Flagler Hospital Patient Safety Record Final Report

Flagler Hospital is based in St. Augustine, northeast of Florida. It is a 335-bed hospital
named after its founder, the Henry Flagler, a 19 th century American industrialist. Since its
founding more than 130 years ago, the hospital has been at the forefront of providing physical,
economic, and social health services to members of not just north eastern Florida but also the
entire state of Florida (Flagler Health, 2019).
Organizational problem
Since its inception, Flagler Hospital has developed a reputation of providing quality
healthcare services to the patients it serves. However, it has recently faced patient safety
problems. These problems have manifested themselves in the form of increased patient injuries
and hospital acquired infections. These patient safety problems fall below the standards of
various patient safety regulatory requirements, notably the Patient Safety and Quality
Improvement Act of 2005 and Affordable Care Act of 2010.
Organizational challenge posed by the problem
Poor patient safety record poses major challenges to Flagler Hospital. One of them is
increased hospital stay length for patients (Waterson, 2018). The longer the patients stay in
hospital the costlier their care becomes. Under the Affordable Care Act of 2010, hospitals have
to bear some of the costs of the increased stay. Additionally, the hospital misses out on the
incentives provided by the Affordable Care Act for healthcare facilities that record high patient
safety record. Thus, longer hospital stays for patients has a negative effect on the financial
performance of the hospital. Poor patient health safety can also lead to increased rates of in-

FLAGLER HOSPITAL PATIENT SAFETY RECORD FINAL REPORT 3
hospital mortality (Waterson, 2018). A combination of longer hospital stays and higher rates of
in-hospital mortality can have lead to significant reputational damage for the hospital. In the age
of the internet where patients often check online for quality of services offered by hospitals
before visiting them, poor patient safety record can result in fewer patients coming to the hospital
which may have a negative impact on the finances of the hospital.
Data supporting the problem’s existence

According to the latest report by Centers for Medicare and Medicaid, Flagler Hospital
scores poorly on patient safety. The report uses a ten-point scale to rank the hospitals. The higher
the score, the poorer the hospital is in patient safety. Flagler scores 6.94 which is just slightly
above average (Centers for Medicare and Medicaid Services, 2017). It, therefore, misses out on
the incentives that were established by the Affordable Care Act of 2010 which also set standards
for patient safety. The Act provides incentives for hospitals to maintain high levels of patient
safety.

How patient safety problem has been addressed in the past at Flagler Hospital

Flagler Hospital has previously had problems with patient safety and addressed. In
previous cases, patient safety problems reported by the Center for Medicare and Medicaid
Services have been a result of either poor data recording and reporting or actual failures on the
part of the hospital (Flagler Health, 2019). As for the former, it is worth noting that Center for
Medicare and Medicaid Services uses data that is self-reported by the hospitals themselves
(Centers for Medicare and Medicaid Services, 2017). Thus, any problem with the manner in
which a hospital records and reports data is likely to impact the information provided by the
Center for Medicare and Medicare Services. Previously, Flagler Hospital solved poor patient

FLAGLER HOSPITAL PATIENT SAFETY RECORD FINAL REPORT 4
safety records reported by Centers for Meidcare and Medicaid Services by improving the manner
in which it collects and reports its patients safety records.

In instances where the patient safety score is not a result of poor record keeping and
reporting, Flagler Hospital has taken a number of measures to improve its score. One of them is
the use of electronic health records (EHR). There are many ways in which electronic health
records improve patient safety in hospitals. One of the causes of hospital acquired infections is
patients taking medications that they are allergic to. Electronic health records keeps all
information about a patient and avails it to clinicians before they prescribe any medication to a
patient (Middleton et al., 2013). Thanks to electronic health records, physicians only prescribe to
patients medications that are unlikely to cause any conflicts.

