If you have ever tried to choose a physician or hospital based on publicly available performance measures, you may have felt overwhelmed and confused by what you found online. The Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Joint Commission, the Leapfrog Group, and the National Committee for Quality Assurance, as well as most states and for-profit companies such as Healthgrades and U.S. News and World Report, all offer various measures, ratings, rankings and report cards. Hospitals are even generating their own measures and posting their performance on their websites, typically without validation of their methodology or data.

The value and validity of these measures varies greatly, though their accuracy is rarely publically reported.  Even when methodologies are transparent, clinicians, insurers, government agencies and others frequently disagree on whether a measure accurately indicates the quality of care. Some companies’ methods are proprietary and, unlike many other publicly available measures, have not been reviewed by the National Quality Forum, a public-private organization that endorses quality measures.

Depending where you look, you often get a different story about the quality of care at a given institution. For example, none of the 17 hospitals listed in U.S. News and World Report’s “Best Hospitals Honor Roll” were identified by the Joint Commission as top performers in its 2010 list of institutions that received a composite score of at least 95 percent on key process measures. In a recent policy paper, Robert Berenson, a fellow at the Urban Institute, Harlan Krumholz, of the Robert Wood Johnson Foundation, and I called for dramatic change in measurement.  (Thanks to The Health Care Blog for highlighting this analysis recently.)

We made several recommendations, including focusing more on measuring outcomes such as mortality and infections rather than processes (e.g. whether patients received the recommended treatment) or structures of care (e.g. whether ICUs are staffed around the clock with critical care specialists). We urged that measures be at the organization level rather than clinician level, to reflect the fact that safety and quality are as much products of care delivery systems as of individual clinicians. We propose investments in the “basic science” of measurement so that we better understand how to design good measures. You can read these and other recommendations in the analysis.

Of the proposals, perhaps the biggest game-changer would be the creation of an entity to serve as the health care equivalent of the U.S. Securities and Exchange Commission. Rather than wading through a bevy of competing and often contradictory measures, patients and others would have one source of quality data that has national consensus behind it. We write:

“Under this model, this entity would set the rules for the development of measures and the transparent reporting of performance of these measures, analyze progress (with input from clinicians, patients, employers, and insurers), and audit publicly-reported quality measure data. Private sector information brokers could then conduct secondary analyses of the reports, much like happens in the financial industry through companies like Bloomberg. This SEC-like model would thus ensure that all publicly-reported quality measure data are generated from a common basis in fact and allow apples-to-apples comparisons across provider organizations.”

Before the SEC was created, in the aftermath of the Wall Street Crash of 1929, information provided by one business typically could not be compared to another, as there were no common standards for reporting financial performance. It’s more than 80 years since then, and health care is stuck in a similar situation, despite great efforts to create measures to drive improvement and inform patients’ decisions. It’s time that we catch up. A SEC-like entity could have private sector rule-setting, public sector auditing and transparency, and private sector reanalysis, working from a common book of truth.

Advancing the science of measurement is one of three content tracks in Johns Hopkins’ first Forum on Emerging Topics in Patient Safety, to be held Sept. 23-25 in Baltimore. Experts from a wide range of backgrounds will gather to help generate ideas around this crucial issue. Among the speakers on this track are Patrick Conway, Chief Medical Officer for the Centers for Medicare and Medicaid Services; John Santa, Director of the Consumer Reports Health Ratings Center; Niek Klazinga, Coordinator of the Health Care Quality Indicator Project at the Organisation for Economic Co-operation and Development; and Robert Berenson of the Urban Institute. Aimee Guidera, founder of the Data Quality Campaign, which has encouraged the creation and use of high-quality data in education, will provide perspectives from her field that may translate to health care. If you are interested in this topic and would like to contribute to the recommendations that come from the forum, please join us in September.

If you follow the world of higher education, you have heard of MOOCs—massive online open courses. Open to anyone, anywhere, these free classes can attract tens of thousands of students whose hunger to learn outweighs the fact that no credits are typically awarded. With many elite universities now offering MOOCs, it’s a movement that is worth following as a potential model for affordable, accessible education in the future.

