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Correspondence: Address correspondence to Denys T. Lau, Assistant Professor of Medicine and Section Director of Health Services and Policy Research, The Buehler Center on Aging, Health & Society, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, Suite 601, Chicago, IL 60611. E-mail: D-Lau{at}northwestern.edu
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Abstract |
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We propose a new concept, called health-related safety in the home and community, which is defined as the minimization of the probability of preventable, unintended harm in community-dwelling individuals. Health-related safety aims to understand how and why adverse health events occur and to identify what breakdowns in the societal system expose individuals to hazards. Subsequently, effective multilevel interventions can be developed to systematically manage or remove the root causes of harm. Our purpose in this article is to present a framework for health-related safety and to propose a research agenda to address, from this new perspective, issues of safety in the broader community and society. In doing so, we apply systems thinking and safety sciences to health-related safety in the home and community. This parallels what other researchers have started to do with the patient safety movement in health services delivery systems.
We begin the discussion of health-related safety among older adults, because this population generally relies on many health and social resources in the societal system to maintain health and safety (Tsilimingras, Rosen, & Berlowitz, 2003). Focusing on older adults can shed light on systemic deficiencies that otherwise might be hidden in more robust populations. We first highlight examples of health risks among community-dwelling elders and review existing interventions designed to meet the health and safety needs of older adults. We then present the conceptual foundation of health-related safety, building on systems thinking from patient safety models, chronic care models, and human ecology. We conclude by proposing a research agenda that will further refine the proposed concept of health-related safety and develop appropriate mathematical and practical models to support this initiative.
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Background |
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TOPAbstractBackgroundHealth-Related SafetyResearch AgendaReferences |
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Health Risks to Community-Dwelling Elders
Injury prevention is a national priority recognized by Health People 2010 and the Institute of Medicine (Bonnie, Fulco, & Liverman, 1999; Institute of Medicine, Committee on Trauma Research, Commission on Life Sciences, and National Research Council, 1985). Unintentional injuries are the eighth leading cause of death among individuals aged 65 years and older (CDC, 2002). Adults aged 75 years and older adults have the highest rate of injury-related ambulatory care visits (Ly & McCaig, 2002; Schappert & Burt, 2006). The top four unintended injuries include falls, being struck by objects, motor-vehicle-related incidents, and lacerations (CDC). Risk factors that may contribute to emergency department visits by elderly persons include the following: solitary living arrangements, poor self-rated health, poor nutrition, lack of social support, multiple comorbidities, and functional impairment (Aminzadeh & Dalziel, 2002; McCusker, Bellavance, Cardin, Belzile, & Verdon, 2000; McCusker et al., 1999; McCusker, Cardin, Bellavance, & Belzile, 2000).
Approximately 10% to 15% of emergency department visits and 6% of all hospitalizations of elderly persons result from a fall, which is the leading cause of unintended injuries in this population (National Center for Injury Prevention and Control, 2003). Falls are also the leading cause of traumatic brain injuries for older adults, leading to more than 80,000 emergency department visits each year (Thompson, McCormick, & Kagan, 2006; Morbidity and Mortality Weekly Report, 2006). The economic costs of falls are significant, with a mean hospital cost for fall-related injuries among older adults (reflecting an average of 7 days of hospitalization) of $17,483. (Roudsari, Ebel, Corso, Molinari, & Koepsell, 2005). Risk factors and the common sequelae of falls, including death, are well described in the literature (Cesari et al., 2002; Resnick, 1999; Runyan et al., 2005; Tanner, 2003). Older adults may experience the highest rates of death from unintentional injuries at home because of their greater likelihood to live alone, be more sick and frail, and spend more time at home compared with other groups. Studies on older adults experiencing adverse health events have largely focused on falls and related environmental factors, such as clutter and lighting problems (Northridge, Nevitt, Kelsey, & Link, 1995; van Haastregt, Diederiks, van Rossum, de Witte, & Crebolder, 2000).
Other health risks among older adults include problems with health maintenance or chronic disease management. Recent rates of emergency department visits increased among those individuals aged 65 and older for arthropathies, diabetes, stroke, and spinal disorders (McCaig & Burt, 2004). Because older adults are likely to have complex drug regimens to treat their multiple health conditions, they are also at high risk for medication mismanagement, such as mixing medications, taking wrong doses, or being nonadherent (Zhan et al., 2001). Lack of provider–patient communication, insufficient patient knowledge, and high medication cost are some of the factors that contribute to medication mismanagement (Kerzman, Baron-Epel, & Toren, 2005). Among older patients who are nonadherent, 33% did not receive any medication instructions and 40% did not use any organizational method to help them adhere to their drug regimen (Metlay et al., 2005). Medication mismanagement can lead to various adverse drug events and the worsening of existing illnesses (Hanlon et al., 1997).
