By Robert Hanscom, VP of Business Analytics
Published in PIAA's magazine, Inside Medical Liability

Healthcare is disjointed, the delivery system has multiple vulnerabilities, and potentially preventable tragedies occur. And, this is despite the entry of electronic health records into the mix — a move that, at one point, was thought to be the cure-all for many of the issues plaguing patient care.

So why hasn’t patient safety taken a stronger hold? There are many answers to that question, and no one singular theory is probably fully accurate. It is almost certainly a sizable combination of factors that go hand-in-hand with one of the most complex businesses in the U.S., if not the world. 

How hospitals, practices, and physicians are paid is a force unto itself, and is one of several drivers of how care is delivered. But that environment is even more confounded by other factors, most notably, practice-pattern variations that surface by specialty, by institution, and even by individual provider. The lack of uniformity, whether it is in process, cognition, skill, or communication, creates a world so full of variables that it is almost impossible, at times, to reach a core understanding as to why unexpected outcomes are continuing to harm patients.

What exacerbates this struggle is the lack of a single “source of truth”—centralized intelligence that allows those responsible for continuous improvement to obtain a full picture of where the most serious vulnerabilities lie. There is no universal view of anything related to the key safety indicators for healthcare.

Disparate data sets exist. Each contains signals telling us where the delivery of care — the processes, the skills, and the decision-making — has been vulnerable in the past, and where that vulnerability may persist. But each segregated data set tells a somewhat different story — if they tell any story at all — and the audience for the lessons learned is decentralized.

Where to start?

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