From an educator’s perspective, it’s also worth trying out. Beginning June 3, I will be teaming up with Cheryl Dennison Himmelfarb, a patient safety expert and associate professor at the Johns Hopkins University School of Nursing, to lead a five-week-long MOOC, “The Science of Safety in Healthcare.” Through the course, participants will explore fundamental topics in the science of safety, patient safety culture, teamwork and communication, patient-centered care, and strategies for assessing and improving care. The course workload is two to five hours per week, which includes up to two hours of video instruction, as well as readings and assignments.

Clinicians, hospital administrators, students, patients—indeed anyone with an interest in this topic—should consider enrolling. Students receive a statement of accomplishment upon passing the course.

Increasing patient safety requires that all frontline health care workers understand the basic concepts and language of health care, and that they develop the lenses to identify the hazards that face their patients. It will be interesting to see, through this course, if the MOOC model can help to efficiently deliver that kind of education on a broad basis. Certainly, becoming a patient safety leader at your unit, department or hospital requires more in-depth training.

Space is unlimited but those interested should enroll as soon as possible. Get more details and register here: https://www.coursera.org/course/healthcaresafety. (If you have any difficulty accessing this link, visit www.coursera.org and search for "science of safety.")

This month the Agency for Healthcare Research and Quality (AHRQ) published a new report that identifies the most promising practices for improving patient safety in U.S. hospitals.

An update to the 2001 publication Making Health Care Safer: A Critical Analysis of Patient Safety Practices, the new report reflects just how much the science of safety has advanced.

A decade ago the science was immature; researchers posited quick fixes without fully appreciating the difficulty of challenging and changing accepted behaviors and beliefs.

Today, based on years of work by patient safety researchers—including many at Johns Hopkins—hospitals are able to implement evidence-based solutions to address the most pernicious causes of preventable patient harm. According to the report, here is a list of the top 10 patient safety interventions that hospitals should adopt now.

Top 10 Recommended Patient Safety Strategies
1. Preoperative checklists and anesthesia checklists to prevent operative and postoperative events.
2. Bundles that include checklists to prevent central line-associated bloodstream infections
3. Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols
4. Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia
5. Hand hygiene
6. The do-not-use list for hazardous abbreviations
7. Multicomponent interventions to reduce pressure ulcers
8. Barrier precautions to prevent healthcare-associated infections
9. Use of real-time ultrasonography for central line placement
10. Interventions to improve prophylaxis for venous thromboembolisms

Source: Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices, AHRQ

But as The Leapfrog Group’s CEO Leah Binder points out in a Forbes.com article responding to the report, the list alone will not help hospitals solve these challenges. Although some of the strategies may sound simple enough—getting doctors and nurses to wash their hands, for example—in reality changing behaviors and work processes can be quite difficult. Increasingly hospitals are told to do more with less all while facing increasing pressure to improve performance on a growing list of quality measures.  

Even with a list of sound strategies, creating a plan to implement all or even half of them may sound like a daunting task. The Armstrong Institute for Patient Safety and Quality has created a checklist to help you get started. 
  
1. Identify priorities and assess readiness for change.
What are your organization’s strengths and weaknesses and how do those compare with best practice organizations? Conduct a risk assessment to identify four to five areas of greatest need and prioritize resources around those areas.

Before implementing any improvement efforts, assess readiness for change. If a unit’s surgical site-infection rate is double the national standard but its surgeons, nurses and technicians don’t know about the issue or understand their role in improvement, then some team education is needed before progress can be made.

2. Establish engagement and accountability at all levels of the organization.
Although leadership consensus and buy-in is an obvious and important step, it’s equally important to involve frontline staff in the process of developing solutions. 

To sustain improvements, every unit and department needs an accountable patient safety champion—an individual with knowledge of the science of patient safety who is accountable for their team’s performance. 

3. Communicate constantly (the good and the bad).
Frequent and transparent communication about what is and isn’t working is an important aspect of any quality improvement project. Recognize employees who speak up to prevent a mistake. Examine setbacks and failures. Regular team meetings and patient safety rounds with a senior leader are valuable venues for discussion.

Before beginning a quality improvement project, tell the story of how the organization is doing today. What is the cost of doing nothing? Build a case for change and communicate often on the journey to improvement.

4. Measure, measure, measure… and then measure some more.
One step that’s often forgotten when implementing operational changes is identifying baseline measurements. Without something tangible to gauge improvements against, it can be difficult to see the impact of invested resources.

