Coming home

Last week, my family returned from a vacation in Jamaica. The kids had spring break and it was great to get away with them. Upon returning to the U.S. and after clearing passport control, the customs agent said “welcome home.” No doubt they are trained to say this; I hear it every time I travel internationally. Nevertheless, those words always warm my heart and make me smile. They reflect for me a national culture, a set of values and beliefs about how we will behave. Welcome home to the U.S. reminds me that we live under the rule of law, that we are all afforded due process, that we have freedoms to voice our concerns, to practice our religions, to vote.

As we drove home, we rounded the corner and our house came into view. Again warm feelings flooded me. Seeing my home, I reflected on the deeply held beliefs of love, of support and nurturing, of forgiveness, of warmth and comfort—the culture of our home.

Two days later, on Monday, I returned to work, starting as the attending physician in the ICU. As I walked into the ICU, I thought about the culture we have created there, the sets of norms and beliefs that govern behaviors, my largely hidden assumptions about the organization and my colleagues.

Clinicians, when you walk into your clinical or hospital, what kind of culture are you part of? Is this a place where patients are the “North Star,” their needs guiding all of your work? Is it a place where clinicians’ egos are put aside and they focus on what is right rather than who is right, where we commit to practice evidence-based medicine, to work as a team, to continually learn and improve? Is it where staff seek to identify and mitigate patient safety hazards, respect the wisdom of frontline workers and empower them to improve? Is it a place where we see our differences as strengths rather than weaknesses, where we support each other, hold each other’s hands when we are down, laugh and cry together?

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Susan BoyleThe video of Susan Boyle’s debut on Britain’s Got Talent is well worth watching. She walked on stage, wearing a frumpy dress, overweight and awkward. Members of the audience snickered and rolled their eyes as this 47-year-old told the judges that she wanted to be a singing star. I suspect she had her own doubts. Yet she had the courage to try. She believed in herself and stunned the audience with her voice.

Susan’s story is typical of so many personal journeys. We face skepticism from others, and we are filled with self-doubt. Sometimes we listen to those little voices whispering: You cannot do this. Yet when we overcome the doubts, we are often successful. If we give into those voices, we will surely fail.

This same self-doubt exists in patient safety. I know because I had plenty of uncertainty about my ability to reduce patient harm. More than a decade ago, we decided to reduce central line-associated bloodstream infections on one intensive care unit. We doubted it was possible and whether we could have a role in reducing harm. Most of the physicians thought it couldn’t be done. Sick people get infected, they said. These infections just happen. In our own way, we felt frumpy and awkward.

Initially, we did not debate whether we could stop these infections. We focused on consistently following those practices shown by evidence to reduce them. We had been complying with those practices just 30 percent of the time. Our clinicians agreed that we would follow a checklist to help ensure 100 percent compliance and then see what happened to our infections. As compliance rose, the rates went to nearly zero, and the doubts disappeared.

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DNAPersonalized medicine is getting a lot of attention, and rightly so. We all have our own DNA, health habits, socioeconomic background and values. Shouldn't the care we get be personalized for us? Basic scientists have provided profound insights about the incredible complexity of disease—for instance, about how breast cancer is not a single disease but comes in one of many forms. The specific type of cancer may determine the patient’s prognosis and which drugs are likely to be effective. Our unique genes also affect how we metabolize certain drugs, a factor that can increase the risks for severe overdosing or underdosing.

Some clinicians may view personalized medicine as opposed to patient safety and quality improvement efforts, which focus on creating protocols and checklists and ensuring that all patients get the same therapy for a given clinical situation. While standardizing work leads to better outcomes for populations, physicians may push back, viewing safety and quality approaches as “cookbook medicine.” They claim that caring for patients is far too nuanced to be reduced to a checklist or protocol.

Yet efforts at personalized medicine and quality improvement are united in a common goal: optimal patient outcomes. They just approach it from different angles. Quality improvement standardizes work when possible, leaving clinicians to focus on the complex, patient-specific situations in which their expertise, analysis and skills are most needed.

