Healthcare literature is replete with articles that document how and why clinical quality and patient safety are problematic in the acute-care setting. The evidence base is much less robust for long-term care, but that does not mean that the factors that lead to suboptimal processes and outcomes are unpredictable in the latter setting, or that known principles about improving performance are necessarily different.
The root causes for suboptimal quality and safety in healthcare can be traced to at least several factors. The first is the sheer complexity of care delivery. A new article is added to the National Library of Medicine at an average of every 10 seconds for every day of the year. A dedicated provider who vows to read two journal articles every day (a difficult task) to stay current with the science of healthcare would be 450 years behind by the end of the first year. Similarly, individuals in long-term care suffer from the same human factors that plague the industry elsewhere, including the effects of fatigue, distraction, stress and cognitive bias, all of which negatively affect performance.
Finally, systems of care in the long-term setting, although not as complicated as those found in acute care hospitals, nonetheless offer challenges of their own. Personnel in long-term care are likely to have less real-time access to medical and pharmacy expertise. The educational background of some, such as staff nurses, also may lack the depth of understanding of pharmacology and/or clinical assessment possessed by their acute-care counterparts.
Improved performance in long-term care means first understanding where and why quality is less than ideal, or safety risk is evident.
Key steps in the process
1. Collect data.
The process starts with data, which must be gathered in order to understand the contributing factors, if not the root causes, of suboptimal performance. What insights can be gained by analyzing performance around problematic processes? Are falls more evident on one unit compared with another, during one particular shift or clustered around certain personnel? Event-reporting systems can be helpful in this regard and used to aggregate data within a structured taxonomy that lends itself to prioritization for the purpose of subsequent performance improvement.
Once data have been collected and a deeper understanding of real and potential failure points gained, improvement efforts can begin. Education is a necessary but insufficient component of performance improvement. At best, education raises awareness on the part of a caregiver but leaves him or her to deal with the same complexities of care, human factors and suboptimal systems that existed in the first place.
2. Reengineer systems.
The next step is to re-engineer the systems of care in a way that makes it easy for the provider to do the right thing, with little or no chance of failure. Busy staff members with large and unpredictable workloads may intrinsically understand the importance of turning immobile residents every two hours to prevent pressure ulcers, but they are set up to fail if they must rely exclusively on their memory to do so.
A better system of care would include having a prioritization system that ranks which residents are more at risk for developing pressure ulcers, establishes a turning schedule that is predictable (ideally involving more than one individual), with built-in redundancies to mitigate failures when they do occur. Similarly, because falls are heavily concentrated around the toileting function and among residents who are infirm and/or cognitively impaired, those individuals should be proactively and routinely approached about their need to visit the restroom.
3. Show commitment.
Suboptimal quality and resident safety frequently reflect a failure of leadership. The pursuit of safe, high-quality care must be one of the highest priorities for the facility, and leaders must sponsor and model behaviors that will support that goal. Quality and safety must be the topic of daily conversations between staff members and leadership. Leaders must actively seek to understand places and times when care is suboptimal, and support fixing broken systems when opportunities arise.
High-quality/safe performance must be celebrated throughout the institution, and staff members who raise reasonable concerns must be praised, instead of berated, for doing so. Without this time and attention from leadership, especially at the most senior level, the pursuit of quality and safety will be difficult, expensive and likely to fail.
Frank Mazza, M.D., chief medical officer, Quantros, is a physician by training (pulmonary, critical care and sleep disorders) and still practices medicine part time. Before joining Quantros, he held several executive positions within the Seton Healthcare Family in Austin, TX, including system-level chief patient safety officer and associate chief medical officer, as well as vice president of medical affairs at Seton Medical Center in Austin.