients in their care, they are not going to get the best outcome."

Dr. Patterson says patient satisfaction surveys are another tool smaller practices can use to get patients' perspective on their care and factors that could contribute to patient safety, like communication gaps. "And communication is very important to patient safety."

She also recommends TeamSTEPPS, an evidence-based patient safety tool developed by AHRQ and the U.S. Department of Defense to improve teamwork and communication among health professionals. 

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


Patient Safety Principles

In 2001, the Institute of Medicine followed up on its sentinel patient safety report To Err Is Human: Building a Safer Health System, with another study, Crossing the Quality Chasm: A New Health System for the 21st Century, that outlines six aims for care delivery redesign. Those aims say ideal care delivery should be:    

  • Safe,
  • Effective, 
  • Patient-centered, 
  • Timely, 
  • Efficient, and 
  • Equitable.    

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Patient Safety Resources 

TMA's free Choosing Wisely® Continuing Medical Education (CME) Webinar Bundle includes patient safety and patient health literacy resources. Sign up for the webinar bundle on the TMA website

Here are some helpful patient safety websites: 

Choosing Wisely

TMA website 

Patient Safety Tools

Patient Safety Movement 
National Patient Safety Foundation 
Partnership for Patients 
Empowered Patient Coalition 
Louise H. Batz Patient Safety Foundation 
Consumers Advancing Patient Safety 
Johns Hopkins Medicine "My Health Notebook" 
Partnership for Healthcare Excellence

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Last Updated On

April 19, 2018

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