Skip to content

Voices for Safer Care

Insights from the Armstrong Institute

Voices for Safer Care Home Designing Safer Systems Rethinking how we think about preventing harm

Rethinking how we think about preventing harm

Captain Sullenberger shared lessons that health care can adapt from aviation at the inaugural Forum on Emerging Topics in Patient Safety.

Last week the Armstrong Institute, along with our partners at the World Health Organization, had the privilege of hosting more than 200 clinicians, patient advocates, health care leaders and policy makers for our inaugural Forum on Emerging Topics in Patient Safety in Baltimore.

The event featured presentations by international experts in a dozen different industries, including aviation safety expert Captain Chesley “Sully” Sullenberger, a former space shuttle commander and the chief medical officer of the Centers for Medicare & Medicaid Services. Other speakers shared their expertise in education, sociology, engineering, nuclear power and hospitality to see what untapped lessons such fields may hold for health care.

Their collective expertise was breathtaking. What was even more impressive was the obvious enthusiasm and spirit of collaboration embodied by a group joined by a common and noble purpose: to overcome the complex challenges that allow preventable patient harm to persist.

At Johns Hopkins, we’ve already seen what’s possible when health care adopts best practices from other industries. Our work to reduce central line-associated blood stream infections (CLABSI) presents a powerful example. By coupling an aviation-style checklist of best practices to prevent these infections with a culture change program that empowers front-line caregivers to take ownership for patient safety, the program, detailed recently on Health Affairs Blog, has reduced CLABSI in hospital intensive care units across the country by more than 40 percent. Similar results have been replicated in Spain, England, Peru and Pakistan.

That effort succeeded because we challenged and changed paradigms traditionally accepted by the health care community. We helped convince teams that patient harm is preventable, not inevitable. That health care is delivered by an expert team, not a team of experts. And, most importantly, that by working together, health care stakeholders can overcome barriers to improvement.

But if there are to be more national success stories in quality improvement, I believe the health care community will need to examine a few of its other beliefs.

Policy makers and purchasers should reflect on whether they can continue to:
•  Accept the measures we have as “good enough” without knowing how good they really are.
•  Believe that extrinsic drivers like pay-for-performance and regulation will motivate underperforming delivery systems without considering more powerful intrinsic motivators, such as establishing new norms and appealing to the professionalism of health care providers.
•  Reduce payment as the sole means to control costs instead of improving productivity.

The Hopkins team chose to focus on CLABSI partly because it was one of the few types of preventable patient harms measured with any degree of accuracy; in order to improve in other areas, valid performance measures are needed.

One idea that received strong support among forum participants is to create an entity like the Securities and Exchange Commission for health care that, similar to its financial counterpart, would standardize, validate and transparently report publicly-reported quality measures, such as how often patients receive discharge instructions before leaving the hospital. If policy makers and purchasers supported such a system, then all of us in health care could operate from a single “book of truth” that allows us to compare the quality of peer institutions.

Health care providers and their organizations should ask themselves why they:
•  Focus on one type of preventable harm when patients are at risk for over a dozen.
•  Rely on heroism — on a health care professional being in the right place at the right time — instead of fixing the broken systems they work in.
•  Believe that patients do not want to be involved in their care and that engaging with them is not a valuable use of time.

If health care professionals are going to move away from a system of competition to one of cooperation, we must be humble enough to acknowledge our shortcomings and support one another in a path towards improvement. Developing more formal peer-to-peer review programs, such as those used by the nuclear power industry, is one way that care providers and their organizations can embrace a learning health care system committed to continuous improvement.

Health care information technology companies should consider whether:
• The electronic medical record is the solution to improving quality and reducing cost.
• Their products are adequately designed to support the needs and workflow of front-line clinicians.
• The company, rather than the patient, should own the data.

In health care, there is no “Boeing” as there is in aviation to integrate all of the technology, devices and people. While health care providers should step up and lead the effort to design safer systems, health care IT companies can support such efforts by agreeing to share their data on an open-source platform that allows medical devices to communicate with one another. They can also remove barriers that impede clinicians from writing life-saving, cost-reducing, patient experience-enhancing applications.

The forum was a huge step towards breaking these paradigms and building momentum for novel cross-industry collaborations. Together, we will overcome the challenges that stand in the way of our common goal: a high-value health care system that protects rather than harms patients.


Peter Pronovost

One of the world’s leading authorities on patient safety, Peter Pronovost served a the director of the Armstrong Institute, as well as senior vice president for patient safety and quality, at Johns Hopkins Medicine from 2011 until January 2018.

Leave a Reply

Your email address will not be published. Required fields are marked *