Electronic health records also significantly improve the safety of patients in emergency
situations. When a patient is unconscious and, therefore, cannot communicate, they can easily
die if clinicians give them medications that worsen their life-threatening allergy reactions.
Thanks to EHR clinicians can determine the likely reactions of certain drugs to patients even
when the are unconscious (Middleton et al., 2013). Additionally, electronic health records can
easily help healthcare professionals to identify and correct operational problems quickly and in a
systematic manner. Operational problems are among the major causes of hospital acquired
infections and injuries (Singh & Sittig, 2016). Thus, when healthcare providers identify and
correct them quickly, they are less likely to act in a manner that may put the patient’s safety at
risk.

Discussion of compliance standards and quality initiatives

FLAGLER HOSPITAL PATIENT SAFETY RECORD FINAL REPORT 5
Patient safety can also be improved by strictly adhering to safety compliance standards.
Patient safety standards set minimum performance levels for organizations. Thus, the more an
organization adheres to such standards the more likely it is to have higher levels of patient safety
standards. In healthcare, there is no single law or regulation that provides healthcare
organizations with set standards to adhere to. Instead healthcare facilities have to adhere to
various regulations contained in multiple laws, their own internal patient safety standards, and
professional expectations of healthcare personnel such as physicians. Apart from Affordable
Care Act of 2010, other laws and regulations that Flagler Hospital adheres to include Health
Insurance Portability and Accountability Act (HIPAA) of 1996 and The Emergency Medical
Treatment and Labor Act (EMTALA). HIPAA advocates for safety of patient data and safe use
of technology (Braithwaite et al., 2015). EMTALA, on the other hand, requires facilities to treat
all patients equally and refrain from offering them poor quality services on account of their
unfavorable financial situation.

Proposed initiative to address the problem

The proposed performance improvement initiative to address Flagler’s hospital safety
problem is error prevention training. Human errors have been found to be a major contributor to
patient safety problems not just at Flagler Hospital but in other healthcare facilities. While the
level of competence of a healthcare worker has an impact on their likelihood of committing
errors, it is not the only factor, let alone the most important one. Most human errors in hospitals
are caused by poor communication among healthcare teams and lack of a patient safety culture.
Patient safety culture includes patterns of behavior, attitudes, values, and assumption regarding
safety of patients in a hospital. When a healthcare facility priorities safety of patients as opposed

FLAGLER HOSPITAL PATIENT SAFETY RECORD FINAL REPORT 6
to other competing factors such as efficiency and costs, there is likely to be positive patient
safety outcomes at the hospital.

Effective communication among healthcare teams is a component of culture of safety in a
hospital. When staff are afraid of seeking clarifications, pointing out mistakes in other workers,
and speaking up to those in positions of authority about actions that may jeopardize safety of
patients, there is likely to be low levels of patient safety. Unfortunately, it is not easy to make
various professionals in healthcare delivery teams to improve their communication. There are
many barriers to effective communication in healthcare facilities that need to be broken. One of
these barriers is the hierarchical nature of healthcare organizations. This hierarchical structure
has the physician at the top of it and other healthcare professionals below them (Kusano et al.,
2015). As a result, there is significant power distance between other healthcare providers such as
nurses and physicians. Due to this power distance, a culture of restrained communication and
inhibition develops instead of one of safe communication and openness (Kusano et al., 2015).
Additionally, there are often very limited opportunities for interaction between the various
healthcare professionals in a regular and synchronous. This is largely because professionals from
different disciplines involved in proving care to patients often operate in different places and at
different times (Kusano et al., 2015). Lastly, differences in training and education among various
healthcare professionals often leads to them having different methods and styles of
communication. Such differences make communication within a team difficult.

The error training intervention measure, therefore, focuses on breaking down these
barriers to effective communication and also improving the skills of the healthcare professionals
so that few to zero errors are committed out of incompetence. The more skilled healthcare
workers are the less likely they are to commit errors. The training will provide them with

FLAGLER HOSPITAL PATIENT SAFETY RECORD FINAL REPORT 7
knowledge and skills to help them identify aspects of their practice that makes them to commit
errors. Secondly, the training will seek to improve communication among healthcare delivery
teams. Hospital personnel rarely provide care to patients alone. Care to patients is a collaborative
effort involving many healthcare professionals that include physicians and nurses (Kusano et al.,
2015). Thus, it is not enough that the professionals providing care to patients be skilled, they also
need to coordinate well with each other. Such coordination requires excellent communication
among all staff involved in patient care. The training will, therefore, address barriers to effective
communication among the professionals and establish mechanisms to improve interdepartmental
communication.

