Selected Podcast

The Patient Role in Hospital Safety

Dr. Cynthia Barnard discusses the most common hospital related injuries, what patients can do to ensure a safe hospital stay, and what patients should do after they've been discharged to continue their recovery and avoid readmissions.
The Patient Role in Hospital Safety
Featuring:
Cynthia Barnard, PhD. MBA. MSJS
Cynthia Barnard, PhD is Vice President, Quality for Northwestern Memorial HealthCare. She has served on the faculty of the Northwestern University Master’s Program in Healthcare Quality and Patient Safety since its inception a decade ago. She has a Ph.D. from Northwestern University in Healthcare Quality and Patient Safety. She completed her undergraduate studies in Psychology at Bryn Mawr College and her MBA in Health Systems Management and Economics at the Kellogg Graduate School of Management at Northwestern University. Her research interests center on patient engagement in quality and patient safety, and quality and safety measurement and improvement methods. She has held leadership roles in the National Association for Healthcare Quality, the Illinois Hospital Association, and the board of Project Patient Care, and has published books and articles in healthcare quality, patient safety, ethics and policy.

Learn more about Cynthia Barnard, PhD
Transcription:

Melanie Cole (Host): Today, we ask the question, what is the patient’s role in hospital safety? Do you have any say over that? My guest is Dr. Cynthia Barnard. She’s the Vice President of Quality at Northwestern Medicine. Dr. Barnard, what is patient safety? What does that mean for the patient?

Cynthia Barnard, PhD MBA MSJS (Guest): Patient safety for the patient means that the course of medical care proceeds as intended and does not introduce new risks or harms to the patient. An obvious example of that would be for example an infection. Patient safety means we avoid harm to the patient such as an avoidable infection.

Host: Have you seen an increased interest in involving the public to enhance the quality of their own healthcare to improve the patient experience or increase their trust in the healthcare system?

Dr. Barnard: Yes. We have seen an enormous increase in patients’ interest in playing a greater role in their own care, seeking out high quality care, ensuring the quality and safety of their care, becoming true partners with their healthcare providers in planning their care and carrying it out. We’ve also seen a wonderful increase in the readiness and energy of healthcare providers for that same partnership.

Host: So, do you feel that the healthcare providers are happy that patients are becoming more of their own health advocates, looking up questions to ask their doctor before a visit, looking up stuff on the internet? Is that a pain or does that help the provider?

Dr. Barnard: That’s a great question. It can be misleading. We know that many patients do extensive internet searches when they have a medical condition or symptom that concerns them. That’s a good thing. We want folks to be engaged and activated in taking good care of themselves. However, there’s also a lot of poor-quality information out there. It is great for a patient to have thought about what bothers them, what concerns them, what worries them and have a good thorough conversation with their healthcare provider. It is not always good if they come to the provider having already perhaps determined what they think is going on with their condition and prescribing their own treatment. But partnership is the aim. The goal is that we all bring our shared knowledge and our special knowledge together to come up with the best care plan for that patient.

Host: What a good answer Dr. Barnard. What’s the difference between patient safety as we’ve discussed a little bit and quality?

Dr. Barnard: Great question. When we think about the quality of medical care, and healthcare in general, we are thinking about a consistent ability to produce good outcomes and involve the patient and make sure that the care proceeds as planned. When we think about patient safety, we think about avoiding preventable harms to the patient. When the patient comes into the healthcare system, whether in a hospital or in a clinic; the patients usually are focusing on quality. Who will provide good surgical care, who will provide a good diagnostic experience, how can I get exactly the technology I need to deal with my illness? The patient may not be thinking about potentially avoidable harm that can arise in healthcare. That’s our job to think about that and do everything possible to prevent those harms. But some harm as implied by the title of this podcast, some harm can only be avoided if the patient and the healthcare team collaborate. There are harms that occur because of a disconnect in information or a disconnect in carrying out the plan of care. And that’s where we really need patients to partner with us so that together we deliver both good quality and safety.

Host: One of the things I think consumers and patients are concerned about, if they know they have to go to the hospital, is they hear about hospital acquired infections, staph infections, those sorts of things. What are some of the most common hospital related injuries or ailments that you see and along those lines, is it okay if a patient is interested in that No Harm initiative to say did you wash your hands or to question those kinds of measures?

Dr. Barnard: Another wonderful question. Yes, it is very much okay for a patient to ask all the questions that they are concerned about and it is very much okay for the patient to watch someone walk in the room, if they are in inpatient or in a clinic and say I’m just asking, you did clean your hands, right? That is what we want to hear. We want patients to ask their visitors the same question, and that the patients themselves are encouraged to clean their hands. That’s a great example of a partnership.

