PhD, Organization, Work and Technology Group, ETH Zurich
How can high quality patient care be maintained in times of increasing production pressure within the health sector? In this paper, I will take an organisational psychologist’s perspective and discuss the risks of focusing heavily on cost reduction and production pressure in healthcare; and review measures for maintaining high quality and safety of patient care while reducing costs.
With the introduction of the Patient Protection and Affordable Care Act of 2010 (ACA) a major change in the U.S. healthcare system was initiated. The ACA intends to expand health coverage and access to care in the U.S. Indeed, since its open-enrolment period started in October 2013, the percentage of adults without health insurance declined by 5.2 percent by June 2014.1 More adults now report having a personal doctor and less difficulties paying for healthcare.1
The ACA also intends to increase the quality and efficiency of healthcare. For example, via the Hospital Value-Based Purchasing Program by the Centers for Medicare and Medicaid Services, hospitals will be paid with respect to how well they performed on defined measures rather than for ‘just having’ performed the measures. The goal is to improve patient safety and to reduce medical errors; preventable admissions and re-admissions; and healthcare-related infections.
The ACA emphasises both production pressure (more access to healthcare) and quality pressure (pay for performance). If reducing costs and increasing quality were considered as mutually exclusive, this would pose a dilemma for the healthcare industry. Access to care appears to currently be the ACA's primary focus 2 and the sustainability of covering broader access is—understandably—considered dependent on controlling the costs of care.3
There are risks of looking at the healthcare industry from a mainly cost-saving perspective. This perspective sets off a mind-set of efficiency rather than effectiveness. The risks of this mind-set are threefold:
First, it puts healthcare providers under pressure to be efficient rather than thorough.4 The perceived work pressure makes people use opportunistic quick-and-dirty solutions (“I don’t have time to double-check this diagnosis”). This supports a system which is reactive rather than proactive and makes the occurrence of errors more likely.4 There is much evidence indicating that unfavourable contextual factors are associated with adverse events. For example, the risks of retention of a foreign body after surgery increases in emergencies5 and patients who have elective surgical procedures carried out on a Friday or a weekend have a higher risk of death compared with patients having surgery on Monday.6
Second, production pressure and communicated efficiency make it harder for healthcare providers to speak up. Speaking up, that is voicing suggestions and concerns and asking questions, is crucial for problem-solving, organisational learning and achieving safety.7 Without speaking up, potential harm for the patient (eg, anaphylactic shock after being administered a wrong drug) will not be prevented.8 Growing research emphasises that speaking up does not come easily. For example, in a recent study only 22 of the participating 54 anaesthesia physicians and nurses spoke up during simulated cases when confronted with critical opportunities.9 Personal and social hurdles to speaking up are often daunting, such as the fear of being wrong, expecting negative consequences, perceiving a conflict of efficiency versus safety, and perceiving time pressure.10 11 Organisations focusing on quick task execution rather than on learning seem to make speaking up even more difficult.8
Third, increased work pressure does not only make speaking up more difficult, it also leaves less opportunity to reflect on recent events and learn from mistakes (“I don’t have time to report this incident”; “I don’t have time to talk about what happened during this surgery”). Reflection has a reputation of being luxurious and dispensable. It is quite the opposite. Reflection is essential for learning from what went well and what did not go well; and for not making the same mistake over and over again. It is a core ingredient for organisational learning and for increased professional effectiveness. Through the use of observations, questions, speaking up and discussion processes, outcomes can be critically examined, incidents and bright spots be explored, and new solutions be uncovered.8 However, increased production pressure makes it much more difficult for healthcare providers and their teams to engage in either ‘online’ reflection (eg, preventing errors by ‘pausing’ the management of an emergency for 10 seconds to re-evaluate the situation)12 or ‘offline’ reflection after procedures have been finished.13
These risks of the reducing costs mind-set should be taken seriously. Instead of seeing investing in safety as cost-only and as non-productive, spending money on safety should be considered as an enabler for productivity via ensuring that as many processes as possible go right.4 Potential uncertainties should be managed rather than attempted to be reduced14, for example via designing structures and fostering cultures that promote reflection and speaking up. Speaking up may even increase uncertainty at first because doubts about a particular action are raised or new options suggested.15 While this may not seem affordable at that particular moment, it is likely a wise investment in the future because errors may be prevented and better quality of patient care ensured – which is also required by the ACA.
The three following examples demonstrate how investing in safety can reduce costs while increasing quality and safety. These are: a) an intervention programme to decrease catheter-related bloodstream infections in the ICU; b) deliberate efforts to provide opportunities for speaking up and reflections within healthcare teams such as the After Action Reviews (AARs) and the WHO Surgical Safety Checklist; and c) simulation-based team trainings.