The envisioned performance improvement initiative will have all of the hospital’s staff
that are involved in primary care of patients undergo regular training in error prevention
techniques that will be conducted by coaches who are experts in the field of patient safety. The
training will be conducted thrice a year and will last for a period of one week. It is hoped that
such training will lead to strengthening of a culture of patient safety at the hospital where
healthcare workers prioritize safety of patients above all other considerations in the course of
their work.

Data determinants of success for the initiative

The success or failure of the intervention measure will be determined using both
qualitative and quantitative data. Qualitative data will include opinions of the staff about the
training. A survey will be used to find out whether the hospital staff feel that the training was
useful or not. The training will be deemed successful if large numbers of hospital staff deem it to
have been useful. More importantly, the success of the training intervention will be measured by

FLAGLER HOSPITAL PATIENT SAFETY RECORD FINAL REPORT 8
data that reflects level of a hospital patient safety record. This data include number of patient
injuries and hospital acquired infections recorded. These numbers will be compared with those
taken before the performance improvement measure was implemented. If it is found that such
numbers had dropped after the implementation of performance improvement measure then the
measure would be deemed a success.

Interdepartmental communication channels used for plan implementation

The proposed patient safety improvement plan will involve multiple departments in the
healthcare facility. As such, it will be necessary to establish communication channels that make
it easy for personnel from different departments to communicate with each other. Since staff
from different departments will be trained together, communication among them will take place
face-to-face. They will also communicate via email and mobile phones. For instance, a nurse
will be able to quickly share all the relevant information about a patient to a physician via a
secure mobile phone communication channels.

Data interpretation used to communicate findings

Data used to determine whether the initiative is leading to improvement in patient safety
or not can be presented in various forms to make it easy to understand. In the intervention plan
envisioned here, data will be communicated in the form of graphs. Using graphs to
communicate the findings will make it easy for all staff to understand the findings and monitor
progress. The visual nature of graphs makee them highly suitable to communicate information.
For instance, there will be graphs comparing various aspects of patient safety problems such as
number of hospital injuries and hospital acquired infections at various times during
implementation of the intervention measures.

FLAGLER HOSPITAL PATIENT SAFETY RECORD FINAL REPORT 9
Hypothetical effect of the proposed plan on patient care outcomes

The proposed intervention measure is likely to significantly improve patient outcomes.
With more patient safety levels, patients are likely to have shorter hospital stays. With shorter
stays they will spend less on hospitalization costs. More importantly they will enjoy better
outcomes. Some patients have experienced life-changing injuries while in hospitals or even died.
With better patient safety measures, patients will experience less of such adverse events.

Hypothetical impact of the plan on the culture of safety at Flagler Hospital

Regular error prevention training will lead to the development of a positive patient safety
culture that will help the hospital to achieve high levels of patient safety. This patient safety
culture includes open communication, patient-centered care, evidence-based care, teamwork, and
leadership (Waterson, 2018). All these factors will be oriented towards achieving improved
patient safety at the hospital. Thus, the error prevention training will lead to a culture that
supports safety of patients.

Hypothetical financial implications if the initiative is successful

If the initiative succeds, Flagler hospital will enjoy massive financial benefits. Patient
injuries and hospital acquired inflections lead to significant financial losses to hospitals. It has
been estimated that hospitals spend two times more money on patients who get injured or suffer
from hospital acquired infections than patients who do not. The costs rise even higher when the
infections or injuries are serious and, therefore, require significantly longer hospital stay.
Additionally, patients who suffer from hospital acquired infections or injuries are more likely to
be readmitted. Hospitals, therefore, save a lot of money when they improve their patient safety

FLAGLER HOSPITAL PATIENT SAFETY RECORD FINAL REPORT 10
levels. Apart from saving money, improved patient safety records also lead to hospitals receiving
more money as part of the Affordable Care Act incentive programs. More importantly, patient
safety improvement creates a good reputation for the hospital. As noted earlier, many patients
avoid hospitals that have poor patient safety record. Without patients, a hospital cannot make
money to sustain their operations. On the other hand, more patients provide hospitals financial
resources to support their staff, improve the quality of their services, and expand as a business.

