Patient Safety at 15: How Much Have We Grown?

Fifteen-year anniversaries often come and go without fuss, overlooked in favor of those we can mark in full decades. Yet recently, at Johns Hopkins and nationally, we've crossed that mark for a couple of events in patient safety that merit both celebration and reflection.

In January 2001, a series of lapses at Johns Hopkins led to the preventable death of Josie King, a toddler recovering from second-degree burns before her condition deteriorated and she developed sepsis. That tragedy, and the June 2001 death of a healthy 24-year-old clinical trial participant, Ellen Roche, brought our organization to a crossroads. Were we going to circle the wagons or take an honest look at ourselves so that we could do better?

The most recent issue of our flagship newsletter, Dome, chronicles the transformation that has taken place as we challenged ourselves to improve. It highlights past and ongoing efforts to change culture, groundbreaking work that slashed central line-associated bloodstream infections at Johns Hopkins and around the world, and programs and innovations that engage all heath care staff members — and patients — to eliminate harm. Though we remain humbled about the task at hand and the work to be done, we have learned a lot.

The timing of our journey loosely mirrors that of the nation at large. In December, the National Academy of Medicine's annual Rosenthal Forum convened a broad panel of experts to mark roughly a decade and a half since two landmark Institute of Medicine reports, "To Err Is Human" and "Crossing the Quality Chasm," issued 1999 and 2001, respectively. These events are commonly regarded as the birth of the patient safety movement in the U.S and across the globe.

Stepping back to reflect on this time period, it's natural to pause for a proud papa (or mama) moment. Despite these signs of maturation, this 15-year-old movement still has some growing up to do. Entrenched hierarchies that prevent clinicians from raising patient care concerns and keep patients from partnering in their care have been battered, but they have not yet been toppled. Organizations profess patient safety as a top priority, but they are still figuring out how to manage it with the same rigor, discipline and accountability that they do their budgets. There are encouraging success stories everywhere, yet they often do not get traction beyond the local setting or target more than one harm.

What will it take for this movement to mature, for us to see the widespread harm reductions that we all hope to achieve? Here are several key growth areas — by no stretch the only ones:

• Develop sound metrics. The plethora of ratings issued by government agencies, insurers, private companies and even journalism organizations too often confuses and overwhelms. We need better systems to create and vet new measures to ensure they are scientifically sound and truly meaningful to all users — clinicians, hospitals, patients and payers.
• Manage data better. Finance departments can track the performance of virtually any aspect of hospital operations, from a transplant surgery program to gift shop revenues. Yet at too many hospitals, data on patient safety performance are squirreled away in different formats by various departments, with no central coordination. For patient safety to be treated with the priority it deserves, data management systems must be as robust and coordinated as those used by finance.
• Enhance transparency. Patients have preciously limited valid data about the quality of care provided by their physician or hospital or the costs they may incur. For example, patients have a difficult time finding out how many times a surgeon or hospital has performed a procedure, although volumes are often related to outcomes. To be helpful, the data must be valid and transparent.
• Build accountability systems. It's one thing for hospital leaders to declare patient safety as their chief priority, but it's another entirely to make goals explicit and hold themselves and others responsible for them. All members of health care organizations — from the bedside to the executive suite — should not only know their organization's patient safety goals, but also understand how their work contributes to meeting them, and they must have the tools, training and time to fulfill those goals. It sounds simple, but it's surprising how rare that is.
• Motivate change. Pay for performance clearly is not resonating with physicians and is contributing to sky-high burnout rates. Rather than relying on such extrinsic motivation to coerce improvement, we must find ways to tap clinicians' intrinsic motivation to deliver safe care.
• Advance the science of safety. Knowledge of how to prevent harm continues to advance, yet this research still receives a sliver of all biomedical funding. As a nation, we must recognize the importance of treating the delivery of care as a field of scientific inquiry and discovery that is as important as finding a new treatment, and fund it accordingly.
• Re-engineer care. Health care is a severely underengineered system, in which clinicians must often take heroic actions to prevent harm. Our current technologies have to improve upon their clunky and clumsy technology and their lack of interoperability. Care delivery systems should work with clinicians, not against them.
• Target all harms. We have to move from projects focusing on one type of harm to efforts seeking to prevent all harms. A patient who develops ventilator-associated pneumonia doesn't care if he or she avoids 20 other harms.
• Pursue high reliability. Organizations in some high-risk fields, such as nuclear power, perform well day after day despite the constant threat of catastrophic failures. Health care organizations should adapt the lessons and behaviors from these fields. Among other things, this means being preoccupied with identifying what might go wrong, taking proactive steps to prevent those events, and being able to minimize and bounce back from them when they do occur.

As these high-reliability fields demonstrate, we should never expect a point at which we can say, "Our work is done." It has been, and will be, a constant struggle to improve. Yet hopefully, another five, 10 or 15 more years down the road, we'll be able to look back and see that we're grown up and finally moving the needle on patient safety on a broad level.