The other day I asked my daughter Sydney what book she was reading. She said, "I don't like to read." I asked again since I know that she enjoys reading and she continued to declare, "I don't like to read." As one last try, I said to her that I don't understand because she reads all the time. She said, "Dad, I like to read. The book I am reading is called "I Don't Like to Read." It was a modern day Abbott and Costello routine and a lesson on improving communication.
Today, I had a chance to hear the update around our readiness to perform as a High Reliability Organization (HRO).
Health Performance Improvement, LLC (HPI) provided some information I found interesting. While communication is almost always cited as a primary problem in running our business, the statistics were a little surprising.
HPI identified five areas that cause individual "failures." The top problem? Breakdowns in critical thinking. An example of a critical thinking breakdown: a physician doesn't respond to changing laboratory findings because he/she was focused on the patient’s presenting symptoms. The doctor could be communicating like crazy with the patient, but if he misses a significant change in his/her labs, communication doesn't matter.
The second most significant problem was identified as compliance error. Example? A nurse changes a patient's dressing without consulting the physician because in the past the physician has ordered it. This could be categorized loosely as a lack of communication, but mainly it is a lack of compliance with procedures put in place to provide the safest, highest quality care for the patient.
Communication (lack of information exchange) tied for third with competency (lack of skills).
Speaking of communication, we also learned at the presentation today that the average baseline for serious safety events in hospitals reviewed by HPI was 1.19 per 10,000. I'm proud to say St. Joseph Medical Center's baseline is .45 with an ultimate goal of zero, of course.
I look forward to hearing how your organizations focus on improving safety.