How existing information management systems would contribute to the plan’s success

The success of the plan is dependent on many factors, not just buy-in from hospital staff.
One of them is existing information management system. The proposed intervention plan seeks
to improve effectiveness of healthcare teams by improving communication among members of
the teams. The existing information management system can improve such communication by
providing team members with vital information a timely manner (Waterson, 2018). When
healthcare professionals caring for a patient receive all the information that they require in a
timely manner, they are unlikely to make mistakes that would jeopardize safety of their patients.

Organizational processes that will lead to continued viability of the initiative

The viability of the performance improvement initiative can also be improved through
various processes. Without improvement in hospital processes, it is very hard to have the desired
patient outcomes. The performance improvement initiative, therefore, will be greatly aided by
processes that support patient safety. These processes include steps that hospital staff have to
take when treating patients of various diseases. When such steps are strictly followed at all times,
there is likely to be consistent good patient safety outcomes.

FLAGLER HOSPITAL PATIENT SAFETY RECORD FINAL REPORT 11
Interdepartmental communication patterns needed for ongoing engagement of the initiative

As noted earlier, healthcare professionals work as teams when caring for patients. These
professionals come from different departments. For instance, one patient may require
coordination of the clinical and emergency departments when they are in an emergency
departments with nurses coordinating their care of the patient with physicians. For the
coordination to be effective, it is important that there is proper communication between the
departments and the professionals involved in the care of the patient.

Conclusion

Improving patient safety is a challenge that many healthcare facilities face. There is no
single solution to this problem because it involves many factors. One of the most important of
these factors is human error. Such errors can be a result of negligence, poor coordination among
various healthcare professionals, and lack of timely information on a patient. Focusing on
regular training of nurses and physicians helps reduce instances of human error and improves
coordination among various caregivers thus significantly improving patient safety. The training
will provide healthcare professionals with skills to improve their competence to help them avoid
making unnecessary errors. More importantly, the training will help improve communication
among various healthcare professionals involved in caring for patients. The better the
communication among the members of healthcare provider teams the better the patient safety
outcomes.

FLAGLER HOSPITAL PATIENT SAFETY RECORD FINAL REPORT 12

References

Braithwaite, J., Wears, R. L., & Hollnagel, E. (2015). Resilient health care: turning patient safety
on its head. International Journal for Quality in Health Care, 27(5), 418-420.

Centers for Medicare and Medicaid Services (2017). Hospital-Acquired Condition Reduction
Program (HACRP). CMS. Retrieved on 12 th November 2019 from
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/AcuteInpatientPPS/HAC-Reduction-Program.html

Flagler Health. (2019). About Us. Retrieved on 21 st December, 2019 from

Kusano, A. S., Nyflot, M. J., Zeng, J., Sponseller, P. A., Ermoian, R., Jordan, L., & Ford, E. C.
(2015). Measurable improvement in patient safety culture: A departmental experience
with incident learning. Practical radiation oncology, 5(3), e229-e237.

Middleton, B., Bloomrosen, M., Dente, M. A., Hashmat, B., Koppel, R., Overhage, J. M., … &
Zhang, J. (2013). Enhancing patient safety and quality of care by improving the usability
of electronic health record systems: recommendations from AMIA. Journal of the
American Medical Informatics Association, 20(e1), e2-e8.

Singh, H., & Sittig, D. F. (2016). Measuring and improving patient safety through health
information technology: The Health IT Safety Framework. BMJ Qual Saf, 25(4), 226-
232.

Waterson, P. (Ed.). (2018). Patient safety culture: theory, methods, and application. CRC Press.