Using Always Events to drive quality improvement
Focusing on the positive
Serious reportable events — the words can send a shiver up the spine of a quality professional, and any healthcare professionals who are present when such events occur.
In stark contrast are Always Events, which the Institute for Healthcare Improvement defines on its website as "aspects of the patient experience that are so important to patients and families that health care providers must perform them consistently for every patient, every time."
"Patients can experience Always Events," says Martha Hayward, the lead for public and patient experience at the Institute for Healthcare Improvement (IHI) in Cambridge, MA. "They are positive. And the thing is, where we fail to meet quality and safety goals usually has to do with patient experience. If we eliminate harm and increase safety and fail to focus on patient experience, we are missing the most important thing: how those initiatives translate to patients."
For years, Always Events were the baby of the Picker Institute, which, until it closed at the end of 2012, offered matching grants to organizations that came up with ideas for great Always Event projects. After its closure, the grants ended but the mission continued, bequeathed to IHI.
To qualify, an Always Event must be something important to patients, says Hayward. "You have to start not how we as a system perceive what should happen, but how patients do. We have to go to patients and ask them, not as perfunctory participants, but as guides."
The second requirement for an Always Event is that it has to be evidence-based — something that is known to make a difference in outcomes or safety or how patients feel about their care. Third, it has to be measurable and sustainable, and lastly, low cost. What they find, Hayward notes, is that most Always Events — 98% — relate to issues of communication, which can usually be implemented with a minimum of financial input. "Communication seems to be where we fail patients and families dramatically."
Hayward’s own story is an example of why this kind of work is important. She was a cancer patient, admitted to a hospital at 7 a.m. one morning seven years ago for a bilateral mastectomy. She and her husband came in and, as they put on her wristband, she was asked what she was in for. She choked out the words, not knowing that it was just the first of 12 times she would be asked between then and the operating room what she was in for. The last time, as she lay on the gurney, gowned and ready for surgery, her husband "freaked out" and started yelling at the staff, wanting to know why they were asking his wife this question, why they did not seem to know.
Of course, the reason was safety. "But it cut my confidence and led to me having a racing heart as I went into surgery," she says. "If someone had said at the start that safety was the number-one concern and that everyone would be asking me why I was there, I would have felt completely different. I would have felt cared for."
Because they tend to be cheap fixes, Hayward says, Always Events are attractive to the bottom line and the folks who are watching costs. And because they are meaningful to patients, they are very attractive to frontline staff — they can see the impact of their implementation quickly. "It gives meaning to the work they are required to do," she says.
Accumulating evidence
Even for those who might be skeptics, there is increasing evidence that this is part of good care. "There is a lot of evidence about patient engagement in general, and about specific Always Events, we are accumulating evidence," she says. "The field of person-centered care is exploding. It reduces readmissions, costs, improves outcomes — we know this from the literature. And implementing Always Events can drive culture change. If you have a system that is frustrated with patients who aren’t engaged, you can take this to leadership as a way to engage them."
The next two articles (see pages 99 and 100) include examples of Always Events that made a difference to patients, providers, and facilities — bringing benefits to all involved.
The IHI website has a starter kit on Always Events at http://www.ihi.org/resources/Pages/Tools/AlwaysEventsGettingStartedKit.aspx. It includes outlines of requirements, as well as of some of the successful events that have been tried in the past.
"Always Events translate patient experience into events," Hayward explains. "We are moving from knowing what patients want to behaviors that meet those desires. I do not want to feel like a number. I want to be known. How do we translate that into an event? What does that look like? It means the patient will always be asked how they like to be addressed and then be referred to in that manner. Always."
For more information on this topic, contact: Martha Hayward, Lead, Public and Patient Engagement, Institute for Healthcare Improvement, Cambridge, MA. Email: [email protected].
