“How many of these have you done?”

A recent opinion piece in the Journal of the American Medical Association drew attention to the issue of procedural experience in healthcare.

 

Titled “How many have you done?”, the piece described the experience of a doctor who required a procedure herself, in this case, an amniocentesis.

 

Of course, what the patient was really asking is, “How can I be reassured you know what you are doing?”

 

The thrust of the piece was that the training doctor who performed the procedure had felt compelled to misrepresent their experience with the technique, deftly deflecting questions by the patient and her partner that explored his competence.  The author calls for a more honest response to these types of questions, while acknowledging that this is often difficult to do.

 

But is it any wonder a young doctor has trouble answering this question?

 

Healthcare continues to battle with the issue of competency.  It is still rare for doctors to be formally certified to perform specific procedures.  In fact, the industry still does not have a shared understanding of what competency actually is!

 

Furthermore, because it is uncommon for doctors to assiduously record their activity and outcome data, and even more rare for them to benchmark against their peers, most clinicians are simply oblivious to performance level.

 

So when patients are searching for reassurance that they will be cared for as best they can be, most of us struggle to be clear and meaningful in our response.  Because most of the time, we just don’t know.

 

Wouldn’t it be much better for the junior doctor to answer with authority?

 

“Well, I’ve completed a recognized pathway and been certified to practice after a period of supervision by experts.  Furthermore, I continuously review my performance results and feel comfortable that I’m doing well.”

Osler Community Survey – Results

Thanks to all the respondents to our first Osler Community Survey!  The response rate we received was highly encouraging, and the feedback quite insightful in relation to professional development, clinical governance, credentialing, logbooks and desirable Osler product features.   We look forward to putting the input and feedback received to good use in the next versions of Osler and we will keep you apprised of the upcoming launch of Osler Community later this year via our newsletter and here on the blog.

 

Congratulations to N Kumta (Australia), M Hoops (Australia) and DP Bowles (UK), our three winners of the free 12 month subscription to Osler!

 

The infographic below provides a summary of your feedback and our findings.

Osler Clinical Performance

 

Or, you can download it from the link below:

Osler Survey (June 16) Results

Mobile Evaluations are Here

Mobile Evaluations – Osler Version 2

One of the features of Version 2 of Osler Clinical Performance that we are most excited about is mobile enabled assessments – an important component of a complete clinical governance system.

Evaluate your team and provide immediate feedback with evaluation for compliance and clinical areas such as:

  • Basic Life Support
  • Advanced Life Support (ALS)
  • Falls Prevention
  • Direct Observation of Procedural Skills (DOPS)

all from your handheld Android or iOS device!  Evaluate on the go so you can claim more of your precious time, and aren’t spending it filling out evaluations.

You can design Assessment Forms to support pass/fail, multiple choice and rating scales (level of mastery or competence) questions, and file uploads to incorporate evaluations into any Osler Learning training plans.

 

Combined with our mobile procedure supervision & evaluation,  Osler Clinical Performance can enable vastly improved clinical governance and provide a real time solution to your credentialing & compliance requirements.

Osler Clinical Performance Version 2 is available for providers and institutions now.  30 day trials can be accessed on the AppExchange.

 

Clinical governance assessment

The 3rd leading cause of patient death might well be the hospital system itself

Another week, another report illustrating the harm that the healthcare industry inadvertently causes to its patients.

 

This week the British Medical Journal published a report by renowned patient safety champion Marty Makary which examines the role of healthcare error on mortality.

 

Healthcare error take many forms, including :

  • Unintended acts (either commission or omission)
  • Execution errors
  • Interpretation and synthesis errors
  • Planning errors, and
  • Deviations from processes of care

 

The report highlights the lack of visibility surrounding healthcare error. Annual causation mortality data is often compiled from death certificates and coding, based on classifications such as the International Classification of Diseases (ICD) code.   Such systems do not routinely account for healthcare error, and so do not feature on such annual lists.

 

The fact that healthcare error results in patient deaths comes as no surprise to most practicing clinicians, many of whom have either witnessed patient deaths related to management errors, or even been a part of the process themselves. And it’s not a pleasant experience.

 

What should be startling is that the issue has been recognized for so long, yet little progress seems to have been made. It’s now over 15 years since the seminal work of Lucian Leape and colleagues (1) highlighted as many as 98 000 American lives are lost each year related to iatrogenic factors in hospitals, with countless more injured. Many of these deaths are thought to be potentially preventable.

 

Despite the furore that Leape’s To Err is Human report generated, little seems to have changed. Subsequent reviews (2-6) have since estimated that between 200 000 and 400 000 US deaths can be connected to patient error annually.

 

Extrapolating the published literature, Makary and colleagues suggest that, if true, iatrogenic causes of death would rank third on the all-cause mortality table in the US (behind heart disease and cancer).

 

It’s hard to imagine that if healthcare error was viewed as a disease, widespread public awareness campaigns, fundraisers and dedicated research would be inevitable.

 

No one who works in healthcare could possibly suggest that a zero patient death rate due to iatrogenesis is possible. The healthcare system is almost as complex as the humans it cares for. It’s clear that the vast majority of patients who traverse the system are well cared for by highly motivated and caring individuals, and the results are usually positive.

 

That notwithstanding, healthcare needs to re-evaluate its approach to safety. The external perception of the acute care industry is that of a High-Reliability Organization, where safety is prioritised against all other factors. Industries such as oil and gas exploration, aviation, and nuclear power have demonstrated that this approach can reduce injury to almost zero.

 

The serial failure of our industry to embrace standard, risk averse behaviours contributes greatly to the harm it generates :

 

  • Failure of orientation
  • Failure to validate procedural competence
  • Failure to ensure equipment familiarization
  • Failure to embed policy and procedural change
  • Failure to embrace literature and national standards
  • Failure to embrace technology that can improve and enhance safety standards
  • Safe working hours
  • Failure of process documentation and audit
  • Communication failure
  • Failure to measure and report outcomes transparently
  • Failure to ensure critical incident learnings are widely distributed
  • Failure to report and investigate “near miss events”
  • Failure to create a no-blame culture

 

Applying these principles to the healthcare sector will inevitably create tensions and encounter barriers to implementation, but the first step is an acceptance that we can do better.

 

“I think doctors and nurses and other medical professionals are the heroes of the patient safety movement and come up with creative innovations to fix the problems,” he said. “But they need the support from the system to solve these problems and to help us help improve the quality of care.” Marty Makary (source CNN)

 

 

References

  1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system.National Academies Press, 1999.
  2. Leape LL, Lawthers AG, Brennan TA, Johnson WG. Preventing medical injury. Qual Rev Bull1993;19:144-9.pmid:8332330.
  3. HealthGrades quality study: patient safety in American hospitals. 2004. http://www.providersedge.com/ehdocs/ehr_articles/Patient_Safety_in_American_Hospitals-2004.pdf.
  4. Department of Health and Human Services. Adverse events in hospitals: national incidence among Medicare beneficiaries. 2010. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.
  5. Classen D, Resar R, Griffin F, et al. Global “trigger tool” shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff2011;30:581-9doi:10.1377/hlthaff.2011.0190.

American Hospital Association. Fast facts on US hospitals. 2015.http://www.aha.org/research/rc/stat-studies/fast-facts.shtml

 

About the author

Dr Todd Fraser is a passionate campaigner for patient safety through better process.  He is an Intensivist and Retrieval Physician, and co-founder of Osler Technology.