When health professionals and leaders talk about safety, they are most often talking about preventable physical harm to patients. Increasingly, though, many are recognizing that other forms of harm — such as emotional, psychological, and sociobehavioral harm — are also prevalent in health care and can be just as important to address.
But even those willing to expand their definition of patient harm often need help knowing where to begin. While all health care organizations have systems for capturing, assessing, and understanding physical harm, they don’t necessarily have the same resources in place to address “non-physical” harm. At Beth Israel Deaconness Medical Center, we began by thinking and talking about preventable non-physical harm in the same way as preventable physical harm — by digging into the root causes.
Defining and Categorizing Harm
In our organization, we framed emotional, psychological, and sociobehavioral harm using the concepts of respect and dignity. We define dignity as “the intrinsic, unconditional value of all persons” and respect as “the sum of actions that honor or acknowledge a person’s dignity.”
Disrespectful behavior is an affront to a patient’s dignity and can cause real and lasting harm. But what is it? How do we get to its root cause and develop corrective action?
Like many organizations, we review patient experience surveys such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Yet review of survey data provides only a piece of the picture. Considering HCAHPS data in isolation would be like looking at surgical site infection rates without thinking about the causal factors.
To get beyond the statistics and into the stories, we tapped our patient relations office, which categorizes and responds to patient grievances. Every hospital has such a department and can learn volumes about how respect is — or is not — practiced in the organization by reviewing issues reported by patients and families.
Situations that motivate someone to contact patient relations often reveal that there is more than meets the eye. Disrespect and subsequent harm can be caused by an offhand comment by an individual, but many times more issues are at play, such as missed or poor communication, uncoordinated care, failures to preserve privacy, or the loss of irreplaceable valuables, for example.
Communication failures can be particularly complex, because while they may involve a misstep on the part of an individual communicator, they can often be linked to systems issues. For example, if leaders of a health system strongly prioritize beginning the ambulatory surgical day on time, frontline staff may in turn instruct the first patients of the day to arrive extra early to avoid delays, even if it means some arrive before there is anyone to greet them. Such unintended consequences may be perceived by patients as the health system “tricking” them, rather than treating them as responsible adults and valuing their time. The subsequent harms can include frustration and anger (i.e., emotional harm), and in severe cases may develop into distrust, negative ratings of care, and an unwillingness to return to the health care organization (i.e., sociobehavioral harm).
System-level solutions that could help prevent future harm include better patient-engagement to co-design the pre-surgery instructions, more nuanced communication about priorities by leaders, and staffing or facilities adjustments to ensure patients who arrive early feel welcomed.
Creating a Road Map for Respect
Of course, respect is a two-way street. The work we have done so far at our organization is elevating and informing other work, such as the development of systems for addressing disrespect shown to staff by patients or peers. In essence, the “practice of respect” is an umbrella initiative to raise the conversation around the question, “What are the ways we want to treat each other, and how do we do so more reliably?”
When we talk to other health professionals about these issues, we find that the concept resonates, but it is broad and complex, making it difficult to know where to start. Recently, we convened a diverse, interdisciplinary group of experts to discuss these issues.
What is most striking about the “road map” that resulted is that the recommendations, strategies, and tactics this group agreed upon to promote the practice of respect — and prevent non-physical harm — are very similar to what an organization needs to do to prevent physical harm. Culture, accountability, leadership, an engaged workforce, patient-family-professional partnerships, learning systems, and measurement are all key ingredients to this work.
For many organizations, the key may be to begin by capturing and analyzing individual harm events. Treating failures – i.e., episodes of disrespect – with the same rigor applied to other harm events should be part of every organization’s journey towards high-reliability. Such stories can help the organization learn and they are a critical part of expanding our concept of patient safety to encompass the prevention of both physical and non-physical harm.
Ultimately, practicing respect should not be seen as something new or separate from other work around preventing harm. It needs to be considered a part of who we are and how we work together with patients and each other.
Finding ways to help organizations be more reliably respectful is no small task, but the history of preventable harm gives us reason to be hopeful. For instance, it was not so long ago that we accepted that central line infections were an inevitable complication in a certain percentage of patients. But today, with evidence-based methods, training, and consistent application, central line infections are considered to be almost completely preventable. It will take time, but we believe we should aspire to a similar arc of improvement with preventable emotional, psychological, and sociobehavioral harm from disrespect.
Patricia Folcarelli, RN, PhD, is Vice President of Health Care Quality, Beth Israel Deaconess Medical Center. Lauge Sokol-Hessner, MD, is Attending Physician and Associate Director of Inpatient Quality, Beth Israel Deaconess Medical Center. They will speak on this topic at this year’s Lucian Leape Institute Forum & Keynote Dinner on Thursday, September 13, 2018 (Boston, MA, USA).
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