An article published in JAMA Network by Susan Haas, MD, MSc; Atul Gawande, MD, MPH; and Mark E. Reynolds examined patient safety risks due to health system expansions. The healthcare system in the United States is undergoing substantial consolidation through mechanisms ranging from mergers and acquisitions to institutional affiliations to single service agreements, often with expectations of improving the safety and quality of care. However, there has been little evaluation of the risks that system expansion has on patients.
In a partnership between a medical liability insurer (CRICO/Risk Management Foundation) and a health systems research center (Ariadne Labs), an analysis analyzed the patient safety risks for Harvard-affiliated institutions by interviewing clinicians and convening system leaders both locally and nationally.
System expansions create three types of significant safety risks, often unrecognized and unaddressed, that are related to changes in patient populations, infrastructure, or clinician practice settings. After system expansion, healthcare institutions may experience significant changes in patient populations, including increases in general volume and in patients with demographic characteristics or conditions that are new to a facility.
When institutions anticipate changes in patient population (e.g., opening a substance use disorder service), they commonly make unit-level adjustments such as training support staff. However, staff who interact with these patients elsewhere in the hospital may also need new knowledge, skills, practice patterns, and support, such as having the ability to recognize and promptly treat withdrawal symptoms.
Further, these changes are often not anticipated; an increase in referrals may bring an influx of non–English-speaking patients, for instance, who require more interpreters, institutional relationships with different community services, and increased awareness of economic and social challenges these patients face in following care guidelines. Lack of wider institutional attention to specialized needs can result in serious deficiencies in provision of safe, timely care.
Achieving the financial benefit of system expansions often involves making substantial changes in supplies, equipment, formularies, protocols, and information systems.
Changes in infrastructure create significant challenges for clinicians and are common in systems expansion. Without planning, such changes can cause significant patient risk. Even with training, a learning curve makes formerly routine tasks more time- and attention-intensive and error-prone; finding the correct form in an electronic health record for ordering a test, identifying the correct substitution medication and dose from a new formulary, or transferring a patient.
The attention clinicians must now give to once “automatic” tasks also distracts from other aspects of patient care or slows throughput. Unless schedules and capacity are adjusted, such shifts in time and focus not only may result in dissatisfied patients but also in increased likelihood of major errors.
Teams with little expertise in patient safety are typically responsible for implementing healthcare mergers, acquisitions, and affiliations. Their primary impetus is often financial rather than clinical, and when the impetus is clinical, the concerns usually involve patient access and services rather than the way care is practiced in the affected institutions.
To address these risks, a patient safety toolkit for system expansion has been developed to support clinical planning between institutions prior to launch. Find it at www.ariadnelabs.org/safe-expansion/.
