Patient Safety and Patient Satisfaction

Educational Objectives

The goal of this program is to enhance patient safety and increase patient satisfaction. After hearing and assimilating this program, the clinician will be better able to:

1.   Identify common practices in health care settings where medical errors occur.

2.   Describe the dominant mental model of patient safety and medical errors.

3.   Communicate with patients to reduce unmet concerns.

4.   Use consultation time effectively to complete patients’ agendas.

5.   Provide feedback and acknowledge needs of patients, family, and staff.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Wachter is on the Scientific Advisory Boards for Google, IntelliDOT, and Hoana Medical, and on the Board of Directors for the American Board of Internal Medicine. Dr. Howell and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Wachter spoke in San Francisco, CA, at the Postgraduate Course in General Surgery, presented March 27-29, 2008, by the University of California, San Francisco, School of Medicine. Dr. Howell was recorded in Orlando, FL, on July 14, 2008, at the 30th Annual Internal Medicine Conference: Back to the Patient!, presented by Orlando Re­gional Healthcare. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Enhancing Patient Safety

Robert M. Wachter, MD, Professor and Associate Chair, Department of Medicine, University of California, San Francisco, School of Medicine

Introduction: study found 44  000 to 98  000 Americans die from medical errors per year (may be slightly underesti­mated; analogy of equivalence to large airplane crashing every day); consider policies, regulations, costs, and train­ing to prevent medical mistakes; costs of improving medical settings high (eg, $50  000-$70  000/doctor for computers)

Progress of medicine: slower pace, less technology, and fewer number of specialties 30 yr ago; mental model of pa­tient safety from 1960 to 1970  —  “I’m going to prevent medical errors by being really well-trained and really, really careful”; does not apply to present environment; modern model of patient safety  —  recognizes complexity of envi­ronments, involvement of many people, and importance of training and caution; creates set of systems and condi­tions that anticipates and catches errors before they result in death; involves technology, relationships, and communication

Case example: 2 patients in hospital, Jane Morrison and Joan Morris; Jane Morrison  —  had palpitations, syncope, near syncope, and recurrent episodes of tachyarrhythmias on electrocardiography (ECG); patient admitted to hospital and scheduled for electrophysiology (EP) study for Wednesday morning; Joan Morris  —  had headaches; admitted to same hospital floor as Jane Morrison; computed tomography (CT) showed 2 intracerebral aneu­rysms; interventional radiology (IR) embolization of first aneurysm performed on Tuesday morning, second em­bolization scheduled for few weeks later; patient in recovery until Wednesday; patient identification error  —EP laboratory used informal scheduling system (ie, not linked to hospital’s data system; “homegrown email-gener­ated” system); on Wednesday morning, nurse or clerk in EP laboratory called nurses’ station on hospital floor and said, “we’re ready for Morrison to come down for her EP study”; clerk saw name “Morris” on white board and called Joan Morris’s nurse, who assumed, “I guess the doctors ordered this and nobody told me about it; hap­pens all the time”; Joan Morris awakened by nurse, confused and slightly disoriented, but goes to EP laboratory; flawed consent procedure  —  nurse in EP laboratory checked patient’s wristband and saw name matched name on chart, but did not see consent form; since language on consent form difficult to understand for patients, fellow able to obtain consent from Joan Morris; EP attending did not recognize that Joan Morris was not his patient (he stood behind console and Plexiglass screen, and patient draped head-to-toe; failed to reintroduce himself to pa­tient before beginning procedure); discovery of error  —  neurosurgery fellow looked for Joan Morris in hospital room for discharge, but she was not there; fellow ran to nurse’s station and EP laboratory, and thought, “I guess my attending must have ordered this procedure and didn’t tell me”; neurovascular attending physician discovered Joan Morris not in hospital room, discovered mistake, and stopped procedure

Conclusion: Joan Morris accepted apology and said, “I hope people can learn from this so it doesn’t happen again”; who’s at fault  —  EP nurse who failed to use complete identification to call for patient; ward nurse who released patient to EP when unsure why patient receiving procedure; EP attending for failing to reintroduce himself to pa­tient; neurosurgery resident for allowing concerns to be allayed; error committed by people who thought they were doing the right thing in complex environment; examine and repair system that allowed error to happen

