“Actionability” – the Appropriate and Necessary Outcome of Investigations

In the previous commentary in this series about enhancing the value of investigations, I discussed the findings of an investigation involving missed/delayed diagnosis of acute leukemia. The original investigation had focused only on assigning blame, thus missing opportunities for learning. A deeper-dive investigation identified many actionable opportunities for improvements:

1. Overbooking of clinical staff
2.  Utilization of cognitive diagnostic bias influenced by task saturation, conflicting obligations and personal time management issues
3. Incomplete medical records documentation
4. Lack of a tracking mechanisms to assure tests ordered had been performed, results received and acknowledged by the physician
5. Lack of a tracking mechanism to ensure patient follow-up appointments
6. Lack of flagging mechanisms for patients warranting special attention

The real issue now becomes whether the clinic staff could or would commit time and resources to improve the structures and processes of care that contributed this patient safety incident.  Would anything change?  If so, would the changes be limited to this particular work-center? Or would they be shared with other work-centers within the hospital and clinic setting?

All too often, results of investigations reside in folders and files and nothing really changes.  Or if changes are put in place, they are not sustained nor are they shared. In the US, the National Patient Safety Foundation has formulated its approach to investigations with the acronym RCA-A for “Root Cause Analysis AND Action which specifically addresses this deficiency. However, both local work-center and institutional issues may impede progress. The roadblocks may not be local, but rather reside at higher levels.”¹¹ which specifically addresses this deficiency. However, both local work-center and institutional issues may impede progress. The roadblocks may not be local, but rather reside at higher levels.
 

Case Study Follow-On:

The clinic staff conducted two after-hours brainstorming sessions in an attempt to prioritize the opportunities for improvements, categorizing them in terms of urgency, time requirements, personnel resources required, expenses, and other factors. The team included clinical and administrative staff plus two patient representatives, e.g., all front-line stakeholders in healthcare.

The team then presented its findings to the senior leadership in this large, multispecialty, combined primary care and specialty consultation clinic. They requested administrative support, funding and time allocations apart from clinical responsibilities. The most important request was for training, as no one in the clinic had ever had specific training in process improvement techniques, including the pragmatic and statistical methodologies (such as PDSA cycles) so necessary for continuous process improvement endeavors^22,33. Without support from leadership, it seemed unlikely that any improvements would be put into place despite leadership’s demand for changes.

Unfortunately, the leadership of this organization was under pressure from its board of directors to increase clinical productivity in order to enhance financial performance.  From the chief executive’s perspective, any work on process improvements would have to be done in addition to normal clinical activities and without additional administrative or financial support. Allocating time outside of clinical duties for training was simply out of the question. His view was, “It’s so obvious what you need to do that you should just do it and get on with business.” Certainly some quick fixes might have been appropriate, but without appreciating the complexities of processes and the knock-on effects that changes in one process can have on others, mistakes may be made with unexpected consequences.

Sadly, priorities can become muddled. This is especially true when healthcare institutions are under increasing fiscal pressures in times of cost-containment, budget reductions and financial penalties imposed by payers for not meeting designated performance metrics. This is not to say the metrics are not important. Performance must be measured, but the metrics must be meaningful, appropriate and actionable. The complexity of factors affecting performance as part of any metric are often not appreciated by those who do not work on the frontlines where metrics take on a human quality and people can and do get hurt.

The lack of leadership focus on safety and quality contributes to the culture of an institution. When the culture is focused on performance metrics of dubious value instead of improving optimal outcomes, which has been shown to decrease costs of healthcare, this cultural attitude permeates the thinking of front-line staff, and runs the risk of degrading morale and adversely impacting performance.

To improve performance and achieve higher reliability in healthcare, leaders must listen to the concerns, foster the ideas and enthusiastically support the efforts of those on the frontlines, both clinicians and patients. Continuous quality improvement projects can lead to enhancements in systems and processes of care and improvements in patient safety and quality outcomes. These are the quintessential defining elements so appropriate and necessary to achieve healthcare goals for individuals and for populations.

*Reference:

1. RCA²: Improving Root Cause Analyses and Actions to Prevent Harm. National Patient Safety Foundation, Boston, 2016 (accessed at http://www.npsf.org/?page=RCA2).
2. How to Improve – The Science of Improvement: Testing Changes, Institute of Healthcare Improvement (accessed at http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx).
3. How to use a Drive Diagram. Institute for Healthcare Improvement (accessed at http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/GoldmannDriver.aspx).