Measure early and measure often. Share data transparently so that employees know their performance individually, and as a team and organization.

5. Learn from mistakes and commit to continuous improvement.
Quality improvement is a never-ending journey: there is always room to improve. Even when an organization achieves its goals, then the new challenge of sustaining that success arises.

Best practices must be continuously evaluated as they evolve; medicine must work with industry to develop technology and tools that better support the needs of patients and their care providers; and continued investments of staff time and education are all needed to reduce patient harm, optimize outcomes and reduce waste.

A machine that detects minute eye movements that are difficult for most physicians to notice may be a more reliable and cost-effective way to diagnose stroke in patients with dizziness.

Although misdiagnosis may kill up to 80,000 annually—more people each year than firearms and motor vehicle accidents combined—you won’t find it on the list of the country’s leading causes of death.

Most Americans don’t realize how frequently well-meaning medical providers get it wrong. Just last year Johns Hopkins researchers found that one in 12 ICU patients die from something other than what they were being treated for. Aside from a handful of instances covered by the national media, misdiagnosis hasn’t received much attention from the public or the medical community. One such tragedy is the death of Rory Staunton, a 12-year-old boy who was treated for an upset stomach and dehydration instead of sepsis, a severe response to infection that requires immediate treatment with antibiotics. To make a complex diagnosis like sepsis, a doctor may need to assess a couple dozen different factors.

One solution is to arm clinicians with better problem-solving tools and improved IT systems to help them identify possible diagnoses faster and more accurately, especially for conditions that are commonly confused or missed altogether. This week at Johns Hopkins, a team of researchers shared some promising results about a new way for emergency medicine doctors to accurately detect stroke in patients with dizziness.

That team, led by Armstrong Institute faculty member David Newman-Toker, found that a portable bedside device that measures eye movements could accurately predict whether a patient’s dizziness was caused by a life-threatening stroke or a less time-critical issue like a balance disorder. The machine could be a time saver for busy emergency department doctors who often rely on brain imaging, typically a CT scan—an expensive and inaccurate technology for this diagnosis.

"We're spending hundreds of millions of dollars a year on expensive stroke work-ups that are unnecessary, and probably missing the chance to save tens of thousands of lives because we aren't properly diagnosing their dizziness or vertigo as stroke symptoms."

-David Newman-Toker, lead author

If their results can be replicated on a larger scale, the device could one day be the equivalent of an electrocardiogram, the go-to tool to rule out heart attack in patients with chest pain.

For more details, read a press release about the study or watch David's interview with CBS This Morning.

Among other efforts on the diagnostic errors front at Johns Hopkins, an international conference was hosted on our campus this past fall. 

Congratulations to David and the whole team on their exciting and important work to save or improve the quality of life for the 20,000 to 30,000 patients who suffer an overlooked stroke each year.

Maybe it's just wishful thinking, but it seems like we're reaching a critical mass where enough people are interested in improving patient safety that we can make a serious impact. In just the past week, several national media outlets have focused attention on this issue. At 4 p.m. Eastern today, I'll appear on a special segment of Katie Couric's program, "Katie!" that is devoted to the topic of medical mistakes. One takeaway from this program is that there are many things that patients and their loved ones can do to reduce the risk of medical errors and preventable complications.

In other news, the nationally syndicated public radio program Marketplace recently ran a segment about efforts by Johns Hopkins clinicians and safety experts to reduce harm in intensive care units. Listen to the program or read the story online to learn how the team is tapping clinicians, engineers, patients and families to design an ICU that is safer and more integrated.

And the Wall Street Journal this week launched an online forum about health care, The Experts, in which 10 health care experts offer their take on issues facing the field. The questions we answered this week also had slant toward improving safety, quality and value in health care—for instance, about the effect of limiting how long resident physicians can work in a shift.

It's rewarding to see that the public and the press are turning their attention on these issues. I'm proud of the dedicated clinicians, patients and others at Johns Hopkins and elsewhere who are helping to push the issue and advance our knowledge of how to prevent harm.

