Hospitals still lag in developing safe practices

Proactive processes are needed

While hospitals are doing will in complying with a number of the National Quality Forum's (NQF) guidelines of 30 safe practices, there are some areas in which significant improvement is still needed, according to new research from the Emory Center on Health Outcomes, and Quality, Rollins School of Public Health.1

While most hospitals had adopted seven of the nine medication-related practices, lower adoption rates were seen for resource-intensive safe practices such as consultant pharmacists (52.0%) or computerized physician order entry or CPOE (2.7%). The "culture of safety" questions revealed wide adoption of non-punitive error reporting (83.7%), but more limited adoption of proactive processes to detect and prevent errors (44.9%).

The results were based on a retrospective review of annual self-assessment surveys from 2003 to 2004.

"We certainly know that all hospitals face the challenge of meeting an ever-growing number of standard national guidelines," notes lead author Kimberly Rask, MD, PhD, who is director of the Emory Center on Health Outcomes and Quality; associate professor of health policy and management in the Rollins School of Public Health at Emory University; and associate professor of medicine in the Emory School of Medicine, explaining the rationale for the study. "In Georgia, we have a unique opportunity with the Georgia Hospital Association [107 hospitals around the state] trying to proactively report regionally and nationally."

In addition to major hospitals in large urban areas such as Atlanta, the state has a large number of rural facilities; more than half the state's hospitals have fewer than 100 beds. This, thought Rask, provided a unique opportunity.

"What interested me was the opportunity to look at the whole range of facilities," she explains. "We know about early adopter hospitals, and how they have the experience and the resources to jump on [new initiatives], but what about those facilities that do not have large quality departments and still face the same requirements — where are they?"

Surprising findings

Surprisingly, says Rask, the research showed that size did not matter nearly as much as one might suspect. "We expected that perhaps there might be a very big difference between what large urban hospitals and small rural hospitals did [in terms of compliance], but we found very little difference," she says. "What kind of hospital you were had very little impact on whether you hit the [compliance] target."

The most common barrier faced by all hospitals, she continues, is resources — which might, again, seem to put rural hospitals at a disadvantage.

Not so, Rask insists.

"What's interesting is that having senior administrators do floor rounds, for example, is easier and more feasible in more smaller hospitals so they might be more likely to perform more of the hands-on, proactive activities," she explains.

Being proactive

Rask and her colleagues noted a distinct difference between how successful hospitals were in responding to quality issues, as opposed to anticipating them — thus, the emphasis on proactive processes. "Across the board, although we feel very good about [how hospitals are] setting processes in place, when you look at the difference between that and proactively identifying and preventing errors before they occur, that's where most hospitals struggle," she notes.

What are some of the proactive strategies Rask recommends to improve safety? "Pilot testing practices are important," she says, "and performing an FMEA [failure modes and effects analysis] proactively with that pilot program."

In other words, she says, look at what some of the key problems might be. "Ask questions such as, 'If we change this, what might happen?''' Rask suggests. Such a prospective FMEA, she notes, adds the opportunity to prevent errors, rather than just reacting to poor processes after something happens.

"It takes a different mindset, and it's tough to do in an environment where resources are already strained; you feel you've enough to do chasing after what has already happened," she concedes, "but you could see some benefits."

Such a proactive approach, says Rask, can also help you obtain valuable information without investing a fortune. "For example, we've talked about piloting processes before you put in new pieces of equipment," she suggests. "It could be done on a small scale, rolling out new technology or processes in one unit at time before going live on a wider scale. You can perfect it up front and do it right, avoiding those messy 're-dos.'"

Don't forget the docs

The study also noted that hospitals were having difficulty with safe practices that involve hospital-based physicians, such as ensuring that new prescribers had access to all currently prescribed medications and minimizing distractions during order writing. In addition, they found lower adoption rates in areas that required direct physician participation, such as eliminating verbal orders and using standardized abbreviations.

"Some practices require a lot of physician input, such as using abbreviations and verbal orders, and we wanted to put out a call to hospital-based physicians that this is where you can make a difference," says Rask. This, the authors suggested, should entail physician involvement as clinical leaders and team builders.

"That can certainly be a challenge," Rask concedes. "But many hospitals have found that if they have hospitalist physicians, they are really interested in getting involved in QI. They spend a lot of time inside the hospital and can, therefore, spend some of it on QI interventions."

Finally, the researchers recommended, it is important to develop more robust error monitoring systems. "Many hospitals are limited to voluntary reporting of errors and adverse events," Rask notes, "and a lot of data out there tell us that a very small percentage of events are reported."

If you really want to know if your policies are making a difference, she continues, "you need to know what happens before, during, and after a program is put in place. Increasing automation in data flows in hospitals gives us an excellent opportunity to collect these data routinely."

[For more information, contact:

Kimberly Rask, MD, PhD, Department of Health Policy and Management, Rollins School of Public Health, 1518 Clifton Road NE, Atlanta, GA 30322. Phone: (404) 727-1483.]


  1. Rask K, Culler S, Scott T, Kohler S, Hawley J, Friedman E, Naylor DV. Adopting National Quality Forum medication safe practices: Progress and barriers to hospital implementation. J Hosp Med 2007;2:212-218.