Another way to detect breakdowns in care

A program encouraged patients to report problems that arose during hospitalization.


Background

Hospitalized patients can be reluctant to report issues with their experiences, including breakdowns in care. The standard approach has been for hospital staff to wait for a patient to initiate a report of a problem, but a more proactive model may help detect and correct problems more efficiently, said Kimberly A. Fisher, MD, MSc, an associate professor of medicine at the University of Massachusetts Medical School and a pulmonary and critical care medicine physician at UMass Memorial Medical Center, both in Worcester, Mass.

In a study in which structured interviews were conducted with 979 hospitalized patients, published in 2017 by the Journal of Hospital Medicine, Dr. Fisher and colleagues found that nearly 40% believed they had experienced at least one breakdown in care, most frequently involving exchange of information and medications. To make it easier for patients to report such breakdowns, they developed the We Want to Know Program, which was implemented at one Baltimore hospital from June 2014 to May 2017.

How it works

As the program's name suggests, it encouraged patients to report any perceived problems in care delivery. Dedicated We Want to Know specialists performed active outreach, going to patients' rooms and asking about their stay. The specialists tried to determine whether there had been any breakdowns in care. “And then, if they identified a problem, they would want to understand what the impact of it had been on the patient and then would also take steps to immediately resolve the breakdown,” she said.

Other core features of the program were providing multiple channels for patients to report breakdowns themselves, including a website and a phone number, and using posters, cards, and digital displays to increase patient awareness, “with the goal of making patients and their families aware, No. 1, just that we want to know if there are problems, and then giving them venues by which they could speak up,” said Dr. Fisher.

Results

Over the course of about three years, We Want to Know specialists interviewed 4,676 patients, and 822 (18%) reported a breakdown in care. Of these, 313 (38%) had not spoken with anyone at the hospital about the breakdown, and 547 (67%) described associated harm, according to results published in the May Joint Commission Journal on Quality and Patient Safety. In addition, there were 55 patient-initiated reports to the program, 41 (75%) of which reported a care breakdown.

These results suggest that hospitals that rely on patients to report are likely to miss many problems, said Dr. Fisher. “I think that the biggest takeaway was . . . the difference by an order of magnitude in the reports that we got through active outreach as compared to patient-initiated reporting,” she said. “That's not to say that the patient-initiated reporting venues aren't still valuable to have, because we did get reports that way, but it's really not enough.”

Challenges

One challenge was the limited reach of the project's specialists. “Although the active outreach and going to patients and asking them if they have any problems is a much more effective way to find out if there are problems, it's resource intensive, and even with dedicating one individual to primarily do that, we reached a small fraction of the number of patients who actually come through that hospital,” said Dr. Fisher.

A more surprising obstacle was distributing the awareness campaign materials as external researchers, she added. “We thought the easy part would be getting the campaign out there and setting up the freestanding channels that patients could report breakdowns through, and it turned out that even just getting the We Want to Know posters up in all the patient rooms was more of an operational challenge than we anticipated,” Dr. Fisher said.

Lessons learned

To deal with the problem of getting the program's specialists to patients, Dr. Fisher said one of her coauthors has advocated that physicians and nurses ask about breakdowns at the bedside. It's important for clinicians to be aware that patients frequently experience problems during hospitalization without disclosing them, Dr. Fisher said. “Those were some of the lessons that I took away and that are on my mind as I see patients,” she said.

Next steps

The next task is to find other less resource-intensive ways to gather this information, Dr. Fisher said. “Our focus is really on the challenge of how do you learn about these breakdowns and make it easy for people to speak up about them, but be able to broaden the reach,” she said.