The AHRQ, aka the Agency for Healthcare Research and Quality, had Web M&M editor Dr. Robert Wachter sit down with Dr. Tejal K. Gandhi to discuss the National Patient Safety Foundation and the organization’s evolving role in enhancing healthcare safety at a national level.
What is the NPSF? The National Patient Safety Foundation’s vision is to create a world where patients and those who care for them are free from harm. A central voice for patient safety since 1997, NPSF partners with patients and families, the health care community, and key stakeholders to advance patient safety and health care workforce safety and disseminate strategies to prevent harm. NPSF is an independent, not-for-profit 501(c)(3) organization.
Before we get to the interview snippet, remember that NPSF is holding its 16th annual Patient Safety Congress this May 14th-16th at the Renaissance Orlando at Seaworld. Simulation continues to increase its presence at this event, and here is a full day pre-conference workshop I found on the topic taking place May 14th:
Wednesday, May 14, 2014 | 8:00 AM–4:00 pm
Continuing Education for this Program
6.5 contact hours for physicians, pharmacists, nurses, health care risk managers, health care quality professionals, and health care executives
This interactive, multidisciplinary session will push the boundaries of traditional health care simulation programs. During the first part of the program, participants will look closely at the spectrum of simulation, experience live demonstrations, help write patient safety simulation scenarios, and participate in hands-on opportunities with simulation equipment. During the second part of the program, participants in the patients and families session will join the group for a joint learning opportunity. Simulation experts and patient and family representatives will work together to provide attendees opportunities to examine ways in which patients and families, who are integral parts of the health care team, can provide perspective and knowledge not always gained through the use of traditional health care simulation programs. This session will incorporate the patient and family perspective, and participants will have opportunities to identify and apply ways to improve the patient experience and improve the safety of their organization. Take-home tools will be provided.
I have excerpted some of the interview text for you below, but you can read the full interview on the AHRQ website linked at the bottom of this post. (You can also listen to a portion of the interview here).
RW: Much of what NPSF does is education and convening. Is the new technological world that we find ourselves in—the world of MOOCs and videos—changing the nature of how you think about getting people together and working collaboratively across time and space?
TG: This is an area that we’re just starting to explore. We, and I think other organizations, have found that it’s harder to get people to travel to meetings. Even though the one-on-one networking at meetings is really valuable, given financial and time constraints, this is a challenge for many organizations. I think we are going to be much more engaged in other forms of convening technology and best practice sharing technologies. We’ve done webinars, but in the next year or two we will be exploring other ways to try to convene folks that doesn’t involve face-to-face interaction.
RW: You’ve been one of the leading experts in the role of information technology (IT) in patient safety. We’ve gone from 10% IT in American hospitals and clinics to probably 60% to 70% in a few years because of Meaningful Use incentives. How has that changed the environment for safety generally and then NPSF specifically?
TG: I’m a firm believer that health information technology can improve the safety of the care we deliver. This rapid transition is a good thing. We’re getting over that adoption hump and getting into these new systems, which have great potential to improve care. The challenge is that often the systems are not necessarily implemented to optimize safety and quality for a variety of reasons, whether it’s workflow or poor design. But there are many reasons why I don’t think we’re maximizing the benefits of health IT. Another big issue—it often feels like every implementation is standalone, where every hospital or clinic is trying to decide which way is the best way to do things. Best practices around how to implement are starting to come out but are still quite rudimentary.
Many decisions are made in implementation that have big impacts on quality and safety, but they are decided in one-off situations instead of having a standard for how we should be implementing to optimize quality and safety. A concrete example is around drug interactions. Which ones should we show or not show to optimize the benefits while minimizing over-alerting? It’s a decision that every place makes on its own. It strikes me that there should be a standard for something like that, but also there’s all this work happening at each site that could be avoided if there was a best practice around this. Another example is around medication lists: who can touch them, how should they be kept accurate, what should a specialist do versus a primary care doctor? I know places are spending days, weeks, months, and years trying to figure this out. Is there a way to get some best practice standards out there to help people optimize these things? Because having an accurate medication list is such a fundamental component to delivering safe care, yet we really struggle with it. I feel like the role of the National Patient Safety Foundation is to use our convening function to create some of these best practices around health IT implementation, for example.