Thrust into the national spotlight by the Institute of Medicine (IOM) report "To Err is Human," patient safety has become a hot topic among providers, consumers, purchasers, payers, policymakers, and the media. 1 Research has also shown that adverse health outcomes attributable to medical errors cost the United States billions of dollars. 2,3 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has recently approved 2003 National Patient Safety Goals. 4 To address this complex issue, healthcare organizations and professionals must collaborate in identifying barriers to and strategies for improving patient safety. Following the release of the IOM report, the Iowa Department of Public Health initiated a collaborative partnership with the Centers for Disease Control and Prevention (CDC) to research provider perceptions of patient safety.
Focus groups were conducted with Iowa healthcare leaders representing 3 professional groups: nurses (n= 8), pharmacists (n=6), and physicians (n=8). These leaders included representatives from the regulatory boards, statewide associations, public and private universities, integrated health systems, and private practice. The objectives were to define patient safety, identify system characteristics influencing patient safety, identify specific barriers to providing safe care, and identify strategies to address these barriers. The research team analyzed the transcribed comments and grouped them together by common themes.
Defining Patient Safety and Healthcare System Influences
Participants were asked, "What is patient safety?" Despite the frustration of defining patient safety because "it is a moving target and the public perception of safety has changed dramatically," the consensus definition that emerged was "do no harm." Doing no harm was seen as including health promotion, addressing both health and social system breakdown, and the safe delivery of medications.
The second question was, "What are the health system characteristics influencing patient safety?" The following characteristics were identified: regulatory/legal, financial, staffing, the healthcare environment, consumer attributes, provider and consumer education, provider attributes, and communication.
Barriers to Patient Safety
Participants were then asked to identify specific barriers to patient safety (doing no harm) within these system characteristics. Barriers related to the general healthcare environment included the production pressure and the resulting lack of time: "healthcare organizations making money from quantity of care not quality;" "people knowing what to do, wanting to do it, but don't have [the] time to do it;" and "the number of patients necessary to maintain reimbursement and salaries creates . . . difficulty in recruiting good physicians." Other financial barriers were related to the "focus and priority around dollar signs. [We need to have] patient safety and quality of care get the same level of priority in our system. [There] has to be an awareness of how [what we purchase] impacts the patient."
Communication barriers identified problems between and among all healthcare stakeholders. Participants noted "there is no real reimbursement for communication." In fact, "a provider may actually lose money [by communicating with patients]." In addition, "we don't always get all the information needed. More communication would be helpful among institutions and providers."
Regulatory/legal barriers, such as too many regulations, administrative burden, and tort legal risk, were a major concern: "legislating staffing ratios runs the risk of putting people in situations that meet the 'letter of the law,' but [it jeopardizes] patient safety due to the inexperience of the 'warm body.'" In addition, "It irritates me that Medicare makes me be the interpreter of their policies, regulations, and rules. They passed them and they should be educating the patient on what they are going to cover."
Participants also mentioned barriers related to the nursing shortage, rural staffing issues, and scope of practice; provider and consumer education; administrative burden and tort legal risk; variability and lack of data collection and the punitive attitude toward error reporting; the misuse of and lack of funds to purchase technology; and lack of provider accountability, ability/resistance to change. These barriers provide additional valuable insight into system components that can negatively affect patient safety.
Strategies to Address Barriers to Patient Safety
It is often much easier to identify problems than it is to provide solutions, especially where so many system barriers interact synergistically to cause harm. However, participants identified many strategies for improving patient safety that will interest administrators seeking innovative solutions. Many of these suggestions can be classified as a "paradigm shift."
Participants felt that shifting the current healthcare paradigm would require significant changes in both the system and its stakeholders: "One billing form and one medical record. Access to that record needs to be uniform. Until we address this barrier, we can invest money in other things, but we will just be banging our heads against the wall." Participants advocated shifting the focus of healthcare beyond acute care to other settings, and to health promotion and patient advocacy. They also recommended shifting relationships: "Current culture is that it is not okay to sit down and talk with patients. Third-party payers should let providers make decisions with patients. Shift the focus to patient satisfaction rather than money."
In addition, various educational strategies were suggested to improve patient safety: multidisciplinary teams, teaching best-practice guidelines, reducing competition by encouraging joint educational experiences with various provider groups and within diverse healthcare settings, using simulations to improve communication competency, closing the gap between education and what is needed in the "real world," mandating continuing education regarding patient safety, and "educating patients to expect safety... and about their role [in safety]".
Other strategies included increasing reimbursement, tort reform, using technology or "smart systems" for safer drug prescribing and dispensing, setting standards for provider/patient ratios, and clarifying the roles and responsibilities of each type of provider.
Provider Similarities/Differences
Analyzing the data between provider groups exposes some interesting commonalities and differences in perceptions and priorities. All 3 groups overwhelmingly identified lack of time as a barrier to providing safe care. The related barriers of inadequate staffing, lack of funding, and too many regulations also emerged from all 3 groups as priority causes of unsafe care. All 3 groups advocated strategies to increase the funding stream and address regulatory and legal constraints. However, only nurses discussed strategies to address lack of staffing.
A "Paradigm Shift"
Perhaps the most illuminating finding of this study was the emergence of a paradigm shift as a strategy to improve patient safety. This shift requires that culture changes occur throughout the system and that stakeholders examine their perceptions and become willing to think and act "outside their individual boxes." This new system will emphasize multidisciplinary patient care teams, improved communication among providers and between patients and providers, a focus on prevention and health promotion, and a return to patient-centered practice. This shift will not only be difficult, but will require a unified vision and a major commitment of time, energy, and resources.
The identified patient safety themes provide an organizing framework to study and address the myriad factors influencing the safe provision of healthcare. Administrators can use this information to understand the perceptions of providers as they lead the effort to transform the healthcare system into a safer place for healing without harming.
Acknowledgment
This project was supported under a cooperative agreement from the Centers for Disease Control and Prevention through the Association of Schools of Public Health and the University of Iowa (Grant Number U36/CCU300430-20). The article contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC, Association of Schools of Public Health, or the University of Iowa.
The authors acknowledge the support of Senator Tom Harkin in the implementation of the Iowa Patient Safety Project.
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