Your Patient Safety Survival Guide

by Gretchen LeFever Watson

  Engage with Patients, Families, and Communities

  Engage the Healthcare Community

  Partner with Key Stakeholders

  Impact Healthcare Leaders and Policymakers

  Furthermore, as of 2016, the foundation’s theme became “United in Safety,” meaning “everyone involved in the healthcare process plays a role in the delivery of safe care.”2

  This chapter introduces a well-established public health strategy that is tailor-made for operationalizing the foundation’s vision. Although community coalitions have been largely ignored by the patient safety movement, they have a proven track record for addressing public health problems with characteristics just like patient safety’s most pressing issues, which is why it is my hope that creating community-based patient safety coalitions and connecting their efforts with hospital-based initiatives becomes the next wave of the patient safety movement.

  This chapter explains how community coalitions specific to patient safety can overcome existing barriers and why doing so represents an urgently needed strategy to kick-start a new wave of the movement.

  The Road to Harm Is Paved with Good Intentions

  What has been the fallout of healthcare’s repeated failure to create patient advisories and engagement interventions that offer sufficient input from their target audience? According to an analysis conducted by a now former fellow at the Harvard School of Public Health, existing advisories—even those created by leading US healthcare organizations—generate unrealistic expectations.3 Among other problems, they may create unreasonable demands on lay caregivers given people’s schedules, preferences, and capabilities. Worse yet, some might precipitate a loss of confidence and trust in hospital care.4 Consider the following information that has been extracted from prominent patient safety advisories.

  Unrealistic Expectations—Example A

  Ask a trusted family member or friend to stay with you, even overnight, when you are hospitalized. You will be able to rest more comfortably and your advocate can help to make sure you get the right medications and treatments. . . . If you do not recognize a medication, verify that it is for you. Ask about oral medication before swallowing, and read the bags of intravenous (IV) fluids. If you’re not well enough to do this, ask your advocate to do this.5

  Unrealistic Expectations—Example B

  If you’re going into the hospital . . . your most important step is selecting someone you trust to be your healthcare advocate. . . . The most important attribute for your healthcare advocate is the willingness and ability to speak up—to ask questions when things happen that you don’t understand and to insist that people take the necessary measures to protect you from harm.6

  It is easy to imagine how anxious a patient and/or family members might feel upon reading such information while in the hospital or shortly before someone is admitted. Raising public awareness about safety is important, but current approaches have done little to help people protect themselves or their loved ones. The availability of informational pamphlets certainly hasn’t put a dent in the magnitude of the crisis.

  What’s more, the Harvard analysis also suggests that existing advisories may do more harm than good by exacerbating a lingering sense of guilt among patients and family members. When mishaps do occur, patients might be left feeling like they should have done more especially if they didn’t speak up or believe they should have persisted longer when providers rebuffed their concerns. The advisories could also cause providers to view outspoken patients as “difficult patients” and allow this perception to influence the quality of their care.

  Undoubtedly, patients can play a critical role in decreasing the occurrence of patient safety events—but the utmost care must be taken to prevent the perception that the healthcare industry wishes to transfer the burden of responsibility for safety to patients. Yes, hospitals and other healthcare organizations have an obligation to invite patients to engage in the process—for everyone’s well-being—but healthcare organizations cannot demand that all patients become effective partners in safe care, nor can they blame patients when they fail to come to the aid of their providers.

  I will never forget when a neurology colleague lambasted me for what he perceived as my causing patients to challenge his authority. This otherwise measured and kindly pediatrician stormed into my office one day and screamed, “You’re causing patients to question my diagnosis. This needs to stop!” He also asked administrators of the medical school where we worked to cease and desist all media attention for my work that exposed the overuse of psychiatric drugs and threatened my career mobility. Although this occurred more than ten years ago, the experience is a potent reminder that unintended and negative consequences might befall patients and others who speak up for safety unless their providers are also prepared to view such actions in a positive light.

  The health and functional ability of providers are also riding on the development of realistic patient-engagement strategies. Think about the various examples of tragic errors in this book. How can we meaningfully engage patients in safety initiatives without inappropriately shifting the burden of responsibility to them, without disrupting the patient-provider relationship, and without otherwise causing more harm than good?