Although a variety of adverse events among elders have been documented and classified, many studies are limited to examining individual-level risk factors and proximal characteristics of the adverse event. Few studies have investigated the root causes and sequence of events leading to adverse health events, or documented details about the physical and social context in which the injuries occurred (McCusker, Karp, Cardin, Durand, & Morin, 2003). Having a comprehensive, in-depth understanding of the conditions and causal factors resulting in adverse health events and injuries will be important for preventing such incidents from reoccurring.
Health and Safety Interventions
Current health and social service organizations offer a variety of assistance to community-dwelling elders to age in place in a healthy and safe manner; however, many services are limited in scope, geography, or eligibility. At the national policy level, public programs include those funded through Medicare and Medicaid. Medicaid home and community-based services waiver programs are state administered and offer varying levels of long-term care services by state, including home nursing, respite care, home modifications, social care, and case management. However, as Medicaid programs, these services are available only to low-income elderly and disabled populations, and evidence of the program's quality varies from state to state (Institute of Medicine, 2001).
Medicare reimburses limited home health services for older adults with acute medical problems after a hospital stay. Skilled nursing services and physical and occupational therapy are reimbursed as long as the acute medical condition persists. Physical therapy and occupational therapy can become involved in home assessment and home safety, under a physician's order and for a limited time. However, Medicare does not provide the continuous long-term health services needed to meet the ongoing health and safety needs of older adults who age in place.
The Program of All-Inclusive Care for the Elderly (PACE), considered the most comprehensive public program, coordinates health care, nutritional, social, and transportation services to older adults. Offered in local communities of 18 states, PACE leaves large areas without services. PACE is found to lower the unnecessary use of health services and increase the quality of life and functional status of enrollees, but these favorable outcomes are achieved at considerable cost (Keough, Field, & Gurwitz, 2002; Gross, Temkin-Greener, Kunitz, & Mukamel, 2004). Other privately funded programs, such as Meals on Wheels and ComfortKeepers, exist to help elders age in place. Although these programs do not require means testing for eligibility, many charitable, nonprofit programs offer their services only to elders with the greatest economic or social need.
At the community service level, there are fee-for-service geriatric case-management agencies that offer a variety of medical and social services, but many are prohibitively expensive. Other community-based geriatric health and safety interventions are offered only at the point of medical service, such as in the emergency department (Aminzadeh & Dalziel, 2002; Gerson, Rousseau, Hogan, Bernstein, & Kalbfleisch, 1995) or at the outpatient and inpatient settings (Kuo, Scandrett, Dave, & Mitchell, 2004). Such interventions yield inconsistent outcomes for a variety of reasons, including difficulty identifying at-risk persons and lack of control over services outside the acute health care setting (Miller, Lewis, Nork, & Morley, 1996).
To address the quality of health care services specifically for chronic medical conditions, Wagner and colleagues developed the chronic care model (CCM; Wagner, Davis, Schaefer, Von Korff, & Austin, 1999), which describes improvements to practices in primary care settings for patients with chronic illness. The model describes an interacting system that consists of consumers' self-management support, delivery-system redesign, decision-making support, and clinical information systems. Over 1,000 health care organizations and 500 community health centers use the CCM framework (Wagner et al., 2001). Most of these organizations have made measurable improvements in the quality of their care (Bodenheimer, Wagner, & Grumbach, 2002). Recently, the CCM has been adapted for the international context to create the Innovative Care for Chronic Conditions framework (Epping-Jordan, Pruitt, Bengoa, & Wagner, 2004). The revised framework expands on the community and policy aspects of improving health care for chronic conditions and describes the overall relationships among patient and family, health care organizations and community, and policy and regulatory initiatives. Such multidimensional models for chronic disease management are informative for developing a framework to address the ongoing health and safety needs of older adults more generally.
To date, well-coordinated comprehensive services remain lacking and are needed to expand health care and housing options, improve home environments, promote self-sufficiency and independence, and offset social isolation (Lawler, 2001). These programs should be grounded in a strong theoretical framework, similar to chronic disease care grounded in the Innovative Care for Chronic Conditions framework, that aims to coordinate the physical and social institutions within the societal system and holistically address the biological, social, physical, and psychological needs of elders. In this article we propose such a new framework.
