Assuring safety

Assuring safety

Measuring non-catastrophic ‘negative’ outcomes (such as pressure sores, in-hospital falls, infections, medication errors and read missions) can be done and is a foundation of safe and high reliable care.

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Yet there are an infinite number of things that can go wrong, and properly reporting all of these – in a reliable way, properly corrected for the case-mix of the population – would be a very costly endeavor, adding to the administrative burden for providers, and ultimately not realistic 1,2,3. (Not surprisingly, many of the critical comments of the health providers referred to these types of public measures.)

“Not dying is not the best measure of quality in surgery. We are beginning to see registries of patients and outcome information that are true windows into the quality of the procedure that was performed.” - Dr. Cynthia Ambres, Partner, KPMG in the US

In addition, a core focus of ‘patient safety’ is avoiding catastrophic, rare events (like wrong-side surgery, foreign objects left in the body after surgery, serious medication errors, and so forth).4 Reporting on such events reliably is statistically impossible. Also, the safety precautions should be such that the risk of such event occurring is as minimal as possible, and that when it occurs, the organization will act swiftly and decisively, deal with the patient (and family) with respect, and prevent further harm to the patient as well as future patients.

Resorting to publicly reporting on care bundles (how many patients received all necessary steps of a carepath) is not a solution either, since the list of such processes is equally enormous. Measuring key bundle compliance for internal purposes is crucial, but citizens and payers are not interested in long lists of things that (almost) went wrong. Too much focus on this also disempowers professionals and providers rather than supports them, tapping both moral and real resources that could have been spent more wisely.

“Certification is arguably the most effective way to reassure the public that care is safe.” - Dr. Marc Berg, Principal, KPMG in the US

Certification is arguably the most effective way to reassure the public that care is safe, and organizations such as the US Joint Commission, Accreditation Canada, DNV and the Australian Commission on Safety and Quality in Health Care have all introduced programs in recent years. Not all of these programs have incorporated the state-of-the-art risk management insights, however. Ideally, the certification process would focus on how far a particular organization has proceeded on the path to becoming a high reliability organization (which stage of reliability is achieved), zooming in on whether the organization is building the right structures and processes, and, crucially, the right culture.

As leaders seek to create a safe organization, they need to ensure that they:

  1. measure the right processes and safety-outcome measures at the right level.
  2. align these measures with clear responsibilities and accountabilities for safety, both for the patient-focused pathways and the central units, such as intensive care and wards.
  3. combine zero tolerance with openness to learning, and to collectively discussing process failures, near misses and patient harm.
  4. make processes ‘fail-safe,’ and owned by staff with appropriate authority.

BMJ Outcomes journal

Supported by KPMG International, the British Medical Journal (BMJ) is currently working on a new initiative to provide a journal and repository for publication of outcome measures to help facilitate discussion and support the consolidation of knowledge in this area. The aim is to create an international forum for debate and consolidation of knowledge on how to measure the key outcomes that matter for patients, professionals, providers, payers/commissioners and the public.

Hopefully, BMJ Outcomes will contribute to a growing body of evidence and industry best practice in the approach to outcomes measurement at an individual, organizational, regional, national and international level.


1 The Contextual Nature of Medical Information. Berg, M. and E. Goorman, International Journal of Medical Informatics,. 56: p. 51-60, 1999.

2 The three faces of performance measurement: improvement, accountability, and research, Solberg, L.I., G. Mosser, and S. McDonald, Joint Commission Journal on Quality Improvement, 23: p. 135-147, 1997.

3 Evaluating policy and service interventions: framework to guide selection and interpretation of study end points, Lilford, R. J., et al.British Medical Journal, 341, c4413-c4413., 2010.

4 Facts about the Sentinel Event Policy, Joint Commission, Sept, 2009.

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