  Lessons Learned from Solving Other Tough Problems

  Insights about how to best engage patients and families (as well as providers) may be gleaned from the work of Jerry and Monique Sternin. As a couple, the Sternins spent their careers tackling complex public health problems around the world. In every instance, they discovered effective solutions by connecting with the people who were dealing with the problem on a personal level. In fact, this insight represents the prevailing message conveyed in the book that they coauthored with Richard Pascale, a global business consultant and associate fellow at Oxford University’s business school. The Power of Positive Deviance provides vivid and compelling examples of the power of ordinary people to come up with ingenious, inexpensive, and sustainable solutions to complex problems.7

  As explained in The Power of Positive Deviance, the Sternins discovered that stubborn crises, like reducing childhood malnutrition in Vietnam and curbing the practice of female genital mutilation in Egypt, are best viewed as adaptive problems. Adaptive problems refer to issues that are (a) embedded in complex social systems and (b) require social and behavioral change to yield transformative results. Solving adaptive problems always requires getting people to break old social and behavioral patterns and replace them with new ones. Getting a handle on the “technical stuff” (specific practices and tools) is important, but it was never sufficient to counteract longstanding, culturally embedded social norms that sustain adaptive problems. The hardest part of the Sternins’ work always involved making sure technical know-how was incorporated into daily routines.

  Lesson One

  Solving seemingly insurmountable public health issues often has less to do with figuring out what needs to be done and more to do with figuring out how to get people to do what needs to be done.

  Positive deviance refers to a people-driven and bottom-up approach to solving seemingly insurmountable problems. It accepts as a given that solutions will be dependent on discovering what can and will work by connecting directly with those whose behavior needs to change. Positive deviance succeeds by first identifying those rare individuals who have managed to overcome a problem that is endemic to their environment. The Sternins referred to such shining stars as positive deviants because their behaviors deviated from cultural expectations in ways that enabled them to succeed against the odds. In each case, they discovered that leveraging positively deviant practices was key to mitigating the public health crisis. Invariably, the positively deviant practices involved actions that could be attained by anyone in the community and did not need to be forced on a community by outside experts.

  Lesson Two

  Paying attention to the rare few community members wh
o seem to succeed against the odds brings to light solutions that would otherwise remain “invisible in plain sight.”

  After the Vietnam War, a variety of factors seriously undermined the country’s rice production. As a result, by 1990, about two-thirds of all Vietnamese children under the age of five suffered from malnutrition. International feeding programs that temporarily improved the situation also engendered a sense of passiveness among the program beneficiaries. As soon as the programs ended, the villages relapsed into hunger. The Vietnamese government wanted the Sternins to help it create a lasting solution to the country’s widespread problem of childhood malnutrition.

  The Sternins began their work in Vietnam by searching for a few children who were thriving. Once found, they observed these families until they saw the solutions that had been invisible in plain sight. For example, in the positive deviant families, parents made sure that the young children were fed more than three times per day. It turns out that the young children could not finish their allotted food ration in one sitting. However, by increasing the number of meals they were fed each day, the thriving children ended up consuming a greater number of calories because they ate their entire ration. Unbeknownst to others in the community, the positively deviant families also added other foods to their children’s meals—foods that were freely available to everyone but universally disdained (greens, shrimp, and crabs).8 The successful practices of positively deviant families were accessible to all community members. In fact, some of the positive deviants were among the poorest families in their communities. That’s what made them a turnkey solution to the widespread problem of malnutrition.

  Lesson Three

  When a broad segment of the population is affected by a given health problem, workable solutions must involve straightforward and inexpensive actions.

  The Sternins then recruited volunteers to help measure and monitor progress in spreading the positive deviants’ solutions to malnutrition. Within less than six months, the positively deviant practices had been widely embraced and more than 40 percent of the children in the Vietnamese villages were well nourished. Another 20 percent had moved from severe to moderate malnutrition. Rather than lecturing families, the Sternins and the volunteers provided concrete ways for families to experience the results of simple behavioral changes. Working together with other villagers, the local volunteers made sure that families were involved in weighing their children and monitoring their weight gain. Parents could see for themselves those families that embraced the positively deviant practices—including supplementing their children’s meals with foods that had been considered off limits—had children who gained weight and thrived.

  Lesson Four

  It is sometimes easier to get people to act their way into a new way of thinking than to think their way into a new way of acting.

  About ten years ago, a handful of healthcare professionals began taking note of the power of positive deviance; a few had the courage to test its mettle in the hospital setting.

  Necessity Is the Mother of Invention

  Dr. Jon Lloyd was responsible for reducing the spread of MRSA in the Veteran’s Administration Pittsburgh Healthcare System, and he had become exasperated by his failed attempts to solve this problem. During this time, he learned about the positive deviance process. Recognizing that entrenched healthcare traditions and cultural norms made it difficult for staff to call out infection-spreading behaviors, he jumped on the idea that the positive deviance process might help identify and address other barriers to effective infection prevention. When asked about his decision to pursue the people-driven positive deviance approach, Lloyd said:

  The US healthcare industry has been too focused, for too long, on fixing errors, too preoccupied with making right what is wrong. Nurses and hospital staff have been bombarded with a litany of top-down, expert-driven directives to fix a broken system.9

  From the start, Lloyd was acutely aware that hospitals don’t have the time or resources to allow their staff to participate in time-intensive, bottom-up work that is a keystone of the positive deviance approach. So, he thoughtfully compressed the positive deviance time frame by engaging hospital staff through lightly facilitated conversations with frontline workers to discover solutions. These conversations replaced the slower-paced, positive deviant process that the Sternins had used in their fieldwork in developing countries. As indicated in the table below, every facilitated conversation addressed six questions that were key to engaging a community and uncovering positive deviance.

