WANTED: Clinicians for long-term relationship to lead unit and department safety efforts. Must be passionate about improving patient outcomes and value, have skills needed to lead these efforts, and enjoy working as part of a team.
Dr. Martin Luther King, Jr., in pushing the civil rights agenda, spoke of the "fierce urgency of now." Recent news reports highlight the fierce urgency of now in health care. The U.S leads the developed world in preventable deaths, as preventable harm continues unabated, insurance premiums have increased 9 percent while GDP remains flat, and investments in health care are crowding out investments in other important areas such as K-12 education. The fierce urgency to improve health care value not only impacts patients and health care providers, but all of society.
There are two main reasons why progress in improving safety and quality has been slow and difficult. The first is the field has largely run away from science, seeking quick fixes rather than deep understanding, focusing on what we do rather than the results we produce. The second reason is that health care lacks the capacity (infrastructure with skilled people) to improve quality and value. Because we have treated patient safety and quality as a project rather than a way of life, we have failed to create the necessary infrastructure to support the needed quality efforts.
If we are to improve quality, we will need to create an infrastructure to support patient safety. It is not surprising that most of the published literature in quality and safety comes from units (such as intensive-care units) that have dedicated physician and nurse leaders; there is someone in place to closely manage the work. Research and experience shows that units with dedicated physician leaders have lower costs, higher quality and better patient satisfaction.
While we do not really know what this patient safety infrastructure should look like, we have experience and theory to guide us. I believe that every unit needs named physician and nurse leaders to oversee patient safety efforts. These clinicians should have skills in safety and improvement science, as well as dedicated time (likely 10 percent for physicians and 20 percent for nurses) to oversee unit-level quality and safety efforts. They should also be held accountable for patient outcomes on the unit.
These unit leaders should report to department physician and nurse quality leaders who will each have 60 percent of their time dedicated to quality and safety. These leaders should have even higher levels of training, likely a master’s in public health or other relevant training in patient safety. The department-level leaders need to be supported by a full-time data analyst/patient safety improvement coach, with master’s training. The physician departmental quality leaders should report to both the department chair and vice president for medical affairs; the departmental nursing quality leader will report to the director of nursing and hospital director of patient safety.
The hospital quality leaders should also have master’s-level training and will report to both their hospital or health system executives (and in the case of Johns Hopkins Medicine, to the Armstrong Institute for Patient Safety and Quality). Here at Hopkins, the Bloomberg School of Public Health is developing a certificate in quality, patient safety and outcomes research which will help train our future leaders in this area.
This is the type of infrastructure that would be needed to advance quality. This is the type of infrastructure that will be required if we have any chance of reducing our costs in response to the forthcoming reductions in payments from Medicare and Medicaid. This is the type of infrastructure that is needed to take quality to the next level.
No doubt the structure this takes would vary among the hospitals and other entities that are part of the Johns Hopkins Health System. Sibley Memorial Hospital will look different than Suburban Hospital; Howard County General Hospital will look different from Johns Hopkins Bayview. Yet they will all have an infrastructure with skilled people who are held accountable. Just as the organizations do for finance.
The cost to finance this at The Johns Hopkins Hospital is less than 1 percent of revenue. Given that complications double or triple the costs of care, that approximately 30 percent of hospital costs are deemed preventable, and that complications increase readmission risks, the investment would likely pay for itself many times over.
If we are to take quality to the next level, these efforts must be led by clinicians and guided by science. We must insure we have the infrastructure, skills and accountability mechanisms. We need all clinicians to answer the call to lead their practices, their units, their departments, and their hospitals on the journey toward eliminating preventable harm.
In the Department of Psychiatry, several nurses and MDs have worked together for decades to protect patients against harm from themselves, other patients, adverse events from medications. We are prepared to work with the Armstrong Institute to develop teaching modules for patient safety and share our successes with our sister hospitals.