Personalized medicine (largely genetics) has taught us that we can no longer allow the patient’s disease alone to define appropriate treatment. We must also view the patient’s specific genes as defining appropriate therapy, when that genetic knowledge is available. However, without also focusing on patient safety and quality, these medical advances will increase the risk of error. Right now, patients receive roughly half of the recommended therapies for common diagnoses that physicians see every day, such as urinary tract infections or diabetes. Imagine the number of permutations of recommended therapies (and thus the risk for error) that would exist if we needed to start remembering that a disease with one gene gets Treatment A while the same disease with another gene gets Treatment B. Diagnostic and therapeutic errors will skyrocket if we do not couple these advances in basic science with similar progress in health care delivery science. This often neglected field shows us how to take existing scientific knowledge, translate it into everyday bedside practices and implement it on a large scale. We need a cadre of experts who look at the breathtaking discoveries coming out of laboratories and clinical research and find a way for patients everywhere to consistently benefit from them. That is the promise of medicine.

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cockpitIn the world of patient safety, we’re constantly reinforcing the importance of teamwork and communication, both among clinicians and with patients. That’s because we know that patient harm so often occurs when vital information about a patient’s care is omitted, miscommunicated or ignored.

Yet for all we do to improve how humans work together, clinicians compete against an environment in which there is very little teamwork or communication among the technologies that they need to care for patients. And there’s little that clinicians or hospitals alone can do about it.

Take, for example, the plethora of alarms from cardiac monitors and other devices that compete for clinicians’ attention. Vendors act as if we are in an alarm race, with each making their devices’ beeps more annoying but no clear prioritizing of the most important alarms. A study on one 15-bed Hopkins Hospital unit a few years ago found that a critical alarm sounded every 92 seconds. As a result, nurses waste their precious time chasing an ever-growing number of false alarms—or becoming desensitized to false alarms and ignoring them. Across the country, this has had tragic consequences, as patients have died while their alarms went unheeded. (Read a 2011 Boston Globe series about this issue.)

In most other high-risk industries, such as aviation and nuclear power, technologies are integrated. They talk to each other, and they automatically adjust based on feedback. Indeed, because of systems integration, pilots fly a small amount of a flight, and even in some treacherous situations, they hand over the reins to the autopilot. Although Southwest Airlines or the U.S. Air Force can buy a working plane, you cannot buy a working hospital or ICU. You must put it together yourself. Continue Reading ...

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Central LinePatients, providers and the public have much to celebrate. This week, the Centers for Medicare and Medicaid Services’ Hospital Compare website added central line-associated bloodstream infections in intensive care units to its list of publicly reported quality of care measures for individual hospitals.

Why is this so important? There is universal support for the idea that the U.S. health care system should pay for value rather than volume, for the results we achieve rather than efforts we make. Health care needs outcome measures for the thousands of procedures and diagnoses that patients encounter. Yet we have few such measures and instead must gauge quality by looking to other public data, such as process of care measures (whether patients received therapies shown to improve outcomes) and results of patient surveys rating their hospital experiences.

Unfortunately, we lack a national approach to producing the large number of valid, reliable outcome measures that patients deserve. This is no easy task. Developing these measures is challenging and requires investments that haven’t yet been made.

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Kendra HarrisEvery clinician has encountered patients whose memories stay with them for years. The patients who stick usually are not the ones for whom the clinician made a brilliant diagnosis or provided evidence-based therapies. They are the patients who touched clinicians' hearts, the ones they formed a relationship with, the ones in whom  they saw themselves or a loved one—ultimately, the ones who taught them how to be better, more compassionate caregivers.

For radiation oncology resident Kendra Harris, one such patient was a woman she met during a rotation as a medical student. The woman had a form of amyotrophic lateral sclerosis (aka Lou Gehrig’s Disease) in which the neurodegenerative disease started by claiming her ability to speak and express emotion before it affected other motor functions. Not surprisingly, she had trouble communicating her needs or concerns about her treatment.

Kendra says she often thinks about this patient as she cares for others today. Although these patients can speak, when they get a cancer diagnosis, they are often blindsided by the news and don’t readily know what choices lie ahead. Kendra’s reflections land on an aspect of patient-centeredness: “It’s not just about answering their questions, it’s about helping them to understand what those questions are.”

Kendra’s story is part of our Heart of Caring podcast series, which invites patients and clinicians to share experiences that capture the essence of patient- and family--centered care. Please listen below and consider sharing your story.

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ListeningI was reminded again recently of how important it is to sometimes just sit back and listen to what our patients have to say. Every month, as part of our hospital-wide patient safety efforts, I meet with staff and interview patients, seeking to learn how we can improve the care we provide to them.