A few months ago, I posted about the pleasure of meeting Horst Schulze, a former Ritz-Carlton executive who created his own ultra-luxury hotel chain based on many of the principles he employed while working for the Ritz-Carlton. It was clear to me that the hospitality industry has something to teach health care about what it takes to create a culture of service excellence, and what it truly means to treat employees and staff with the utmost respect.

For that post, I only heard about Ritz-Carlton; I now got to experience it. As part of the Baldrige Executive Fellowship Program, I spent two days in January with the Ritz-Carlton in Pentagon City. Aside from hearing from senior leaders how they maintain excellence, I lived the Ritz-Carlton experience as a hotel guest.

The Ritz-Carlton understands deeply that to satisfy their customers, they must excel in the technical and emotional delivery of service—not only clean rooms and timely room service, but creating a feeling that guests are unique and important. And it was almost eerie For example, from the bellhop to housekeeper to concierge, the employees all knew my name, as if it was a game they played to memorize who their guests were. They seemed to be mind-readers. Once, when I left the meeting room to take a call, the concierge sensed my needs for a quiet place to speak and motioned to me to come into an empty room that was quiet and had excellent reception. A second latter, he handed me a bottle of water, which he somehow sensed I wanted. You could tell by the way that they addressed me that these “ladies and gentleman”—who are never referred to as staff—took great pride in their work. Their leadership knows that when people feel respected, they are better employees and serve customers better.

Where does this come from? How do they ingrain desired behaviors and habits across their hotels? This is something I wanted to find out on my visit. As I learned, it takes more than words to support this culture.

Here are a few of my takeaways:

Disciplined goal-setting and measurement
The Ritz-Carlton rigorously measures its performance and these measures “cascade” down across the organization, so that each hospital, department or group knows its role in helping to achieve the corporate goals. The entire organization has a widely important goal, or “WIG.” For example the main WIG, customer satisfaction, is measured as the percentage of visitors who give the highest possible rating to all three key questions that they answer in surveys after their stays: overall satisfaction, willingness to return and willingness to recommend.

We visited several departments and in every one, they had the overall WIG for their property prominently displayed on a board. The departments defined their role in meeting their hotel’s WIG, and then measured their performance in that area. For example, Room Service may measure the percentage of meals without mistakes. Every department had this type of cascading goals, and every morning in their daily “line-ups” (more on that to follow), they reviewed their WIG and departmental performance.

Focusing on behaviors
Every morning, Ritz-Carlton hotels have a “line up” both for all hotel staff and then for individual departments, such as the kitchen. Aside from reviewing their WIG performance, they read one of 16 key expected behaviors, rotating daily. For example, “I am always responsive to the unexpressed and expressed needs of our guests.” They also review plans for the day and any potential concerns. And it is not optional.

There is still an implicit trust in employees’ decision-making and ability to live out these behaviors. Any employee can spend up to $2000 per event in which a customer is dissatisfied or their needs not meet. No questions asked. However, the monetary amount is symbolic. They have rare occasions to use those funds because problem resolution training at Ritz-Carlton is comprehensive and frequent.

Cultivating employees
To echo my previous post about Schulze’s Capella hotel chain, the Ritz-Carlton does not just hire people; it selects them. Indeed, even for entry-level positions, they do behavioral profiling; they want to match an applicant’s personality with the job. For example, those who interact with customers should be extroverts, with a warm inviting smile who enjoy conversation. All employees go through 10 days of training to learn the culture, to understand expected behaviors and to ensure they have the skills to perform their jobs.

Recognition as currency
The Ritz-Carlton understands that recognition and praise are rewards in and of themselves. Two of their programs put this belief in action. Every Monday and Friday the Ritz-Carlton properties around the world share “WOW stories”—tales of random acts of kindness by employees that are shared at the daily line-ups twice a week. These stories inspire the others at Ritz-Carlton by demonstrating outstanding service

For example, one WOW story from The Ritz-Carlton New York, Central Park came from a man who had arranged a hotel stay as a special treat for an aunt who was losing her battle with cancer, as well as for his mother. He wrote about how the staff “took it upon themselves to ensure that this trip was unforgettable”—for instance, by sending flowers to their room. He praised the hotel for empowering employees “to make decisions based on guests’ needs.”

