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Continence Coach: Informed Decisions for Improved Patient Safety
Patient safety has become the catch phrase of the 21st century. Unlike recent decades when the priority seemed to be record-keeping and documentation (in part, to protect providers from litigation), we now are re-defining patient safety in terms of the action of keeping one safe—ie, free from fear, injury, and harm. Thankfully, this perspective is (appropriately) far more patient-centered and focused on expectations, effective intervention and care, and outcomes.
The impetus for increasing the attention on patient safety was provided by the Institutes of Medicine (IOM), which issued two landmark reports1,2 on how much medical errors were costing our country in terms of money and lives. The Leapfrog Group (LG), funded by the Business Roundtable, responded to the IOM’s challenge by advocating that patients should seek hospitals and physicians performing the greatest volume of identical procedures. The premise was that high volume is correlated with expertise and high quality.3 The LG assumed that costs will be lower by forcing concentration of specialized care, particularly on high-risk procedures. The mandate was a payor-driven initiative, fueled by the self-interests of self-funded health plans of large employers; patients had no input and limited options.
The LG’s assumption was not substantiated for all situations. It failed to address issues of access, such as in rural areas, or issues of management in care arenas where patients deal with multiple chronic conditions. Alarmingly, analysis finds that in healthy patient fields—eg, labor and delivery—specialization is proliferating among community hospitals, limiting access and choice for delivering mothers.4 In continence care, the LG concept fails to accommodate the patient’s need to access an interdisciplinary team of providers, particularly patients served in a fragmented delivery system and/or where their providers do not share a common medical record. Access to experienced practitioners (as well as identifying the experts) versus easy access to local services offering choice of provider is a complex issue, challenging both policy makers and patient advocacy groups concerned with safety.
The Internet connects consumers in new and unique ways. Anyone with access to a cell phone, laptop, or public library, as well as a home computer, now has the opportunity to immediately share a personal story of diagnosis, symptom management, and treatment. When people connect, they find commonality. No longer limited geographically, they “meet” in online forums where they share experiences, building momentum for their cause, enhancing knowledge on a topic of interest, and expanding the number of options. This is how patient advocacy organizations are born, fueling the need, for example, for a stronger safety net for care.
There is a more profound ethical issue to consider when patient safety is at stake. Knowing the guiding principles of ethics in healthcare are autonomy, beneficence, non-malfeasance, and justice, it is easy to see how the formality of informed consent has been purely self-serving at times. Given the traditionally paternalistic nature of healthcare delivery, informed consent insulates the physician, more so than the patient, from harm. In reality, the patient needs not only to be informed of risks, but also to be able to discuss those risks to facilitate shared decision-making regarding plans for treatment or intervention. The starting point for understanding and participation is education. An educated patient (sometimes necessitating the help of family) is undoubtedly a safer patient.
In 2008, the Center for Medicare and Medicaid Services (CMS) began denying coverage for “never events,” including hospital-acquired urinary tract infections (UTIs), injuries from falls sustained while self-toileting during hospitalization, and hospital-acquired pressure ulcers. Private payors are following the federal government in implementing this policy.5 In March 2011, the Department of Health and Human Services6 announced that making care safer by reducing harm caused in care delivery must be among the nation’s top six priorities in its national quality strategy. Certainly, the answer to increasing access, reducing costs, and increasing quality of outcomes will be the result of reducing medical errors, opening up access to primary care, facilitating efficient communication among providers around a patient’s needs, tracking outcomes with information technology, and encouraging innovation in both management and intervention. But only an educated and fully informed patient can be part of the team and function effectively as the cornerstone of this configuration. Nurses are an essential provider of patient and community health education.
Consumers are constantly searching for information to educate themselves, but they often need direction and guidance. That’s where the National Association For Continence (www.nafc.org) can help. Most people know the NAFC for our website content, healthcare education accessible by telephone or email, and publications including our Quality Care newsletter. Encourage us as a resource. Educate your patients and their family caregivers so they become active participants in shared decision-making and appropriately frame their expectations. Be their ombudsman so they participate through a fully informed consent process to safeguard the ethical delivery of healthcare. With your guidance and support, your patients can safely achieve their desired outcomes and expected results.
1. Institute of Medicine. To Err is Human: Building a Safer Health Care System. Washington, DC: National Academy Press;1999.
2. Committee on Quality of Healthcare in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press;2001.
3. The Leapfrog Group. The Leapfrog Group for Patient Safety Rewarding Higher Standards. 2000. Available at: www.leapfroggroup.org/toolkit.htm. Accessed November 17, 2007.
4. Muller NJ. Do General, Community Hospitals Compete by Specializing in High Volume, High Revenue-generating Service Lines? Doctoral dissertation, Virginia Commonwealth University, 2010. Copyrighted and archived at http://hdl.handle.net/10156/3170.
5. Center for Medicaid and State Operations, Centers for Medicare and Medicaid, US Department of Health and Human Services. 2008. Available at: www.cms.gov/SMDL/downloads/SMD073108.pdf. Accessed August 17, 2011.
6. US Department of Health and Human Services. 2011. Available at: www.healthcare.gov/center/reports. Accessed August 17, 2011.