A young patient shared two stories with me, one telling me how we get it right and one reminding me how we sometimes get it wrong, even without realizing it. She was nervously awaiting a procedure in Interventional Radiology when a nurse sensed her anxiety and called in a child life specialist. The specialists came and significantly helped relieve the patient’s suffering. She listened to the patient, offered a comforting touch, and provided her age-appropriate reading material and Sudoku puzzles, a brilliant though infrequently used intervention. If anything could take your mind off of your illness, it is Sudoku.

What was amazing was that after all the patient had been through—weeks in the hospital, countless procedures, scores of clinicians—what she remembered was the nurse’s act of kindness by caring enough to call the specialist. The patient reminded me that though we can cure disease sometimes, we can relieve suffering always, often with nothing more than a kind word, a gentle touch or a warm smile.  

As I listened, the patient, along with her mother, went on to tell me more. They told me how the patient has complex allergies and that her mom knew her disease better than any clinician. They had lived with the disease for a decade. Yet at times, neither the patient’s mother nor the patient felt they were being heard by the doctors. The mom expressed frustration that clinicians often dismissed her concerns and discredited her knowledge.

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checklistFar too many patients are harmed rather than helped from their interactions with the health care system. While reducing this harm has proven to be devilishly difficult, we have found that checklists help. Checklists help to reduce ambiguity about what to do, to prioritize what is most important, and to clarify the behaviors that are most helpful. 

The use of checklists helped to reduce central-line associated bloodstream infections at The Johns Hopkins Hospital, in hospitals throughout Michigan, and now across the United States. Clinicians have begun to develop, implement and evaluate checklists for a variety of other diagnoses and procedures.

Patients can also use checklists to defend themselves against the major causes of preventable harm. Here are a few you can use:
 
Health care-associated infections

  • Ask about your hospital’s rates of central-line associated bloodstream infections in the intensive care unit. The best hospitals use the definitions provided by the Centers for Disease Control and Prevention and have rates less than one infection per 1,000 catheter days. A rate above three should cause concern. 
  • Whenever clinicians enter your room, ask if they have washed their hands. Request that visitors also wash their hands often. Washing can be with alcohol gel or soap and water.
  • If you have any type of catheter, ask every day if that catheter can be removed.

Identification errors

  • If you are admitted to the hospital, check your ID bracelet to make sure all information is correct. Staff should use this bracelet to confirm your name before any treatments or tests. 
  • If you are making an outpatient visit, staff should ask you to confirm your name and another unique identifier, such as your date of birth, before treatments or tests.
  • Verify that blood and other specimens taken from your body are labeled in front of you.

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Hand washing

I recently spoke to an executive in the energy industry who had a joint replacement at a hospital in New York. His wound developed an infection, which required four additional hospital admissions and several operations. He asked me about hand hygiene in hospitals. Proudly, I told him that, at Johns Hopkins Hospital, we are at 80 percent compliance with hand hygiene, up from 30 percent not that long ago. I focused on the improvement. He focused on the failures. "So," he said pointedly, "one in five times you do not comply with basic hand washing rules, potentially causing infections—or even death." He asked what we are doing about it.

I told him how we try to learn from the high performers and to improve the poor performers, how we train staff on the importance of hand hygiene, how we report compliance rates to unit teams, how we put pictures of patients with the words “please wash” outside their rooms.      

The executive said, "All that is great, but where is the accountability?" In any other industry, there is accountability to ensure staff comply with safety standards, standards that are often much less consequential than hand washing. Other industries help staff improve compliance; they also hold local managers accountable for poor performance. To get results, you must both support staff and hold them responsible.

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Dan MunozI hope you’ll take the time to check out our podcast project, The Heart of Caring, which highlights stories that deepen our understanding of patient- and family-centered care. A recently added story comes from physician Dan Munoz, who recalls a decision about whether to place a 99-year-old patient on a ventilator. It’s often considered humane to withhold invasive procedures on patients whose lives appear near the end. But as Dan points out, clinicians need to make sure that they carefully weigh the case of each patient as an individual rather than make decisions based solely on age or other such factors.

Dan tells the story so eloquently in the recording below:

If you have an experience of patient- and family-centered care to share in a podcast, please e-mail Elizabeth Tracey at etracey@jhmi.edu with a short description. She will respond to discuss the possibility of recording your story.

Or, if you prefer to have your story in written form only, just post it to this blog as a comment.

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