Patient harm can be prevented. Here's how MedStar Health is doing it

At MedStar Health, taking on patient safety has come to look a lot like treating disease.

How so? Just look at the evolving spectrum of care available to prevent and address heart disease. Long before a patient has any sort of illness, doctors encourage them to avoid smoking, eat healthily and exercise. Once a patient has some cholesterol buildup, their clinicians screen for additional risk factors and provide mitigating treatments. 

And, if a patient does have a heart attack, they are offered interventions to treat and manage heart failure and advanced disease. 

“We used to just treat heart attacks by waiting until someone had a heart attack,” said Terry Fairbanks, M.D., assistant vice president for ambulatory quality and safety at MedStar. “We transitioned to thinking, ‘Let’s take care of people before they even get heart disease.’” 

In the same way, Fairbanks said, the health system has begun focusing its clinical team around preventing patient harms before they happen.

That effort takes form in the PST model—primary, secondary and tertiary responses to adverse events that encompass both a proactive and a reactive approach, leaders at the system said at a session at the Institute for Healthcare Improvement’s National Forum on Quality Improvement in Healthcare. 

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A safety mindset allowed the system to develop a series of interventions to prevent harms and to effectively address them should a safety lapse occur. Steps at the earliest level include adjusting hiring to bring in the best team members and offering training to enhance their skills in safety as needed. 

Other proactive steps MedStar took include making safety central to the culture of its hospitals, tracking patient satisfaction to identify risks and offering standardized work processes. 

To plan for “secondary” prevention, MedStar expanded its definition of harm from "serious safety event" to "serious unanticipated outcome." Doing so allowed the system to monitor harms that may not be caused directly by providers, said Seth Krevat, M.D., assistant vice president for safety at MedStar. 

That definition switch led the number of reports to increase significantly, providing a greater database for new initiatives, Krevat said. For example, in 2018 so far, 239 unanticipated outcomes have been reported, compared to 41 scenarios that would be considered “serious safety events.” 

Further secondary steps taken by the hospital include diving deeper into claims data and patient surveys to flag issues and identify near misses. 

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The final category, tertiary, drives how MedStar responds should harm occur, the leaders said. Krevat said it mobilized a go team to react in four ways: 

  • Review the situation. He said MedStar used to consider this a “root cause analysis” but dropped that terminology as there is rarely one root cause.
  • Communicate with the patient. Support the patient through an internal consult service.
  • Provide support for staff. Care for caregivers involved in the situation
  • Resolve the situation. MedStar will offer an apology and in some cases may hold patients’ bills if harm occurs. 

“As soon as a negative outcome occurs, we find out what the patient needs immediately...and that’s before figuring out what went wrong,” Krevat said. 

MedStar’s team offered examples of how this thinking played into real-world prevention. The system uncovered, for instance, that its electronic health record had unclear options for nonclinical staff who are processing test results and passing them on to physicians, said Kate Kellogg, M.D., associate medical director for quality and safety. 

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Once the reports are scanned in, staff members had the choice to select “sign”—which few chose as they felt they were not qualified to sign documents—or “save and close”—which left the documents in a staffer’s personal inbox, thus not passing them along. 

When MedStar uncovered the issue, it discovered that more than 61,000 documents had been filed to the staff members’ inboxes. After having a pair of nurses evaluate the reports, the system identified no instances of harm, but still worked with its EHR vendor to tweak the system to avoid a risk in the future. 

“It could have been a tertiary event but ended up staying in the secondary bucket,” Kellogg said. “We were able to address it proactively—before anyone got hurt.”