Unsafe for every need: Too many details for patient safety goals can be trouble

Some efforts to comply with goals can backfire

As hospitals continue their efforts to comply with the National Patient Safety Goals issued by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations, some risk management and quality assurance experts are issuing a strong warning: Don’t go overboard with your efforts to write new policies and procedures because they can create unnecessary liability risks.

The problem occurs when well-meaning hospital leaders develop overly detailed and prescriptive policies and procedures to ensure compliance with the safety goals, says Geri Amori, PhD, ARM, FASHRM, president of Communicating HealthCare, a risk management consulting firm in Shelby, VT, and past president of the American Society for Healthcare Risk Management (ASHRM). Some health care organizations are painting themselves into a corner with these new policies and procedures, she says. "You create a policy and procedure that nobody can keep up with," she says. "Then you go to court and the attorney says, You have a policy and procedure. Why didn’t you follow it?’ Either you have to make an excuse for not following it or you have to say you didn’t know about it. Neither one sounds good in court."

Get real and keep it that way

That’s not to say that policies and procedures won’t be necessary in your efforts to meet the patient safety goals. It might even be appropriate to develop entirely new policies and procedures. But Amori says you must be careful not to make them so strict that they don’t apply to all situations and your staff can’t follow them. Policies and procedures should be based on reality, not an ideal, she says. "I think what’s happening is we’re getting these new goals but we don’t know how to deal with them, so we create more policies and procedures because that’s what we know how to do," she says. "All we’re really doing is creating more liability."

System analysis necessary for safety goals

JCAHO announced the first set of National Patient Safety Goals a year ago and they are in effect through this calendar year. In January 2004 the next set of goals take effect. The goals are intended to help accredited organizations address specific areas of concern regarding patient safety. Each goal includes no more than two evidence- or expert-based recommendations. To ensure a greater focus on priority safe practices, no more than six goals are established for any given year. Each year, the goals and associated recommendations are reevaluated; some may continue while others will be replaced because of emerging new priorities. New goals and recommendations are announced in July and become effective on Jan. 1 of the following year. (Editor’s note: For the 2003 and 2004 goals, see the JCAHO web site at www.jcaho.org.)

All JCAHO-accredited health care organizations will be surveyed for implementation of the recommendations, or acceptable alternatives, as appropriate to the services the organization provides. Alternatives must be at least as effective as the published recommendations in achieving the goals. Hospitals have a strong motivation to comply — failure by an organization to implement any of the applicable recommendations (or an acceptable alternative) will result in a special Type I recommendation — and that is spurring some of the policy and procedure overkill Amori says will create new liability.

Developing a proper response to the patient safety goals should involve far more than just writing or revising a policy, Amori says. First, she says you should look at the processes that the goal assesses in your own institution. Then you need to look at the broad reasons why your system works the way it does regarding that goal.

"You’re really doing a failure mode analysis and sort of a root-cause analysis to determine why it’s working that way in your system," she says. "Is there something in your policies and your system that is creating a system where you are not monitoring high-risk medications or that allows you to misidentify patients, or whatever the goal is? Once you have the data showing what’s going on in your organization, only then do you go about developing policies and procedures to improve the situation."

If you put too much focus on writing the policy and procedures, you may not be paying enough to the actual process improvement, she says. When you have created a better process, then you might want to document that through a new policy and procedure.

"We’ve said that for a million years in risk management," Amori says. "Policies and procedures don’t change behavior. They should memorialize the type of behavior we think is important. Change the behavior first and write a policy and procedure that reflects that change."

That advice is seconded by Marie Pears, RHIA, CPHQ, quality coordinator at Meadville (PA) Medical Center. She says her hospitals has struggled with its efforts to comply with the patient safety goals, at first developing some policies and procedures that went overboard. For the 2003 goal regarding identification of patients, for instance, Meadville at first developed a policy that required proper identification for any kind of encounter with a patient, but then Pears and others realized that wasn’t what JCAHO intended. But they still had to figure out how to meet that goal.

"We did have policies and procedures for patient identification in place already but we didn’t have two patient identifiers, so we went to work on that," she says. "In this case, we almost went overboard because we said that whatever you do with the patient you have to use those two patient identifiers. But in some cases that’s not necessary. We wrote the policy saying that at first, then we went back and rewrote it. That’s an example of how you can go overboard with your policies and procedures."

