Amplifire’s Clinical Innovation Advisory Board are some of the most accomplished thought leaders in American healthcare, helping target and develop course content and strategic direction in the evolving healthcare landscape. This group of scientific experts examine training solutions and their use in real clinical applications, especially within the Amplifire Healthcare Alliance. In their recent article published in the New England Journal of Medicine Catalyst, “Patient Safety Performance: Reversing Recent Declines through Shared Profession-Wide System-Level Solutions”, the authors investigated the recent troubling decline in patient safety performance, indicated by an increase in errors leading to adverse patient outcomes. In taking a deeper look, they identified commonalities that contributed to that decline. The authors also analyzed decades of patient safety research, determining which practices work, and which do not.
They found that two systems-level factors contributed to patient safety declines: the first being the fact that patient safety systems vary widely across health systems; the second being unprecedentedly high staff turnover rates. Despite these deeply rooted and complex factors, the authors presented viable solutions to prevent medical errors and improve patient outcomes in the long-term. Their conclusions are supported by the leading research in patient safety practices and draw on real-world applications to propose solutions. Here are the biggest takeaways from their astute article:
1. Disjointed patient safety efforts result in medical error
“Two decades of patient safety research have found proven best practices for some of the biggest sources of hospital-based care-associated injuries. They demonstrably work,” write the CIAB authors. “Most patient safety breakthroughs came from system design focused on care delivery processes, where errors are considered to be consequences related to upstream systemic factors.” The authors cite studies that show how unified guideline implementation results in subsequent reductions in medication error rates, ventilator-acquired pneumonia, and central-line associated bloodstream infections (CLABSIs) across multiple health systems.
“Patient safety policy and practice has relied too heavily on the vigilance and heroism of clinicians, rather than the design of safe systems,” found the CIAB authors. And while the public are grateful for such clinicians, clinicians need dependable policies they can rely on when burnout inevitably emerges as a result of their overextended heroism.
2. Increasing clinician pressure and burnout is largely responsible for declines in patient safety
As healthcare and health systems have evolved, there became greater documentation requirements on clinical staff, competing against time spent directly caring for patients. At the same time, physicians were still compensated based on volume, despite the effort to switch to compensation by value (in 2021, about 70% of generalist and specialist physician compensation was still based on billing volume). Clinicians found themselves caught in the middle of this dilemma, and then were buried by it when the pandemic maxed out their workload. The moral distress of being forced to weigh their patients’ wellbeing with increased responsibility came to a boil.
“[Clinicians’] core professional values place patients’ health needs as their top priority, but regulatory and administrative documentation requirements and increasing use of Electronic Medical Record systems demanded more and more time, even as patient loads increased. Moral distress, reflected in clinician burnout, was a significant and growing problem well before the… pandemic struck,” wrote the authors.
Hospitals experienced an unprecedented worker shortage. As clinicians sought better working conditions (or left their profession altogether), hospitals faced the challenge of high turnover, inexperienced workers, and onboarding bottlenecks. The authors concluded, “The result of this pandemic-prompted disruption, which exposed the systemic fragility of frontline staffing models, was the loss of comprehensive, coordinated care, the foundation upon which safe care rests.”
3. Establishing and implementing unified patient safety guidelines is proven to reduce medical error
“Going forward, existing patient safety groups — such as the National Patient Safety Foundation (NPSF), the Institute for Healthcare Improvement (IHI) National Steering Committee for Patient Safety, The Joint Commission Center for Transforming Healthcare, and the U.S. Agency for Healthcare Research and Quality (AHRQ) — should gather, along with leading health systems, to coordinate a national patient safety effort,” recommends the CIAB authors. “Working within these frameworks, patient safety researchers achieved impressive advances across a number of high-volume sources of injury.”
Building on the first takeaway, the authors cited studies that demonstrated how guideline implementation and practice make a significant difference in patient outcomes by reducing errors that lead to patient harm. However, they take it a step further to suggest that all hospitals should follow the same guidelines. “Health care systems, thus, would not compete on patient safety, but instead cooperate to support a baseline level of safety that spans U.S. healthcare,” write the authors. In the event of employee turnover in the stress of another health crisis (such as a pandemic), it would be easier for clinicians to onboard or pick up temporary shifts and treat patients faster with highly standardized care.
4. Continued professional education on patient safety guidelines is necessary to achieve long-term error reductions
Considering the future of long-term improvement patient safety, the authors suggest continuous, regular training. They wrote, “Continuing professional education can align to safe systems design, directly linking professional knowledge to effective action within standard patient safety practices. Advances in that field now provide education with less time spent on training, higher satisfaction among professionals taking the training, and documented lower patient injury rates.” The study cited follows SCL Health, a hospital that enacted Amplifire’s adaptive online learning platform to eliminate CLABSI with effective training. In the nine months following training, CLABSI rates declined by 79%.
Notably, the authors inform Amplifire’s Healthcare Alliance, a collaborative ecosystem where the world’s leading health systems. Members of the Healthcare Alliance co-develop both clinical and non-clinical solutions shown to meaningfully improve patient outcomes, reduce training time and costs, and increase revenue generating activities. Members share course libraries developed by leading subject experts, including patient safety courses, that are proven to lead to positive outcomes like the CLABSI course cited above. The Amplifire Healthcare Alliance stands as an example of what continued training in unified guidelines can achieve: a confident, competent workforce and lives saved.
The CIAB authors note the benefits of a unified approach as exhibited by the Healthcare Alliance, “Several care systems have deployed standard computerized training around standard patient safety processes that address specific sources of injury, such as central line access and maintenance, or placing, maintaining, and monitoring urinary catheters. These training systems can quickly identify and target learning gaps… such coordinated education tools greatly reduce training time. That approach has allowed some care delivery systems to train every new clinician as they join a clinical team, even if only for a single shift.” What’s more is that this idea is not merely a theory, it’s proven in practice — and the benefits are tangible.
With these takeaways, preventable patient harm can be prevented. With unified guidelines that are taught at scale with standard, expertly developed training, lives are saved. Interested in learning more about the Amplifire Healthcare Alliance? Find out more.