In terms of the most common preventable harms in hospitals. Probably the most common event is a fall, is that the patient who is an inpatient may not realize that he or she is a little bit weaker or deconditioned after a couple of days in the hospital, maybe a little bit off balance, trying to get up and go to the bathroom typically, may lose their balance and fall. That is an avoidable harm. It is completely understandable why patients think they can get out of bed and go to the bathroom. They do it at home every day. They may not realize that in the hospital, they are just a bit weaker. So, one of the ways we try to avoid harm is make sure patients know we really want you to call before you get out of bed, let us cooperate, help each other out. We can help you just make sure you are safe in getting out of bed.

The other thing the staff will do is they will check on the patient regularly, typically, every hour and just make sure that is it time, would you like a quick trip to the bathroom. Is there anything I can put within your reach, etc.? So that we don’t have those kinds of falls. So, falls are probably the most high-volume safety event that occurs in hospitals. Many falls don’t cause an injury, but quite a few of them can.

The second most common is probably an infection. Not all infections are completely preventable but many of them can be. Cleaning hands is an important strategy to ensure that nothing is carried from room to room across patients. Clearly, that is our aim and our commitment to our patients. But there are other reasons that infections do develop. And so, we are looking for a lot of good cooperation with patients. They can help us by keeping their wound site clean and dry. They can help by alerting the nurse if they experience tenderness or it looks like the dressing is coming loose etc. There are ways we can rely on the patient to help alert us if a symptom is developing that needs attention before it turns into a bigger problem.

Host: Doctor, does the type of hospital you go to matter? And how does an academic medical center differ from a general hospital?

Dr. Barnard: An academic medical center is a teaching hospital which is partnered with a university and medical school typically for three purposes; to deliver great patient care, to teach the next generation of doctors, nurses and others, and to do research. In our environment, a teaching hospital is a place where residents, that is to say doctors in training, come for anywhere from three to seven years or even longer after they’ve completed medical school to take care of patients and while taking care of patients, to continue their learning and develop their skills. These are licensed physicians, but they are not practicing independently. They are under the supervision of the medical staff of the hospital.

An academic medical center is a great place to go if you have a complex medical condition, if you need the latest in various innovative treatments or technologies or if you like to be part of the academic enterprise. There are many patients that appreciate being part of teaching. We have patients who volunteer to come to the medical school to participate in student lectures for example, which is certainly above and beyond. But many patients like to be in a teaching setting. They like the activity and the young learners all around them. They enjoy observing as students figure out what the problem may be, what the best plan of care may be. Other patients are not as enthused at being poked, prodded and asked perhaps extra times. For some conditions, it may be just perfectly fine to be at the closest hospital to your home, a place you consider local and intimate and convenient, a place where you may know some of the people that work there. Many, many medical and surgical conditions can be treated quite well in a local setting.

However, more complex conditions, more intense technology needs might better be met in an academic medical center. Another thing for a patient to consider is, in choosing a doctor, a clinic, a hospital; there can be benefits to choosing an organization that’s part of a larger system. So, for example, if you go to your local hospital, but then it turns out that you need something a little bit more sophisticated, a little bit of technology that is not available locally; if you are in a hospital which is part of a system; it may be a little bit easier to transfer your care, get the next level of care that you need, have your records fully integrated and make sure you get an excellent continuity of care across those settings.

We find more and more patients who when choosing a hospital or doctor raise up the question of a shared medical record. They say I know my doctor is going to use a computer for my medical record. I understand that’s the contemporary standard. I would like to go somewhere so that if my doctor needs to call in other doctors, they will all be able to have access to my record. Where can I go to get that kind of continuity? And we have seen significant improved quality, improved convenience, improved safety by making sure that all the doctors have access to the same medical record.

Host: What a great answer. Are there some tools or organizations that you would like to recommend that patients can use for selecting a hospital?

Dr. Barnard: Yes. The first thing most of us do is we ask our preferred doctor and our friends and family for their experience. And there is nothing wrong with that. Those are perfectly good ways to start thinking about where to get our care. Furthermore, most of us who have the benefit of health insurance, are going to want to check our insurance and make sure there are no restrictions on where we choose to go.

There are several websites that are reasonably credible that can be used to look for more information on a hospital. The one that is most well-known is produced by Medicare. It’s called Hospital Compare and it enables you to choose three hospitals at a time and look at a pretty wide range of quality measures to compare those organizations. There is also by the way, another series of Medicare websites that enable you to compare nursing homes, dialysis facilities, etc. not only hospitals.

Then you can look at your state. In the state of Illinois; which is where I reside; the state of Illinois has published its own hospital report card which also enables you to compare different facilities and get quite a bit more detail on the quality and safety measures and in the state of Illinois, you can also compare billed charges for certain conditions as well. So, it’s got quite a bit of data.

You can look at the local hospital website. In the Northwestern Health System, we have a web site that provides quality data on one of our hospitals. We are in the process of expanding it to cover all of our hospitals in the next several months.