Example 1: The intervention programme for reducing catheter-related associated bloodstream infections
The first example is the successful intervention programme for reducing catheter-associated bloodstream infections. With approximately 17’000 yearly deaths directly related to these infections in the ICU in the U.S.16, Pronovost and colleagues conducted an evidence-based intervention programme in 103 ICUs in 67 hospitals in Michigan aiming to decrease catheter-related bloodstream infections.17 As part of several patient-safety interventions, the specific intervention staff was trained and supported in following an evidence-based procedure to reduce the infection rate (hand washing, using full-barrier precautions during insertion of central venous catheters, cleaning skin with chlorhexidine, avoiding femoral side if possible, removing unnecessary catheters). Within 3 months of implementation, the rate of catheter-related bloodstream infections was zero and was maintained at zero during more than a year of follow-up.17 Notably, this intervention required education, support and an infrastructure allowing for measuring infection rates; but it was simple and did not require additional ICU staff. Broad use of it could not only improve quality and safety of care by reducing morbidity and mortality associated with catheter-related bloodstream infections but also reduce the annual USD2.3 billion in costs associated with these infections in the U.S.17
Example 2: Explicit, structured reflection periods in briefings and debriefings
The second example refers to creating spaces for reflection and speaking up. This is a challenging task. We are not used to regularly reflecting on what we are doing. Especially within teams we are reluctant to talk about the way we work together. However, teams which do reflect outperform teams which do not reflect.18 Thus, since reflection is helpful but not all teams naturally engage in it, it must be explicitly initiated.19
A promising method for this explicit initiation of collective reflection is the debriefing or after-action review (AAR).19-21 Promoting learning from experience, AARs are guided conversations that facilitate the understanding of the relationship between events, actions, thought and feeling processes, and performance outcomes.22 They provide a structure for shifting from an automatic/habitual style of information process to one more conscious/deliberate.21,23 AARs are a simple but potentially powerful infrastructure for data verification and feedback, uncovering and closing knowledge gaps and gaps in shared cognition, structured information sharing and action planning.19,21,24,25 They allow for identifying of how things went wrong or right. This process improves performance by an average of 20 to 25 percent.26
It is important to structure the debriefing on a pre-defined structure. Ill-structured debriefings risk failure due to individual and social phenomena such as preference-consistent information sharing or a lack of psychological safety that may inhibit structured information sharing.19,24 Simply chatting or giving superficial feedback as frequently occurs in the OR-setting does not constitute an AAR (eg, after a resident and a nurse have collaborated to perform a particularly difficult induction to anaesthesia, the supervising attending physician drops by and says “Good job but try to be a bit faster next time” – the resident and nurse do not know what they could do differently to be faster the next time). Medical teams need help to establish debriefing routines, otherwise they would fail to debrief; or their natural information processing tendencies could inhibit the quality of the AAR and the undiscussable would remain undiscussable.24,27
A similar promising method for creating a space for reflection and for setting the stage for collaborating effectively is the briefing prior to working together. Briefings are potentially powerful because they allow team leaders to invite team members to speak up with observations, concerns, and questions. This is called leader inclusiveness and is an effective strategy to create psychological safety—a climate in which team members feel free to say what's on their mind without fear of repercussions and feel ready to be proven wrong.28 The team can establish a shared understanding of when and how to speak up (eg, in routine vs. emergency situations) and how to deal with being spoken up to. Establishing a shared understanding is not limited to speaking up but can include the overall task at hand (eg, confirming procedure, anticipating critical events). A suitable time for this briefing is, for example, the team time out suggested by the WHO Surgical Safety Checklist. Team members of the OR professions are invited to update and potentially correct their shared mental model of the upcoming surgical procedure. Recent data suggests that performing the WHO Surgical Safety Checklist varies and is still met with reluctance but, if properly used, reduces postoperative complications, including mortality.29,30 For example, an effective briefing may only take 2 minutes but can reduce delays by more than 80%.31
Thus, briefings and debriefing are simple, powerful, inexpensive tools to learn from both previous mistakes and particularly good care episodes; and anticipate future complications. The actual use of briefing and debriefings in clinical practice is currently sparse.19 Helping healthcare care institutions to create a briefing and debriefing culture would facilitate their occurrence and quality.