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Health-Related Safety |
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Managing risk and improving safety have been popularized in the health care literature, including medicine, public health, nursing, and physical therapy, by the modern patient safety movement. Modern patient safety emphasizes that adverse events are best addressed systematically from an organizational and process-oriented perspective, rather than at an individual level (Kohn et al., 2000). Because risks are inherent in health care and human error is inevitable, health care systems should be designed to detect and prevent adverse events, thereby minimizing harmful outcomes. To optimize design, highly reliable organizations that prioritize safety call for continuous learning and transparency of information among all stakeholders, including honest reporting of adverse events (Gallagher, Waterman, Ebers, Fraser, & Levinson, 2003; Levinson, Roter, Mullooly, Dull, & Frankel, 1997). To accomplish these goals, patient safety emphasizes culture reform at all levels of the organization.
By extension, health-related safety addresses harm by recognizing that the home and community are part of a complex societal system that consists of interrelated people, places, and institutions. Because health risks are inherent in the societal system, health-related safety aims to provide a holistic understanding of how and why adverse health events occur, and it calls for culture reform and system redesign to address systematic deficiencies. When older adults are at disproportionate risk for harm and they are unprotected or unassisted by the state, it is a societal failure in which we are all implicated (Klineberg, 2002). Important elements of health-related safety include reliable coordination among political, social, public health, and medical institutions, service providers who are well trained in health-related safety philosophy and practices, state-of-the-art infrastructure to support continuous information transfer, and honest sharing of knowledge among stakeholders for continuous safety improvement.
Health-related safety also must weigh an individual's autonomy and choices against the public health interest to protect the individual from harm. Older adults may consider moving to safer but more restrictive environments, limiting their activities to minimize their risk of harm, or maintaining their current level of independence while recognizing their increased risk of harm. Health-related safety therefore recognizes the need for shared decision making regarding an acceptable level of risk among consumers (older adults and family members), service providers, and policymakers. For example, older adults and family members should learn about preventable heath hazards in the home and community, make informed decisions in light of the risks involved without coercion, and accept adverse health consequences that may result from their decisions. Service providers at the community level should educate older adults and their family of the risks and consequences, understand and respect their values and choices, coordinate across departments and institutions to minimize avoidable hazards continuously, and provide necessary care in the event an injury does occur. At the policy level, the rights of consumers and providers should be protected, and incentives and resources provided to encourage shared decision making about negotiated risks.
A Systems-Based, Multicausal Framework
General systems theory provides us with a basis for understanding the concept of multicausality of disease, in which illness is caused by the interaction of biological, psychological, and social factors in a complex and interdependent system (Bertalanffy, 1976; Katz & Kahn, 1966). Similarly, a systems-based framework has been applied to the field of developmental psychology by Bronfenbrenner, who proposed the ecological systems theory (Bronfenbrenner, 1979). Used to examine human development over a life course, this theory describes the roles and interactions of different levels of systems from the immediate environment (such as family and school) to a larger cultural and social context (such as economic and political structures). We therefore extend the systems theory approach to address adverse health events by examining elements of the societal system; this is a distinction from the existing person-focused paradigms of safety that are used in clinical practice and injury research.
Based on existing studies on health risks in the home and community, health-related safety views the societal system as consisting of three levels: micro, mezzo, and macro (see Figure 1). At the individual or micro level, a person possesses biological and psychological characteristics, including attitude, knowledge, health-risk behaviors, and mental, physical, and functional health. The mezzo level includes an individual's social network, consisting of interactions with family, friends, neighbors, and the like. The medical and social services systems, and structural features of the home and neighborhood, are also mezzo-level factors that interact with one another and with characteristics of the individual that predispose the person to health risks. At the macro level, economic, social, political, and natural forces collectively can affect the safety of an individual through the interaction with the physical and social factors. The proposed dimensions and their relationships will have to be empirically explored and validated in future research (see the Research Agenda section).
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Older adults and many other vulnerable groups may be particularly affected by macro-level factors. Complex sociocultural stressors such as crime, economic and social degradation, and the dispersion of the extended family may contribute to increased isolation and hinder an individual's ability to live independently. Deteriorated neighborhoods are more likely to contain substandard housing, have fewer commercial services available, and fewer options for social contact (Pynoos, 1990). Natural forces also have been well documented to pose significant harm to elders. Two striking cases are heat-related mortality in Chicago in 1995 (Klineberg, 2002) and the devastation of Hurricane Katrina in New Orleans in 2005 (Sanders, 2006).
