An acceptable level of preventable patient harm?

I was at the Kansas Healthcare Collaborative (KHC) 2015 Summit on Quality two weeks ago. During the presentation on the Kansas Hospital Engagement Network I learned something disturbing: many hospitals throughout the country agreed to a goal of reducing preventable patient harm by 40% by the end of 2014, as compared with 2010 levels. This goal was set by a program called Partnership for Patients from the Center for Medicare and Medicaid Services (CMS).

Let me state that again: the GOAL — the target that hospitals are striving for as they serve the community — is to reduce preventable patient harm by 40%. I was not aware that harm comes as a mix of acceptable harm and unacceptable harm and the concern is getting rid of the unacceptable portion.

But if hospitals are striving for such a goal, I simply ask that they fully explain this to patients and families. And to help, I would like to provide some ideas for facilitating this communication.

The welcome sign

A warm way to say “Hello”…
welcome sign

The community newsletter update

A truly honest marketing campaign…
community newsletter

The harm tally board

Perfect for the front lobby…
harm tally board

The patient and family conversation script

Because explaining this to patients and families might be a bit tricky…
conversation script

(You have my permission to copy these images and distribute any way you wish.)

And the results are…

The results of the nationwide efforts for 2011-2013 are available, and preventable harm was reduced by about 17%. That trend is definitely in the right direction. The new goal for HEN 2.0, beginning in 2015 is, once again, a reduction of 40%.

A goal of 40% reduction may be appropriate at a national level. But is that the goal you want at your local hospital? From my viewpoint, that goal means, “Let’s tweak things a bit and see what happens”. But a goal of zero means “We take full responsibility for preventable patient harm. Every patient, every time.” Which hospital would you rather receive care in?

I realize that some in the medical profession will argue that unpreventable harm has been mislabeled as preventable, and there is only so much that can be done to reduce patient harm. I will leave it to the experts to respond to that view.

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2 thoughts on “An acceptable level of preventable patient harm?

  1. I would be happier with an organization that aimed for ***and achieved*** a 40% reduction in harm, than an organization that claims to aim for no acceptable harm (safe, reliable, high quality care for every patient, every day) but uses this as a bumper sticker rather than a front line guide to action.

  2. Thanks for this terrific blog. A goal less than zero implies, as this blog aptly illustrates, that some errors are acceptable. While many hospitals have set a goal of zero for hospital acquired infections, there are still many others who argue that one cannot get to zero. This is not the point. Setting such a goal will make health care workers aspire to preventing harm 100% of the time. Back in 2004, the Jewish Healthcare Foundation of Pittsburgh stated their “belief that perfect precision in basic safety practices in every patient encounter and treatment will eliminate unnecessary death and injury. This requires removing every source of harm, every defect in care, immediately upon discovery, a commitment essential to ‘getting to zero.’ ” Let’s have the goal of zero and measure the progress each year and make sure it is moving in the right direction.

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