“Swiss cheese” model: dominant mental model of patient safety and medical errors; nature of error that leads to harm, “human glitch” that should have been caught by system designed to anticipate errors; layers of protection lik­ened to layers of Swiss cheese (ie, “they all have holes”); model suggests futility of spending time and energy on pointing fingers, rather than focusing on layers of protection, shrinking holes, and creating sufficient overlap so holes do not align; examples of holes  —  “mom-and-pop” scheduling system; identifying patient by last name only; tension between safety and speed; culture of low expectations; failure of residents and nurses to express concerns

Safety practices: redundancies; checklists; simplification; standardization; read-backs (eg, reading back critical lab­oratory results to confirm); production pressures  —  consider whether safety trumps production; culture of low expectations  —  article states suspicion that nurses and physicians had become accustomed to poor communication and teamwork; faulty or incomplete exchange of information expected norm; red flags not signified as unusual worrisome harbingers, but as mundane repetition of poor communication to which they had become inured; change organization practices to, eg, “unless I’m sure it’s right, I’m going to assume it’s wrong, and I’ll do whatever it takes to figure that out even if it delays the first case for 10 min”; analysis of 1977 collision of 2 Boeing 747 airlin­ers and other aviation accidents of 1970s and 1980s found poor communication and culture in which people did not feel comfortable speaking up to authority; survey of operating room crews about teamwork found nearly 80% of at­tending surgeons felt teamwork “pretty good,” but perceptions differed by role (eg, anesthesiologist, surgical nurse, anesthesia nurse, anesthesia resident; “never ask the leader how good teamwork is; ask the followers”); consider consequences of environment where people might suspect something wrong but not feel comfortable speaking up; solve problem by understanding most errors committed by good, careful, compassionate people working in unsafe environments

Communication Strategies for Improving
Patient Satisfaction

  Michael L. Howell, MD, MBA, Assistant Professor of Medicine, Florida State University College of Medicine, Chief Medical Officer, Orlando Regional Lucerne Hospital, and Medical Director of Operations, Orlando Re­gional Medical Center, Orlando, FL

Introduction: must improve patient and physician satisfaction with health care; reducing unmet concerns of patients  —  typical length of office visits, 8 to 15 min (important to survey for concerns early; ask patient to bring list of concerns); ask for information in specified manner; early knowledge of patient’s agenda helpful; standard practice of asking for additional information at end of visit results in focusing on chief complaints only (learn to in­corporate important secondary complaints); eye contact and body language and positioning important to patients

“Some” vs “any”: eg, “is there something that you would like to discuss in the visit today?” vs “is there anything that you would like to discuss in the visit today?”; “some”  —positively polarized; occurs in positively framed declara­tive statements (eg, “I’ve got some samples”); does not lengthen office visit; “any”  —  negatively polarized; leaves impression that “you can only tell me a few things”; tends to lead to more questions from patients; unmet concerns  —issues patients aware of before presenting to office that were not addressed during visit (chest pain and heartburn common); patients often ask about ongoing conditions (eg, angina) and medications; in patients with >1 previsit concern, asking with “some” rather than “any” tends to receive better responses and results in reduction of unmet concerns (corresponds to eliminating 78% of all unmet concerns in intervention arm compared to noninter­vention arm; “any” intervention could not be significantly distinguished from nonintervention); positive communi­cation and interaction with use of “some”; office visit length  —average, 11.4 min (SD, 5 min); no significant effect from “some” or “any” intervention, but more information obtained from “some” intervention; patient-centered techniques do not add significantly to length of consultation (especially if patients and physicians prioritize sub­jects to be discussed); “any” intervention relatively ineffective in eliciting additional concerns and in reducing un­met concerns; “any” seems to subtly communicate expectation for “no” response

Correlations between practice style and patient satisfaction: study  —  57 adult primary care physicians with high, medium, and low satisfaction scores volunteered to be videotaped with patients; patients reviewed videotapes and made comments with research assistant; physicians then reviewed videotapes and made comments; study found physicians with high or medium satisfaction scores tended to focus on patient’s agenda and draw out patient’s story, demonstrated understanding, provided detailed explanation, and completed patient’s agenda; completing agendas results in fewer telephone calls from patient