The other program is called a “First Class Card.” When a colleague witnesses outstanding service by another, they write what they saw on a postcard and present it to that person. The cards may go between peers, or from managers to subordinates. We met a housekeeper who told us how she received a first class card five years ago. She keeps it in a scrap book, proudly displaying it for her grandchildren.

My Ritz-Carlton visit further convinced me that a culture of service excellence requires organized work and discipline. It happens when the organization has clear goals, measures to support those goals, and then systems to ensure the goals are met. It happens when the organization focuses on both the technical and emotional aspects of care.

Much of what I learned from Ritz-Carlton can be applied to health care. At Hopkins Medicine, we’ve made a concerted push to clarify what our patient safety and quality goals are: to partner with patients, their families and others to eliminate preventable harm, optimize patient outcomes and experience, and reduce waste. We have identified several key measures that we will use to measure our progress toward these goals. For instance, all of our hospitals are working to reach 96 percent or better performance on all of the 30-plus Joint Commission core measures, 85 percent or better for hand-hygiene in the inpatient setting (90 percent for ambulatory), and for each ICU to have zero central-line-associated bloodstream infections. Hospitals, departments, units or clinics are being held accountable for doing their part to reach these goals, and when they fall short, we provide support to help them meet their goals. We are pilot-testing a new dashboard that summarizes our progress toward these goals and will ultimately be customized for departments and other areas.

There’s more that we could do to infuse Ritz-Carlton methods and rigor into how we care for patients. Should we send weekly success stories? Daily line-ups? Certainly, no two industries are alike. But I am confident that there is still much we could adopt from the Ritz-Carlton model, encouraging our housekeepers, environmental services staff, aids, technicians, nurses and doctors would see themselves more as “ladies and gentlemen” focusing not just on delivering the right medications or treatments, but meeting the emotional needs of our patients.

Peter Pronovost and Bill Clinton

This week marks a step that holds tremendous promise for patients and clinicians. On Monday the Masimo Foundation hosted the Patient Safety Science & Technology Summit in Laguna Niguel, California, an inaugural event to convene hospital administrators, medical technology companies, patient advocates and clinicians to identify solutions to some of today’s most pressing patient safety issues. In response to a call made by keynote speaker former President Bill Clinton, the leaders of nine leading medical device companies pledged to open their systems and share their data.

Today, an intensive care unit patient room contains anywhere from 50 to 100 pieces of medical equipment made by dozens of manufacturers, and these products rarely, if ever, talk to one another. This means that clinicians must painstakingly review and piece together information from individual devices—for instance, to make a diagnosis of sepsis or to recognize that a patient’s condition is plummeting. Such a system leaves too much room for error and requires clinicians to be heroes, rising above the flawed environment that they work in. We need a heath care system that partners with patients, their families and others to eliminate all harms, optimize patient outcomes and experience and reduce waste. Technology must enable clinicians to help achieve those goals. Technology could do so much more if it focused on achieving these goals and worked backwards from there.

Lack of interoperability between medical devices plays no small role in the 200,000 American deaths caused by preventable patient harm each year, such as in the case of 11-year-old Leah Coufal.

After undergoing elective surgery, Leah received narcotics intended to ease her pain. When Leah received too much medication, it suppressed her breathing, eventually causing it to stop altogether. Had she been monitored, a device could have alerted clinicians when Leah’s breathing slowed to a dangerous level. But as we know, clinicians are busy and unfortunately don’t always respond to alarms from bedside machines. If a machine measuring her breathing had been linked with the device delivering her medication, it could have automatically stopped the drugs from infusing into her blue, oxygen-deprived veins.

All of this is possible today; technology is not a barrier. Until now, the only thing that’s stood in the way is a lack of leadership and a lack of willingness for device manufacturers to cooperate.

Through collaboration between health care providers and the private sector, health care can move from a system that relies on the heroism of individual clinicians to one that utilizes safe design.

Additional links:

See my video interview about the summit

Read an article with the pledge

In recent years, Parkland Memorial Hospital in Dallas, Texas has faced intense media scrutiny and government investigations into patient safety lapses. As the hospital searches for a new CEO, the Dallas Morning News asked me and other experts to answer the question: "What kind of leader does Parkland need to emerge as a stronger public hospital?" Below is the column, re-used with the newspaper’s permission. While it is focused on one hospital, the themes apply broadly. The type of leader that I describe is needed throughout health care.