The infrastructure of the societal system, therefore, must be adequate to support healthy living and safeguard individuals against hazardous events. It is the alignment of the failures within each of these interrelated units of the system that allows an adverse health event to occur. This concept is similar to the "Swiss Cheese" model of error causation (Reason, 1997), which describes a catastrophic error occurring when the holes (or breakdowns) of a system are aligned during each step of a process, allowing all defenses to be defeated and resulting in an error. It is important to note that not all adverse health events require breakdowns from all three levels of the health-related safety concept. However, the opportunity for an adverse health event is maximized when multiple failures within the societal system are aligned, and their synergism results in both near misses and materialized harm. The purpose of health-related safety is to focus on the layering of these factors, their arrangement and associations as a whole, and to redesign the societal system so that safeguards are introduced at critical points to prevent harm. Health-related safety therefore calls for a culture shift toward social responsibility and justice, and a well-coordinated, multi-institutional system working together to maintain safety for community-dwelling individuals, especially those most vulnerable.
New Applications From Safety Sciences
The identification of risks and hazards across all levels of the health-related safety framework (micro, mezzo, and macro) is the first step toward managing unintended harm and injuries. Health-related safety will require a new application of risk-assessment tools from safety science to identify health hazards and breakdowns in the broader societal system. Although the following tools are commonly used in patient safety to identify risks in health care systems, they are presented here to begin the discussion on what tools may be adapted and applied to health-related safety in identifying risks in the home and community. Future research will have to investigate the adaptation and application of these tools and develop new assessment instruments.
Root-cause analysis (RCA), traditionally used to investigate major accidents in high-risk industries, has become an effective investigative tool of sentinel events as part of quality-improvement programs across health care disciplines and settings (Battles & Lilford, 2003; Woloshynowych, Neale, & Vincent, 2003). The technique employs a retrospective qualitative case analysis of the underlying critical factors and their relationships to each other preceding a consequent sentinel event (Reason, 1990). To apply RCA to health-related safety, multiple case analyses can be performed, for example, to identify common root causes in the home and community. Based on a collection of similar adverse health events, key causal factors can be identified and categorized according to the three levels of the health-related safety framework: micro (the individual lacks the knowledge or ability to avoid a potentially harmful situation), mezzo (the community lacks the infrastructure to safeguard the individual from harm when high-risk events occur), and macro (no policies exist to mandate and fund safety measures to prevent harm). Depending on the factors identified, intervention strategies at each level can be developed to prevent the reoccurrences of future adverse events.
Trigger tools may be used to identify and address all the events that are highly associated with harmful outcomes within the system of care (Resar, Rozich, & Classen, 2003). These indicators of harm, or triggers, are designed to track known signs of harm that may have or are about to occur. Such a surveillance system can be used to track and capture events that would otherwise go unnoticed and unreported. In health-related safety, triggering events can be identified through the use of RCA and classified according to the micro, mezzo, or macro levels in the framework. Trigger tools can be used to monitor critical events or harmful factors that are highly associated with injuries occurring in the home or community. The technological and infrastructural support necessary to support the use of trigger tools in health-related safety at the community level will require further investigation.
Additional tools include probabilistic risk assessment (PRA), failure modes and effects analysis, and sociotechnical PRA. A prospective modeling technique, PRA analyzes the impact of hazards contributed by both humans and systems, and it uses methods similar to decision analysis. The failure modes and effects analysis approach is useful for modeling complex interactions among multiple failures within a system (Marx & Slonim, 2003). The sociotechnical PRA method incorporates a human dimension and has a unique ability to model combinations of technology and structural failures, human error, at-risk behavioral norms, and recovery opportunities through the use of fault trees. Each of these methods may be adapted for the analysis of the inherently complex, unintended events that result in harm outside of health care institutions. Finally, research on human errors has contributed methods such as critical incident analysis and naturalistic decision making to help researchers further understand the human component in error making. These methods should adapt quite easily to events in the home and community setting.
As already described, the risk-assessment methods developed through safety science research may provide an effective armamentarium of tools to identify causal factors in adverse health events in the home and community, and to target preventable risks. Categorizing the risks and causal factors according to the micro, mezzo, and macro levels of the health-related safety framework provides a strong foundation to develop more effective multilevel intervention strategies. In addition, health-related safety has the potential to advance the methods of safety sciences by combining approaches from the disciplines of medicine, nursing, risk management, quality improvement, home and community regulations, and information technology.
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Research Agenda |
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The first step is to identify the risks and hazards in the societal system that cause or could cause unintended harm and injuries to individuals. This will refine and validate the proposed system-based, multicausal framework of health-related safety using empirical evidence. Health-related safety will extend beyond the current literature on individual-level risk factors and proximal characteristics of adverse health events among older adults. This initiative will identify the root causes, sequence of events, and physical, social, and policy conditions that collectively predispose older adults to adverse health events. Having a comprehensive, in-depth understanding of the conditions and causal factors resulting in adverse health events and injuries will be important for preventing such incidents from reoccurring. To identify the risks and hazards at every level (micro, mezzo, and macro) of the societal system, researchers will need new applications of safety science. Future research is needed to investigate what existing mathematical and practical tools may be adapted or what new tools have to be developed to study health-related safety and identify risks in the home and community (see the section on New Applications From Safety Science).
