Introductory Chapter: Patient Safety and Quality of Care - Inextricably Linked and Absolutely Essential Components of Modern Healthcare

“Those who cannot remember the past are condemned to repeat it.”

- George Santayana.

1. Introduction

Modern healthcare is characterized by two dominant forces—constant change and increasing complexity [1]. The emergence of this modern paradigm dates to approximately 20–30 years ago when the distressing awareness of the system-wide impact of medical errors on patient outcomes and healthcare costs came into focus [2, 3]. With this realization came another revelation—that human performance, team dynamics, communication, and systems-based practice require significant modifications to achieve safety, quality, and performance records that even remotely approximate those of the air transportation, nuclear energy, banking/finance, or other high-reliability industries [2, 4].

The current book initiative reflects a much-needed new addition to our series entitled Vignettes in Patient Safety. When the overall project started several years ago, the focus was to allow authors to contribute their thoughts and experiences based on a clinical vignette, whether actual or hypothetical. The opportunities that these chapter contributors saw to improve on the safety and efficiency of delivering healthcare in a very complex and multidisciplinary environment were highlighted. What quickly became evident through the extensive diversity of submissions was the global recognition of how challenging it is to provide high-quality, safe patient care. Even the most simple of problems often required very challenging solutions, with frequently unexpected and/or unpredictable outcomes. Part of the challenges identified in our earlier endeavors included the vast diversity of systems, processes, multidisciplinary teams, and individuals that must come together to achieve a common goal. Even in the best of circumstances the motivations, incentives, and agendas can be quite divergent, and while consensus building is often required, it becomes imperative that the primary goals (and thus the overarching agenda of patient safety) remain intact.

2. Patient safety reflects quality and value

The relationship between high quality services, patient safety, and the resultant added value is becoming increasingly evident with the growing complexity of our healthcare systems. Within this general context, we must note that good patient outcomes are a result of high quality care delivered by competent and highly trained professionals, at the right time, for the right reasons, and with impeccable care and precision [5, 6]. Given the above considerations, it is not surprising that healthcare institutions that focus on patient safety and care quality are emerging as leaders, and not only doing so in the short-run, but more importantly, in a long-term, sustainable fashion. Key organizational characteristics that correlate with better and safer patient care include the encouragement of in-house quality and safety initiatives, where effective “positive feedback loops” are created that continually reinforce high performance levels and system-based learning and improvement [7]. It is also very important to note that the best system can only be as strong as its weakest link. Consequently, broadly administered educational and training efforts that focus on patient safety and care quality are required at organizational level. Part of this new educational paradigm is the assurance that critical knowledge is not only communicated but also retained, applied, and periodically reinforced.

3. The importance of patient safety education

When transitioning from general educational considerations to more focused, provider-centric initiatives, we must emphasize certain key emerging concepts regarding healthcare provider training and its impact on both care quality and patient safety. Does it matter where a resident completes their training? We know that choosing a post-graduate residency or fellowship is one of the most important decisions medical students will make in their career. Interestingly, there have been several studies and data insights that suggest their decision about where to apply and train for residency may carry consequences that go well beyond what was originally understood. The reason why it may be a “higher stakes” decision is because the various impacts of the imprinting of skills, techniques, attitudes, and behaviors that one gains during residency in the long-term perspective, especially, as it ultimately affects the physician’s practice and their patients’ outcomes. As several studies point out, physicians practice “how they were trained” and thus, where they trained and for how long, most certainly affects multiple downstream manifestations of their post-graduate training and future clinical performance [8, 9, 10].

Further examination of the published literature also suggests that if residents train in learning environments with high quality outcomes, then they will tend to practice in the manner that produced those high-quality outcomes when working as an independent attending. For example, in their 2009 paper on evaluating obstetrical residency programs using patient outcomes, Asch, et al., found that obstetrics and gynecology training programs can be ranked by the maternal complication rates of their graduates’ patients [9]. The authors conducted a retrospective analysis of all Florida and New York obstetrical hospital discharges between 1992 and 2007 and connected those discharges back to physicians and their training programs. Furthermore, researchers at the Dartmouth Atlas Project, a group that uses Medicare and Medicaid data to analyze healthcare outcomes in national, regional, and local markets, has observed that “Physicians who train at institutions with better, more patient-centered, and efficient care will be better prepared to lead the transformation of health care when they are in practice” [11]. Collectively, the above studies and data insights seem to pass the “validation-test” with colleagues as well. Hospitals and health systems with high-quality outcomes have a strong cultural focus on patient safety and their patient safety education programs. These organizations are what Carroll and Rudolph described in their 2006 paper on how to design high-reliability healthcare organizations [12]. The takeaway is that patient safety education has not only a short-term impact on direct bedside care but a long-term impact on safety and outcomes as well. Given this new understanding we can readily see just how important it is where a resident trains.