Finally, there are other sites in the internet that can be researched that do various kinds of comparisons. Each of them has limitations as to where they get their data, how credible it might be, and we do advise patients to be very careful and pay close attention to the source of the data and how that particular organization has modified or chosen to present the data. One of the ones that many people look at is from a consortium of employers called The Leap Frog Group and they update their website once or twice a year with a whole range of data, some of which they collect directly from the hospital and some of which they collect from public sources.

Host: Dr. Barnard, as we wrap up, what would you like patients to know about what they can do to ensure a safe hospital stay, how their friends and family can advocate for a loved one that might be in the hospital and what patients can do and this is a very important point, for providers, what a patient can do after they are discharged to continue their recovery and avoid readmissions.

Dr. Barnard: We would love to partner with every patient to make sure their care is as high quality and safe as possible. If every patient brought to the doctor and if necessary, to the hospital, their full medical history, their most up to date medication list and any advanced directives they have completed such as a power of attorney for healthcare; we would start our relationship with the patient on a much more well-informed note and we can ensure that the care is safe from the beginning. Quite often, patients come to us and perhaps may not remember every medication they take, may not quite get to doses correct, may have forgotten something from their medical history. In the flurry of the moment when there’s an acute medical condition, it’s easy to forget these things. If they are jotted down in your wallet, it makes an enormous difference. If possible, we do encourage patients to complete an advanced directive when they are in good health, when they are talking with their doctor to think about who can help make medical decisions if the time ever comes that they cannot make it for themselves. Those are all good things to bring with you.

The best advice I would have, and I wish I could give this advice to every patient, it is ask a lot of questions, bring a friend, and take notes. Patients should ask their questions. We should welcome their questions. Bringing a friend is helpful because in again, an acute medical condition; if the patient is anxious perhaps in pain, maybe even a little bit disoriented; it’s hard to take in a lot of information. Having a significant other or a friend with you can be hugely helpful and that person can take notes that you can review together later.

As I mentioned, we do encourage patients to pay close attention to medical instructions. If we ask you, please don’t get out of bed to the bathroom. Let us help you. We’d really like it if we could partner on that. Another example a little bit simpler is taking medications as prescribed. Sometimes it’s tempting to skip a dose or split a dose or make other adjustments. Perhaps the medication seems to be causing a side effect. We really want to see some conversation about that rather than have the patient simply make the decision not to take the medication or to delay it.

Another thing to think about is if you are admitted to the hospital, start planning your discharge as soon as possible, even on the very first day. Understand what conditions need to change before you are going to be permitted to go home and then how can you take safe care of yourself at home? Who could be with you? What kinds of post-discharge care are you going to need? And how will you get to those appointments? How will you get that follow-up care? Making sure you know that plan early and that you’ve got friends or family who can help you implement that plan; can keep you safe over the long-term. Friends and family are vital to really help keep care as safe and comfortable as possible. They can take notes. They can remind the patient on different medications and things they need to do to keep themselves safe. They can also say to the patient you know, it looks to me like you’re having some new symptoms here. Maybe that’s something we ought to contact the physician about and make sure that they are taking everything into consideration.

A patient or visitor can also keep track of medications, can ask the nurse if they think it is time for a medication and it doesn’t seem to be showing up yet. They can keep track of those questions and answers. They can help the patient plan for that post-discharge care.

Once the patient does go home, a few things they can do. One is to sign up for the electronic portal. In our organization that’s called My Chart. It give the patient a couple important benefits. One is they can see the record of what’s going on with their care, what’s called an After Visit Summary that will tell the patient this is what happened during your visit or your hospitalization. They can have that handy and always available electronically. The other advantage of the electronic portal is they can ask a question. They can send a question to the physician office, find out about medication side effects, clarify a follow-up appointment, whatever might be needed. You have got very convenient communication. The After Visit Summary should highlight for the patient what are safe activities you can do at home, what are things you should not do just yet, when do we need to see you again, what medications should you take, what kinds of follow-up are needed, appointments, physical therapy, homecare, and so forth. The After Visit Summary also reminds the patient who to call if there are new symptoms or symptoms of concern. How do you escalate that, what symptoms are so important you should consider going immediately to the doctor’s office, Immediate Care or even the Emergency Department, what symptoms deserve a phone call? And finally, there may be perhaps a new surgical wound or drain that needs care and the After Visit Summary will help the patient know how to take good care of that.

Once home, the most important thing for the patient to do, keep an eye on symptoms, follow all those instructions, keep an eye on the website which has all kinds of educational material and stay in good cooperative communication with the physician and the physician’s office.

Host: That is great information. What a fascinating segment. Dr. Barnard, thank you so much for joining us and sharing your expertise, your incredible expertise explaining so very clearly to patients what patient-quality and safety means and how they can be their best health advocate. Thank you again for joining us. To learn more about Northwestern Medicine’s Quality and Patient Safety efforts, please visit www.quality.nm.org, that’s www.quality.nm.org. You’re listening to Northwestern Medicine PodTalk. I’m Melanie Cole. Thanks so much for joining us.