  Table 6.1.

  Using Facilitated Conversations to Identify Solutions, MRSA Case Example

  The Problem

  How do you know if your patient has MRSA or carries the germ?

  Personal Experience

  In your own practice, what do you do to prevent spreading MRSA to other patients and staff?

  Barriers

  What prevents you from doing these things all the time?

  Positive Deviance

  Is there anyone who has a way of doing things that helps them overcome these barriers?

  Stakeholders

  What ideas do you have about others with whom we should meet?

  Volunteers

  What can we do now—any volunteers?

  Source: Karim Saad, “Discovery and Action Dialogues: A Tool for Getting Started,” in Shared Care: Partners for Patients, edited by BC Patient Safety & Quality Council, 2013.

  To maximize involvement, Lloyd and his team invited the entire hospital staff to participate. They ended up facilitating conversations with five hundred staff members; each conversation lasted fifteen to twenty minutes. Through these conversations, staff quickly generated over one hundred ideas, including many viable solutions. Although they didn’t originally plan to elicit patient input, Lloyd also invited patients from one of the hospital units to offer suggestions. This, too, resulted in valuable suggestions. For example, one patient suggested moving hand-sanitizing dispensers from the walls behind patient beds to the walls across from them so that patients could monitor whether staff washed their hands—a change that not a single staff member had considered, but one that proved to be extremely helpful.

  In less than eighteen months, Lloyd and his colleagues identified and implemented a set of solutions that had been invisible in plain sight. As a result, the hospital reduced its overall MRSA infection rate by 50 percent (and by 70 percent in one particular unit). So, while national MRSA transmission rates were increasing fivefold, they were rapidly decreasing in Lloyd’s hospital. If you recall the figures discussed previously, a 50 percent reduction in MRSA would translate to a financial savings of at least $2 million annually in direct cost-savings for an average-sized hospital10 and the avoidance of a great deal of human suffering. Having observed how the process took hold and became self-sustaining, Lloyd said, “It’s like letting the genie out of the bottle—you can’t put it back in.”11

  Praise belongs to Dr. Lloyd for bravely adapting and testing such a novel approach in the hospital where he worked and for subsequently promoting its use in other hospitals. Five of the seventeen other hospitals in the VA Pittsburgh Healthcare System chose to apply to receive training in positive deviance, as did five VA hospitals in other states. The Department of Veteran Affairs and the Agency for Healthcare Research and Quality acknowledged the success of Lloyd’s work, and the Institute for Healthcare Improvement continues to showcase it on its website.

  Given the impressive reduction in the rate of MRSA that positive deviance work generated for the VA Pittsburgh Healthcare System, it is important to address what
may be contributing to the seemingly slow and apparently limited diffusion of such innovation in other healthcare organizations. A recent literature search failed to reveal that the positive deviance approach has been practiced in US hospitals to the extent that one might expect, with little new information appearing since 2008.12

  Accelerating Progress

  It is possible that the positive deviance practices that have worked so beautifully in developing countries are simply too out of sync with normal operations of most modern hospitals. In fact, it is a labor- and time-intensive approach that has had mixed success with large corporations.13 The great news is that, in industrial countries like the United States, community coalitions have already proven to be an effective strategy for discovering and disseminating people-driven solutions, and they do so without disrupting hospital operations. For thirty years, they have been used to address a wide range of complex public health issues, such as teen smoking, childhood immunization rates, car seat safety, and the prevention of a variety of chronic health issues.14

  A community coalition represents an alliance of local groups that share a common desire to make a positive change in their community. Community coalitions represent a blend of grassroots coalitions (which usually form around an acute crisis and last for a limited period of time) and professional coalitions or taskforces (which typically focus on state or national legislation and policy issues). Community coalitions bring together diverse groups and individuals to solve local problems.15 Rather than addressing issues that may affect just one sector of the population, they focus on changes that benefit the entire community.16 Without taking sole ownership for a broadly defined problem, community coalitions enable organizations to tackle issues through the use of pooled community knowledge and resources. The resulting synergy makes it possible to accomplish goals that no single organization could achieve on its own.17 Community coalitions act as a catalyst for change among participating organizations and thereby influence the services provided to individuals, but they do not provide direct services themselves.