4. Safety systems and patient safety champions

While it can be argued that there has been tremendous improvement in patient safety initiatives at all levels within our increasingly complex healthcare system, it must also be recognized that there are always opportunities for improvement. The concept of accepting “average performance only” results in a slippery slope of complacency and an individual or system-wide tolerance toward faults that ultimately may contribute to harm. Even though it is difficult, if not impossible, to directly attribute a single defect within any complex system or process, it must be recognized that “opportunities for harm” evolve over time and ultimately contribute to what is considered the “Swiss cheese model” of patient harm [2, 13]. Rarely does a single “opportunity” in the continuum of patient care result in an adverse or catastrophic outcome. Rather, unsafe systems are characterized by a series of “overlooked opportunities” over time, usually present during the course of the patient’s healthcare encounter.

It has long been known that the avoidance of patient harm requires the constant presence of adequate and proactive oversight. Such oversight cannot be facilitated by a single individual or even a small group of highly committed individuals—there are simply too many “moving parts” for a small group to be effective. Rather, systems considered to possess excellent quality and safety records are characterized by the development of ubiquitous patient safety champions [14]. Within this progressive new framework, patient safety and care quality appear to be directly proportional to the omnipresence of patient safety champions, throughout the entire organization, and within each critical patient care process. Accountability is mutual, and non-judgmental feedback creates the sense of “common mission.”

At the same time, top organizational leadership must actively support and develop patient safety champions, and unless key stakeholders sufficiently value this tremendous amount of work, energy, resources, and are ready to commit financial (and other) obligations that are required to effectively invest in patient safety, it becomes difficult for even the smallest of initiatives to gain traction. Furthermore, while it is difficult to draw a direct correlation between the investment in patient care initiatives and objective outcomes at times, such activities must be ingrained in the culture of an institution and viewed in a positive light. Even though objective outcomes in patient care initiatives can be somewhat challenging to demonstrate, their importance cannot be understated. Therefore, pertinent metrics and expectations should be defined in advance before any further steps are undertaken.

5. The patient safety journey

The patient safety journey outlined in this collection of chapters touches on many important points that are directly relevant to everyday clinical practice and systems-based healthcare operations. From a focus on teams to simulation to electronic health records utilization, the content included herein stresses the importance of constructive and synergistic approaches toward ensuring the provision of quality and safety our patients deserve. Similarly, the various chapters in this volume explore the importance of concepts as diverse as multi-disciplinary approaches, camaraderie, and simulation, to help attain the most important singular and ultimate goal—a “zero defect” healthcare environment [13, 15]. One key aspect, unique about the current book - and we would like to heavily stress this - is the increased emphasis on the critical importance of training on patient safety and care quality during the graduate medical education phase of professional development. That said, we also emphasize that patient safety and care quality, as inseparable components of the healthcare value equation, constitute a life-long journey for each and every individual involved in caring for, and ensuring the well-being of, another human being.

Within the above context, it is critical to recognize that simply “going through the steps” to “check a box”—although certainly a good start—does not inherently translate into the desired outcome. For example, while the implementation of the universal surgical checklist is globally accepted as the “gold standard” in operative patient safety [16], cases still occur where an entire operating room team “agrees” on an incorrect answer or team members fail to actively participate in the process. Such scenarios can easily become associated with retained surgical items or wrong-site surgeries [15, 17]. Consequently, lack of an appropriate championship, combined with a lack of appropriate team focus, can still produce disastrous consequences despite the most well-designed safety systems being in place. Finally, important lessons have been learned during the current coronavirus disease 2019 (COVID-19) pandemic [18, 19]. These lessons further inform our overall understanding of patient safety dynamics under the conditions of extreme healthcare system stress and acute resource limitations.

6. Synthesis and conclusion

In this book, we will explore new developments and evolving trends within the highly complex environment of patient safety, with a strong emphasis on the interrelationship between healthcare safety and quality of care. In addition to presenting various descriptive aspects of patient safety, the chapters enclosed herein also provide a perspective on how to approach different opportunities for improvement at the institutional level. The goal here is to strengthen existing patient safety systems and to facilitate the implementation of specific solutions while addressing major opportunities and concerns. Our key message is, and will continue to be, centered around the importance of teamwork, excellent communication, honest disclosure, and a non-punitive approach to systemic remedies. Only through well-coordinated educational and skill-building efforts, beginning with the earliest stages of medical education, then proceeding through graduate medical training, and finally continuing throughout one’s healthcare career, can we build effective systems that will sustainably deliver high quality and the safest possible patient care.