Parkland rebuilding ‘at the speed of trust’

Public hospitals such as Parkland are a public trust, serving the community's health needs by providing safe and effective care to a population that lacks alternatives.

Major shortcomings in the quality of care provided at Parkland have eroded that trust. Now trust must be restored. The community is counting on it. It's literally a matter of life and death.

Parkland's board is searching for a new CEO to lead this journey. The CEO's task will not be easy: Resources are tight, resident supervision is insufficient, staff morale is low, systems need updating, and preventable harm is far too common.

History may provide some guidance. Historian Rufus Fears notes that great leaders - leaders who changed the world - have four attributes: a bedrock of values, a clear moral compass, a compelling vision and the ability to inspire others to make the vision happen. Parkland needs one of these great leaders.

The key values of the next CEO should be humility, courage and love -- and these values must guide the leader's behavior. Parkland will not be able to improve unless it acknowledges its shortcomings; this will take humility. Yet Parkland is a great organization with a rich past and bright future. The leader must honor the past and look forward. The leader must be able to live with the paradox of being humble yet confident.

The leader will need courage. Author C.S. Lewis once said that "courage is not simply one of the virtues but the form of every virtue at the testing point." The Parkland CEO will be at the testing point many times every day. The leader must be unwavering in the goal to improve care yet humble enough to invite all staff to come together to realize the goal. The leader will need to make tough decisions about where to deploy scarce resources, always keeping patients as the North Star.

To avoid a revolt and get staff passionate about the vision, the leader will need to transparently communicate where Parkland is going and why, how Parkland makes decisions and what those decisions are. Yet the next CEO will need to deftly dance between democracy and autocracy, between conversations and results. To make all the needed fixes, to bring Parkland back to where it needs to be, much needs to be done, and only with a passionate and engaged staff can real change happen.

Yet perhaps the greatest value will be love. Avedis Donabedian, one of the fathers of quality improvement, was interviewed on his death bed by a student. The student asked, "Now that you have been a patient and devoted your life to improving care, what is the secret of improving quality?" Donabedian told him, "The secret of quality is love. If you love your God, if you love yourself, if you love your patients, you can work backwards to change the system."

This is what Parkland needs. The hospital's doctors, nurses and administrators care deeply about patients; they do not want to harm them. They work with broken, underresourced systems. The next CEO must recognize this and seek to understand rather than judge, to learn and improve rather than blame and shame.

This won't be easy. The public wants accountability. Parkland is under scrutiny from federal and state regulators. Yet real improvements will come from internal rather than external motivation.

The CEO will need to help the staff see shortcomings in safety as their problem and believe they are capable of solving it. The CEO will need to inspire with lofty oratory, and then drop down, roll up her sleeves, and get things done.

Parkland's next CEO needs to tap the immense wisdom within the staff by soliciting broad input and inviting hospitalwide brainstorming. The title of CEO still allows the new leader to convene meetings. But true authority comes from trust. Change of this magnitude only progresses at the speed of trust, and trust is based on being perceived as caring and competent. Both are essential. Only through caring and competence can Parkland win back the faith of the community it serves.

Nearly a year ago, one of my blog posts bemoaned a gap in our training of future physicians—a lack of training in the skills needed to lead projects in patient safety and quality improvement.

I wrote the post after speaking to a group of medical students who were energized about this area of work. Yet, as I reflected on the talk:

“I had to confront the sad reality that most of them will graduate ill-prepared to lead the improvements of quality and safety our health care system needs. They no doubt will know chemistry, biology and physiology, but they may not know about human factors, implementation science or performance measurement—the language of quality improvement. They will know orthopedics and genetics but they won't know teamwork and systems engineering. They likely know about German scientist Rudolph Virchow, the father of cell theory, yet they do not know John Kotter, the father of change theory whose model for leading change is highly effective and widely used.”