The second step is to design, implement, and evaluate health-related safety practices that will eliminate or reduce the risk of health hazards and create a culture of positive health-related safety practices. System redesign and intervention strategies for health-related safety practice will require a holistic multilevel initiative that corresponds to the system-based health-related safety framework. For example, at the micro level, every member of the system should understand health risks in the home and community, make informed decisions on minimizing risks while preserving autonomy, and sustain health-related safety practices. This could be accomplished through ongoing education and training to equip older adults and their caregivers to enact safe practices at homes and in the community. At the mezzo level, physical and social institutions would become better coordinated to communicate about safety issues and to implement safe practices. For example, different city government departments (e.g., aging, public health, police, and housing authority) could coordinate with local utility businesses (e.g., electric, water, telephone, and gas companies) to provide targeted services and ensure the well-being of older adults who live alone. At the macro level, policies to provide leadership, incentives, mandates, and resources will drive the system toward the institutionalization of health-related safety. For example, various financing mechanisms, such as tax breaks or contracting, could provide incentives to local businesses to operate in poor communities, thereby sustaining services, goods, and employment opportunities for local residents. This type of effort may help maintain the integrity of neighborhoods, preserving social contacts and ensuring availability of physical goods. It is important to note that policies at the highest level of the societal system will have tremendous influence not only on enforcing safety practices but also toward creating a positive culture of health-related safety. A positive culture of health-related safety will be the foundation for successful health-related safety practices at all levels.
The third step in the research continuum is to maintain vigilance and evaluation to ensure that health-related safety culture and practice remain in place. Maintaining a culture of health-related safety is the prerequisite for sustainable safety practice over time and the prevention of adverse health events from reoccurring. Even though the disciplines of organization psychology and sociobiology have produced some valid and reliable methods for assessing safety culture within the health care field, future research is needed to determine their applicability to health-related safety in the home and community. Experience with patient safety has indicated that creating and sustaining a culture of safety remains challenging (Battles & Lilford, 2003). When the culture of health-related safety is institutionalized, continuous monitoring will have to be implemented to evaluate whether safety practices remains in place over time. The mathematical tools from safety science discussed earlier in the New Applications from Safety Science section can be used to track ongoing safety practices. To evaluate the impact of health-related safety, valid and measurable short-term and long-term outcome indicators will also have to be developed. For example, outcome indicators can be developed at all levels of the health-related safety framework: micro (knowledge and attitude toward health-related safety, rates of adverse health events, and prevalence of institutionalized care); mezzo (number of home and community modifications, access to communication and transportation technologies, and adverse health event reporting); and macro (effect of policies and incentives on promoting safety practices).
Conclusions
According to Healthy People 2010, a healthy community should enable people to maintain a high quality of life and productivity, offer access to health care services and social resources to meet people's needs, and provide a safe infrastructure. We propose a concept called health-related safety in the home and community and a research agenda to further develop the concept and implement the initiative. If properly researched and implemented, health-related safety could minimize unnecessary care and costs by institutionalizing policies and providing coordinated services across societal institutions to promote self-sufficiency and independence, and increase social and structural support for vulnerable individuals. Ultimately, the use of expensive emergency and acute medical services may be attenuated and unnecessary health care costs avoided by the use of the health-related safety approach.
Health-related safety also recognizes that reducing harm and improving safety will require political, financial, and social support, and that institutional leaders in private and public sectors will need to prioritize this effort and provide the necessary leadership, incentives, and resources. In light of the potential limited resources available for systemwide change, developing and implementing cost-effective solutions will be important components of the research agenda. Health-related safety mandates a holistic approach toward healthy living with practical implications. Through system change, health-related safety can enable community-dwelling individuals to continue to live and age in place in a healthy and safe manner.
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Footnotes |
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We thank Theresa Kowalski, BA, current research assistant at the Buehler Center on Aging, Health & Society, and Emily Hagenmaier, BA, and Tawana Bandy, BA, former research assistants at the Buehler Center, for their assistance with the earlier version of this article.
1 Feinberg School of Medicine, Northwestern University, Chicago, IL.
2 Alzheimer's Association, Los Angeles, CA.
Decision Editor: William J. McAuley, PhD
Received for publication January 25, 2007. Accepted for publication May 3, 2007.
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