Patient safety from the perspective of quality management frameworks: a review – Patient Safety in Surgery

The roles of clinical faculty and administration in patient safety: adoption and implementation of best practices in emergency and non-emergency cases

Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay [15]. As per EMTALA, the patient has a right to be treated and clinicians are bound to provide treatment [15]. In this context, let us consider an example of an unconscious patient in the emergency department that does not culturally prefer receiving blood transfusions. In the above case, hypothetically, if the treating provider is not knowledgeable of the cultural preference of the unconscious patient and proceeds to revive the patient via a blood transfusion, then, was patient centered care provided? The answer likely lies in the provider’s assessment in the context of EMTALA. The assessment, first and foremost, relates to the binding duty of the clinician to provide care to every patient, especially in times of emergencies.

The dynamics of the above hypothetical scenario entirely changes in non-emergency situations in which patients can choose a provider to treat them; and reciprocally, even providers can choose whom to treat. The rationale behind this is the physician-patient relationship that specifies the terms and conditions of a physician-patient contract [16]. This legal relationship is based on contract principles because the physician agrees to provide treatment in return for payment in the presence of the contract [16]. The law usually imposes no duty on the physician to treat the patient in the absence of a physician-patient contract [16].

In the process of providing treatment, obtaining informed consent is the concept in which the clinician explains the proposed line of treatment, duration, benefits, risks of opting in as well as opting out of the treatment, alternatives to the proposed treatment with an opportunity to answer patient questions [17]. In 1914, an American judge Benjamin Cardozo composed the foundational principle of informed consent as, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages” [18]. An interesting aspect of treatment in non-emergency cases is when the patient does not agree to informed consent which brings forth the concept of “Informed Refusal” [19, 20]. A living will is an example of an informed refusal document in which the patient states his or her end of life preferences [21]. In the above case, the provider honors the patient’s end of life preferences and/or withholds treatment for the patient as specified in the living will.

The role of leadership is to enforce EMTALA and help clinicians’ awareness of informed consent and informed refusal processes in organizations. Moreover, they ensure that providers implement the above policies regarding patient preferences. In medical cases that fall outside the purview of the already enforced laws, leadership can prospectively make rules but with caution that those rules are not against public policy.

Macro-level healthcare programs focusing on patient safety: prototype policies

Delivery system reform incentive payment program: focusing on alignment with quality management frameworks

The Delivery System Reform Incentive Payment (DSRIP) program is one prototype policy that incorporates six aims for improvement and the Triple Aim model. DSRIP has multiple healthcare projects that improve health statuses incorporating numerous metrics and milestones in primary care, specialty care, chronic care, navigation and case management, disease prevention and wellness, and general categories [23, 24]. These projects are reimbursed by the State Department of Health in a systematic manner when adopted by healthcare institutions [22,23,24,25,26].

DSRIP’s framework involves four components: (1) Infrastructure Development, (2) Program Innovation and Redesign, (3) Quality Improvement, and (4) Improvement in Population Health in states where its projects are implemented [22,23,24,25,26]. In its third year of implementation, the Texas DSRIP program in the southeastern county region had about 172 projects in eight cohorts those being, primary care, emergency care, chronic care, navigation/case management, disease prevention and wellness, behavioral health/substance abuse prevention, and general.[22, 23, 25] Each cohort had a set number of projects that involve meeting patient care milestones and metrics, simultaneously incorporating IOM’s six patient care aims of medical care being safe, efficient, effective, patient centered, timely, and equitable [22,23,24,25].

DSRIP, with all its projects implemented in the adopted regions and counties has been measured to improve population health [25]. A metric of measuring improvement in population health within the DSRIP program was preventable hospitalization rate [24]. The decrease in preventable hospitalization rates may have been attributed to the inherent design and dynamics of the DSRIP policy [23, 24]. Those dynamics comprised of factors such as physician-administrator collaboration, mechanisms of incentive payments, types of measures for reporting outcomes in quality, and interplaying healthcare externalities [24]. In the adopted regions and counties, a statistically significant decrease in preventable hospitalization rates was observed when tested with an interrupted time series method [25].

There were two phases of the Texas DSRIP program, DSRIP 1.0 and 2.0. It was in DSRIP 2.0 that comprehensive Diabetes Care: eye exam metric improved by 16 % while Influenza immunization improved by 12 % in the latter [27]. Researchers Revere et al. have identified that in DSRIP 2.0, the metrics for Central Line Associated Bloodstream Infection (CLABSI) rates, Catheter Associated Urinary Tract Infections (CAUTI), and Surgical Site Infection (SSI) rates improved by 26 %, 10 %, and 9 %, respectively [27].

Quadruple aim framework: focusing on the evolution of the triple aim

The Triple Aim, formulated in 2008, drew focus on three aims which were based on care, cost, and health. Sikka and colleagues, in 2015, constructed a fourth aim, improving the experience of providing care. This was made to acknowledge the importance of physicians, nurses, and all employees in “finding joy and meaning in their work and in doing so improving the experience of providing care” [28]. At the core of the fourth aim is the experience of joy and meaning in providing care making it synonymous with acquiring accomplishment and meaning in their contributions. The Quadruple Aim has broad implications in theory and practice factoring inclusiveness in terms of all members in the healthcare workforce [28].

Hospital-Acquired conditions reduction program: focusing on patient safety

The Hospital-Acquired Conditions Reduction Program (HACRP) is a Medicare pay-for-performance program that supports the CMS’ long-standing effort to link Medicare payments to healthcare quality in the inpatient hospital setting [29]. HACRP focuses on specific conditions that the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) healthcare- associated infection (HAI) measures which are: [30] (1) Central Line Associated Blood Stream Infection (CLABSI), (2) Catheter Associated Urinary Tract Infection (CAUTI), (3) Surgical Site Infection (SSI) for colon and hysterectomy, (4) Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteremia, (5) Clostridium Difficile Infection (CDI).

Additionally, eight Patient Safety Indicators (PSIs) included in the program comprise of: [31] (1) PSI 03 – Pressure Ulcer Rate, (2) PSI 06 – Iatrogenic Pneumothorax Rate (3) PSI 07 – Central Venous Catheter-Related Bloodstream Infection Rate, (4) PSI 08 – Postoperative Hip Fracture Rate, (5) PSI 12 – Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate, (6) PSI 13 – Postoperative Sepsis Rate, (7) PSI 14 – Postoperative Wound Dehiscence Rate, (8) PSI 15 – Accidental Puncture or Laceration Rate.

Hospital readmissions reduction program: focusing on patient safety

The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that reduces payments to hospitals with excess readmissions. The program supports the national goal of improving healthcare by linking payment to the quality of hospital care [32]. HRRP has a specific focus on the following conditions to reduce readmissions that in turn improve patient safety [32]. Those conditions are as follows: [32] (1) Acute Myocardial Infarction (AMI), (2) Chronic Obstructive Pulmonary Disease (COPD), (3) Heart Failure (HF), (4) Pneumonia (5) Coronary Artery Bypass Graft (CABG) surgery, and (6) Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA) [32].