Example 3: Simulation-based training
The third example refers to training using simulation. Simulation-based training (SBT) uses simulation of critical situations to improve relevant clinical and behavioural skills and emphasise their interplay. It builds on a) the assumption that healthcare providers are highly trained and competent individuals wanting to provide the best patient care; and b) the finding that poor teamwork and communication are one of the main contributors to iatrogenic error.25, 32 Therefore, collaborating effectively in inter-professional and interdisciplinary teams is one of the main learning objectives of many SBTs.33 The learning environment represents the actual work situation as much as possible but allows for practicing complex techniques and reflecting on performance in a risk-free way. As SBT relies on experience-based learning, the debriefing of the simulation scenario is a core element of SBT and provides opportunity for offline reflection (eg, reflecting on what has helped to speak up during the simulated case).13 ,25 ,34For example, via SBT anaesthesia resident physicians were successfully educated in speaking up to superordinate physicians using the two-challenge rule (a rubric for challenging others).35 SBT not only provides an opportunity to effectively improve performance and reduce cost 36,37, it can also be used to test and train interventions such as checklists. For example, in a recent simulation-based study, the use of evidence-based checklists during operating room crisis (eg, asystolic cardiac arrest) resulted in an almost 75% reduction in failure to adhere to critical steps in crisis management (eg, immediately starting chest compressions after having called for help).38 The effects of SBT on reducing adverse events have led some U.S. malpractice insurance carriers to provide premium incentive for SBT.
What are potential means of not cutting back on high quality patient care in a period of increasing production pressure? Looking at the three examples outlined above (intervention programme to reduce catheter-related bloodstream infections, structured reflections during briefings and debriefings, simulation-based team trainings), investing in these safety measures is likely to reduce costs and improve the quality and safety of care. The investment is not about expensive technology or hiring new staff. It is about educating, training, and supporting healthcare providers and the teams and units they work in. Just providing healthcare providers with a checklist will not suffice.39 To improve patient care and safety and reduce costs in a sustainable way, checklists, briefings and debriefings, and simulation-based trainings need explicit support, for example by hospital administrators, insurance industry, and healthcare regulators. They can empower healthcare providers and healthcare teams to establish and maintain a patient safety culture, team-based professionalism, and professionalism in giving and receiving feedback.16,40 They can reward when communication barriers are overcome and when healthcare providers use their expertise in learning what works and what does not yet work. This may seem trivial at the first glance, but given the strong empirical evidence on how good communication and teamwork can reduce morbidity and mortality as well as reduce costs, such programmes seem a wise investment in the future.
6. Aylin P, Alexandrescu R, Jen MH, Mayer EK, Bottle A. Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ Open. 2013-05-28 22:31:44 2013;346.
11. Raemer DB. The clinician's response to challenging cases. In: Yano E, Kawachi I, Nakao M, eds. The healthy hospital. Maximizing the satisfaction of patients, health workers, and community. Tokyo: Shinohara Shinsha; 2010:27-32.
13. Rudolph JW, Taylor SS, Foldy EG. Collaborative off-line reflection: A way to develop skill in action science and action inquiry. In: Reason P, Bradbury H, eds. Handbook of action research: Concise paperback edition. London: Sage; 2006.
19. Tannenbaum SI, Goldhaber-Fiebert S. Medical team debriefs: Simple, powerful, underutilized. In: Salas E, Frush K, eds. Improving patient safety through teamwork and team training. New York: Oxford University Press; 2013:249-256.
20. Vashdi DR, Bamberger PA, Erez M, Weiss-Meilik A. Briefing-Debriefing: Using a reflexive organizational learning model from the military to enhance the performance of surgical teams. Human Resource Management. 2007;46(1).
28. Nembhard IM, Edmondson AC. Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. J Organ Behav. 2006;27:941-966.
29. Bergs J, Hellings J, Cleemput I, et al. Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications. British Journal of Surgery. 2014;101(3):150-158.
30. Russ SJ, Sevdalis N, Moorthy K, et al. A qualitative evaluation of the barriers and facilitators toward implementation of the WHO Surgical Safety Checklist across hospitals in england: Lessons from the "Surgical Checklist Implementation Project". Ann Surg. 9000;Publish Ahead of Print:10.1097/SLA.0000000000000793.
36. Cohen ER, Feinglass J, Barsuk JH, et al. Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit. Simul Healthc. 2010;5(2):98-102 110.1097/SIH.1090b1013e3181bc8304.
37. Fernandez Castelao E, Russo SG, Cremer S, et al. Positive impact of crisis resource management training on no-flow time and team member verbalisations during simulated cardiopulmonary resuscitation: A randomised controlled trial. Resuscitation.82(10):1338-1343.