Always Events: Has its time come?

By Nelson Tuazon, DBA, MSN, MAEd, RN, NEA-BC, CENP, CPHQ, FNAP, FACHE, vice president and associate chief nursing officer, University Health System, San Antonio; president, South Central Texas Organization of Nurse Executives

The quest for excellence in patient care and the increasing competition for reimbursement brought about by value-based purchasing (VBP) have compelled hospital leaders to focus on clinical care processes, outcomes and efficiency, and patient care experience (Allen, Rieck, & Salsbury, 2016; Bailes, Rachel, & Keller, 2014; CMS, 2016; Mazurenko, Semke, & Lefforge, 2016). The spiraling costs of healthcare, the high rates of adverse events and readmission rates, and the perception of decreased quality of care have been attributed to the need for payment reforms (Moody-Williams, 2012). The delays in instituting and adopting effective VBP strategies and the lack of sustainability of performance improvement initiatives continue to threaten reimbursement to hospitals. The intensified demands for efficiency and effectiveness and the increased competition for reimbursements in the healthcare structure have driven the development of programs to attract healthcare consumers and providers (Berhane & Enquselassie, 2016; Kavanaugh, Cimiotte, Abusalem, & Coty, 2012). As core components of VBP, the quality of care, conformance with best clinical practices, and patient satisfaction have become focus areas of improvement for hospitals (Ara, Somibala, & Urmila, 2015; Mkanta, Katta, Basireddy, English, & de Grubb, 2016).

Achieving sustained performance through Always Events

The Institute for Healthcare Improvement (IHI) (2016) introduced Always Events as a framework for hardwiring behaviors that sustain positive patient care outcomes while mitigating the risks and threats to reimbursement (Hayward, Endo, & Rutherford, 2014). The definition of Always Events – those aspects of the patient and family experience that should always occur when patients interact with healthcare professionals and the delivery system – has remained at the core of patient-centered care (Picker Institute, 2013). Focusing on improving patient safety, quality, and patient satisfaction, the Picker Institute launched the concept of Always Events in 2010 with the goal of transforming patient-centered care to patient preference-driven care and providing care from a humanistic perspective. The implementation of Always Events aimed to ensure that the aspects of the health care experience that should always happen whenever a patient encounters a member of the healthcare team takes place (James, 2010). 

Always Events: A process and a patient-focused strategy

As a process, Always Events® involves two major components: co-designing an Always Event and reliably implementing standard work over time. The major premise of Always Events is an understanding of what matters to the patients. In order to succeed in the deployment of Always Events, leaders must create a vision, develop an aim statement, generate and test specific change ideas, and specify the details of successful changes for the Always Events (IHI, 2016). As a patient-focused strategy, an Always Event focuses on what is right in healthcare and what is right for the patient. A key to the hardwiring of performance is the identification and development of performance improvement programs that are designed based on standard work and that focus on teamwork and staff engagement (Morgan et al., 2016).

Turning never events into Always Events

The introduction of never events by CMS (2006) emanated from the serious reportable events launched by the National Quality Forum (NQF) (2011). Never events are errors related to the provision of medical care that are clearly identifiable and measurable and that are influenced by the policies and procedures of healthcare organizations (Miller, 2009; NQF, 2011). The never events have led to negative connotations among patients, providers, and healthcare professionals. To counter this unfavorable view on never events, Always Events emphasizes the issues that matter to the patients, promotes a patient preference-driven care delivery, and facilitates a collaborative and integrated performance improvement approach. As a strategy for patient safety, Always Events has the potential to improve clinical care processes, promote efficiency, and enhance the care experience of the patients by promoting standardization and consistency in practice.

The promise of Always Events

The concept of Always Events could become the basis for a positive long-term culture of patient safety (Lembitz & Clarke, 2009). In spite of the rapid advancements in technology and science in the U.S. health care system, health care leaders believe that there are persistent concerns about patient care and patient comfort. The concept of Always Events has been advanced to improve outcomes and patient experience under the framework of patient preference-driven care. Congruent with the principles of Always Events, Bowie et al. (2015) conducted participatory research on Always Events and reported on four themes:

1.      Emotional support, respect, and kindness

2.      Clinical care management

3.      Communication and information

4.      Access and continuity of healthcare

When implementing as an approach to patient preference-driven care, Always Events should meet the following criteria: the importance of the event to the patient as fundamental to their care; the experience is aligned with evidence-based practice, reflecting optimal and respectful care; the experience is measurable and can be accurately and reliably determined as an event that occurred; and the affordability and sustainability of the experience prevents undue stress on the resources of the organization (NHS Scotland, 2013; Picker Institute, 2014).

Implications to leadership and clinical practice

It is imperative for nurse leaders and executives to remember the two overarching goals of Always Events: to improve communication and care transitions (Picker Institute, 2011b). There is consensus among patients, families, and providers regarding the impact of the success of improved communication and transition of care on patient-centered care. As a starting point of care delivery, communication drives the success of every aspect of patient care. A critical element of communication is the ability of the patients and families to identify their physicians and currently name their diagnosis (Olson & Windish, 2010). Patients and families rely upon health care providers and believe that their role in their own safety is to follow the instructions from the providers (Rathert, Huddleston, & Pak, 2011). Unfortunately, many patients do not understand the purpose and side effects of their medications and their discharge information. The lack of effective communication negatively affects the successful transition of care for the hospitalized patients. Healthcare providers acknowledge the pitfalls of communication failures and the potential patient safety risks during handoffs and transitions (AHRQ, 2011). In the most recent published reports on patient safety, transition of care and handoffs remain among the lowest averages on positive responses (AHRQ, 2018).

The future of Always Events

In collaboration with the Institute for Healthcare Improvement (IHI, 2016) and Picker (2017), the National Health Service (NHS) in England piloted the implementation of Always Events from January 2015 to March 2016. The overall feedback of the participants regarding the use of Always Events framework in implementing quality improvement initiatives was largely positive. The program evaluation highlighted the importance of the partnership between the program leaders, end-users, and care providers in co-designing and implementing Always Events. The main challenges on the pilot included a) maintaining the momentum of implementation amidst staff turnover, b) recruitment of patients and their families and caregivers as partners in co-designing the program, c) ensuring engagement of the front-line staff faced with the issues of lack of time, staff shortages, and impact on workload, and d) limitations in program evaluation due to low number of patients and lack of capacity and resources to measure the patient and family experience (Picker, 2017).

Conclusion

The implementation of Always Events has shown positive results because of the alignment of its framework with performance improvement activities. The focus on communication and transition of care promotes participation and engagement from patients, families, and health care providers. The results of the various programs that have implemented Always Events have demonstrated improved patient care outcomes and patient experience (IHI, 2016). The program evaluation on the pilot in the NHS has shown promising outcomes and the challenges in implementing Always Events are manageable. Has the time for Always Events finally come to address the U.S. health care delivery system?

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