So how can medical students, residents and fellows make quality improvement and patient safety a focus of their clinical careers? On Nov. 10, the Armstrong Institute and the American College of Medical Quality will be hosting the National Workshop on Quality for Medical Education—affordable and open to anyone—that focuses on how medical students, residents and fellows can integrate safety and quality into their clinical careers. What career paths exist? What tools and skills are needed to carry out this work, and where do you get them? What kinds of quality and safety projects are residents and students taking on? I’m honored to deliver one of the keynotes—one of many talks by speakers from across the country. I encourage you to attend if you have an interest in this topic or think about pursuing a career in safety. Students in various health care professions, such as public health and nursing, may find this a valuable experience, as would faculty members and physicians who teach and train the next generation of clinicians.

A one-day conference won’t change the realities I wrote about a year ago, but it’s a step in the right direction. At Hopkins Medicine we’re finding other ways to get young physicians grounded in safety and quality work. This past summer, we launched the Armstrong Institute Resident Scholars program—a one-year elective fellowship to train future physician leaders who can bridge systems to improve safety and quality. Sixteen residents are part of the first cohort. Hopkins Hospital also launched a Housestaff Patient Safety and Quality Council, which gives residents a leadership role in improving quality. The council helps lead hospital-wide projects, assists in creating the hospital’s quality and safety plan, and serves as a voice for residents on related issues.

We hope that these and other steps will help foster a cadre of clinicians who champion quality and safety and give us the critical mass needed to drastically reduce errors, improve patient outcomes and prevent wasted health care spending.

One of my colleagues, Nancy, recently shared a surprising experience that she had with her son—one of four children—as she was getting ready to send him off to college. The night before he left, this strapping, six-foot-tall man, who plays football and lacrosse, made an unusual request: He asked his mom to tuck him in to bed. When he returned home for a long weekend, he again wanted to be tucked in.

Nancy and I talked about what it felt like to be tucked in: You felt safe and protected, warm and loved. It is a great feeling and we all need it. 

“Tucking others in” is a beautiful image of the care that is often lacking in health care. I remember a discussion with a family about limiting care of one of their loved ones. The patient, Paul, was 50 years old with metastatic cancer. He was now septic, on a ventilator and unable to communicate. We were meeting with his wife, brother and sister in-law. It was difficult for them to accept that he was dying.

We sat down in a messy conference room crowded with notebooks, the walls covered in reminders to staff. I opened the conversation by asking if they could tell me what Paul was like. I hadn't had the chance to get to know him. All of their eyes lit up, and they told me how he loved to drive around the country to see Bruce Springsteen concerts. He was a ‘60s hippie who never changed. They described his hearty laugh and how he loved to play jokes on people.

I thanked them, and they thanked me for trying to understand Paul as a person. I then asked what they understood about Paul’s prognosis. We talked about what Paul would want done in this situation. The wife and brother looked at each other. Their answer: Paul would want to withdraw life support with Bruce Springsteen playing loudly and the rest of us tailgating in his hospital room.

And that is what we did. The next day, we gathered in Paul’s room, with “Born in the USA” playing. His wife lied in bed next to him, as she had done for thirty years. His brother brought in sandwiches, chips, sodas and pickles that filled the room with a life-embracing garlic smell. The nurse tucked both Paul and his wife into bed, and he passed.

Several hours later, the family came to me and said how comforting it was to be able to talk about what Paul was like, to be able to have him pass on their terms, with music and food, and to be tucked in. The wife said that is what she will remember about being in the hospital.

It is not just patients and families who need to be tucked in. We all do. We need to feel appreciated and at times comforted. Many of us carry heavy burdens. Once, a physician with whom I work yelled at several nurses. When I asked him why he was acting that way and reminded him that his behavior was neither appropriate nor reflective of the kind of person he was, he broke down, saying his wife was leaving him and that he wasn't dealing with it well. We got coffee. He said I was the first person he told and thanked me for listening. I saw a senior nurse chastise and shame a junior nurse. I asked the senior nurse if things were OK, saying she seemed harsh. She told me how she had just put her mother in a nursing home, her husband had lost his job, and she had gained 20 pounds from the stress. I put my hand on hers, told her how much I appreciate working with her and what a great nurse she was, and suggested she talk to someone. She then apologized to the junior nurse.

“Tucking in” patients and others is not just a nicety. It helps us heal, it puts joy in our work and it improves productivity. The little time that it takes to appreciate others is paid back 10 times over in improved productivity.

Imagine the love we would bring to the world and the suffering we would reduce if we made a habit to tuck someone in every day, just as Nancy did to her son going to college.