Focusing on patient’s agenda: draw out story  —  use active-listening responses (eg, listen to 3-5 uninterrupted sen­tences); give opportunity to express fears; ask about concerns; use self-disclosure (ie, use self as example); study found important storytelling did not always occur at beginning of visit; physicians with low satisfaction scores in­terrupted quickly, did not tolerate digressions, and did not have time for minor problems (high-satisfaction groups typically allowed 3-5 consecutive sentences); use responses (eg, “all right,” “okay,” “I see,” and “hmm”) to draw out story; listening did not always lead to lengthy discussions; demonstrate understanding  —  respond empatheti­cally; show caring and familiarity with medical or social history (eg, “how is your mom?”); invest effort in relation­ship; use empathetic responses; provide detailed explanations  — explain what is happening and why; present options to patient; detailed explanations important to patients of all educational levels; complete patient’s agenda  —  deliver what was promised; make sure issues of concern addressed or acknowledged; low-satisfaction groups talked at length about clinical issues, resources, and time management; medium- and high-satisfaction groups attended fully to patient’s medical concerns, considered what was needed to move patient forward in man­agement of concerns, and helped patient become active participant in care

Information sought by patients: whether symptoms concerning or normal; physician’s findings (talk to patient dur­ing examination [eg, “your heart sounds good”]); use visual tools (eg, pictures and charts); discuss medication side effects and allay fears

Communication: use personalized greetings; individualize listening techniques; provide feedback; be responsible and flexible; teach and explain; cover topics of interest to patient (eg, sports and knee injuries); address psycho­social issues; maximize nonverbal communication (eg, eye contact)

Improving “hand-offs”: important information often lacking when patients sent to, eg, hospitalist; hand-offs require reliance on written records; make time to talk to inpatient physician; lack of effective hand-offs shown to cause harm in patients; practitioner knowledge and communication most frequently cited contributor to mishap; transi­tion of ambulatory patient to hospitalist or emergency department (ED) for adequate diagnosis poor; treatment often associated with lack of communication or failure to investigate cause of referral for admission; lack of com­munication between outpatient setting and office to hospital can result in disagreements about correct course of action (eg, “I was uncomfortable because I really didn’t know what to do with the patient; I had a patient I didn’t have a whole lot of information on”); effective communication required when patients sent to ED; insist on 24-hr turnaround time for clinical resumes from hospitalists; research shows strategies can reduce stress; avoid asking “yes or no” questions (focus on open-ended questions); focus on task-at-hand

Techniques: reflective feedback (eg, asking questions back to patient); silence (ie, allowing patient to talk); listen­ing with eyes; positioning (eg, leaning forward); tempo of speech (pause to allow digestion of feedback); tailor language; repetition; request written questions; body language

Reducing liability: improved communication reduces likelihood of being sued; communicate with staff; angry pa­tients and families  —  allow them to vent; show interest and listen; make effort to resolve; discuss events and re­spond in correct context with empathy (eg, “I’m sorry this happened”); positive event management essential; physicians can use innate talents to be effective communicators (“we’re all different; use what you’ve got; make it work for you”); good communication benefits patients and physicians by reducing stress and improving patient relationships and treatment compliance; pay attention to what works and discontinue ineffective methods

Suggested Reading

Jabaaij L et al: Familiarity between patient and general practitioner does not influence the content of the consulta­tion. BMC Fam Pract 9:51, 2008; Liu SS et al: Satisfaction and value: a meta-analysis in the healthcare context. Health Mark Q23:49, 2006; Makary MA et al: Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J Am Coll Surg 202:746, 2006; Sehgal NL et al: A Multidisciplinary Teamwork Training Program: The Triad for Optimal Patient Safety (TOPS) Experience. J Gen Intern Med 23:2053, 2008; Takemura YC et al: Which medical interview behaviors are associated with patient satisfaction? Fam Med 40:253, 2008; Teutsch C: Patient-doctor communication. Med Clin North Am 87:1115, 2003; Wachter RM et al: Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. Rugged Land, 2005; Wachter RM et al: The pa­tient safety movement will help, not harm, quality. Ann Intern Med 141:326, 2004; Wachter RM: Understanding Pa­tient Safety. McGraw-Hill Professional, 2007; Wachter RM et al: Quality grand rounds: the case for patient safety. Ann Intern Med 145:629, 2006.