Meeting JCAHO goals may not be enough

Another example shows how the first reaction to the JCAHO goals may not be the best for your institution. For the goal involving the proper identification of the surgical site, Meadville noted that JCAHO wanted the patient to be identified when the patient enters the surgery room. The hospital’s policy already ensured that the identification was confirmed by then, so the first reaction was to say that the goal had been met. But then the team working on that goal realized that Pennsylvania law requires the patient be identified before going into the surgery room. That prompted a close look at whether the entire pre-surgery identification system was sufficient.

"When we took a close look at it, we decided to revise our policy and procedure because there was a potential for misidentifying the patient after the patient leaves the holding area but before entering the surgery room," she says. "So now we have a surgical pod where everyone stops and we identify the patient, the surgical site, and the procedure."

Goal-oriented groups

That experience with patient identification confirmed the value of the team approach Meadville uses for meeting the patient-safety goals. Pears put together an overall team made up of key department leaders to address the goals, then that group broke up into smaller teams to look at individual goals. After allowing some time for the smaller teams to work, everyone regrouped to discuss their findings and recommendations.

Some teams determined that the hospital was already meeting that goal and no further action was needed. (In that case, Pears still was careful to document the team’s analysis and recommendations.) To keep up with all the teams’ work and ensure that the goals would be met on time, she used a matrix that listed each goal, who was working on it, the team’s recommendations, and when any actions should completed.

Each team investigated what Meadville should do to comply with the goal, mainly by asking these questions: What is the patient safety goal? What problems have we had that pertains to this patient safety goal? Do we have data available on this topic? Do the data show we’ve had a problem in this area? Do we already have a policy and procedure in place? Are we already in compliance with what the goal says? Is that enough or do we want to do better? How far beyond compliance do we want to go?

The goals give you areas to focus on that might not otherwise capture your attention, Pears says. Even if it seems you are already meeting the safety goal, Pears says you should still study each one carefully. Use the patient safety goals as a reason to carefully assess your own policies and procedures for loopholes and weaknesses.

You won’t have to develop a new policy and procedure for every goal, Pears says, but you will want to take a look at each policy and procedure addressing the goals. Some might be fine as is, some might need improvement, and some goals may need completely new policies and procedures. Whether you’re refining or developing them from scratch, Pears echoes the advice of risk managers:

"You certainly can go overboard with policies and procedures," she says. "You need to keep them simple. The more complicated a policy and procedure gets, the harder it is for people to comply and that gives you more chance for error. You could be creating a problem just by the way you’re writing the policy and procedure."

Physicians may be more wary than others

When addressing the patient safety goals, don’t be surprised if physicians are more skeptical than others about your efforts. They tend to be resistant to such efforts in general and many are expressing concerns about how new policies and procedures could be a burden to their practices, says Fred Meyerhoefer, MD, a retired pediatrician who now consults with physicians regarding JCAHO compliance.

"Physicians can be concerned about putting themselves in a legal bind, maybe more so than the hospital, when you’re talking about how to treat the patient and respond to some of the patient safety goals," he says. "But I’ve found that when I talk to them and show them why this is good patient care even if they have to alter their practices a little bit, the majority of them have backed off."

In many cases, physician compliance comes down to how detailed you have made your policies and procedures, he says. Physicians will be skeptical of any policy and procedure that dictates an overly specific manner of care, and unlike many hospital staff, physicians have the clout to speak up and say no. With hospital staff you might not find out until it’s too late that you’ve written too much into your policy and procedure.

Amori says that, in general, you should avoid writing a highly detailed policy and procedure. When in doubt, err on the side of being too general, she says.

"It can be extremely detailed if there is a complex process that only can happen one way, but my guess is 99.9% of our processes aren’t that way," she says. "In most cases, you’re probably better off not spelling out the step-by-step details of what a nurse should do in a certain situation, unless it’s absolutely a situation where you know that’s the best way and the nurse knows where the policy and procedure is, and it happens with enough frequency that people are going to know to look there. Otherwise, you’re giving a plaintiff’s attorney lots of ammunition and you’re going to have lots of frustrated staff."