Insights from the Armstrong Institute
For years, physician assistant Stephanie Figueroa has worked with our Emergency Department and the sickle cell care team to improve the treatment of patients with… Read More »Patient Safety and Quality Champions Grow into Leaders
Imagine you were seeking major surgery, and the hospital's consent form contained this surprise statement, which you were asked to initial: "I understand that this… Read More »Can Hospitals Police Themselves to Avoid Too-Risky Surgeries?
Consider, for a moment, that you are a new physician. A patient, who is a lifelong smoker, comes to your clinic complaining of shortness of… Read More »Mining Patients’ Wisdom for Safer Care
Years ago, I felt firsthand what it was like to be the helpless family member of a hospitalized patient. My mother had undergone surgery in… Read More »Getting Patients’ Loved Ones off the Sidelines: The Family Involvement Menu
More than a decade ago, a team of Johns Hopkins safety and quality scholars began meeting in a small office building along the Baltimore waterfront… Read More »New Bloggers, New Name, Same Mission
As standardized exam scores increasingly define success for students, teachers and schools, parents worry about the dangers of “teaching to the test”—and of their children being judged by tests with low or unknown validity. We want our children to perform well on tests, of course, yet only if they measure something that students, patients and teachers believe really matter. We also want the education system to inspire students develop into well-rounded people, not just skilled exam-takers.
In health care there is a similar danger of focusing on improving our “test scores” at the expense of real improvement in patient safety—and in this case, the exams have serious flaws. The federal government uses a composite measure of patient safety to help determine whether hospitals are penalized under two programs. One of those programs, the Hospital-Acquired Conditions Program, in December reduced Medicare reimbursements by 1 percent for 721 hospitals for their rates of preventable harms, such as serious blood clots, pressure ulcers, and accidental punctures and lacerations.
Serves them right, you might think. These hospitals are unnecessarily harming patients. That might be true if the test of their patient safety performance was scientifically sound. However, these programs have a serious methodological flaw: Many of their component measures are not based on reviews of the clinical record, but are rather derived from billing information, which produces a high rate of false positives. Indeed, for some of these measures, more than half of the incidents identified as preventable harm turn out to be false, once we review the clinical documentation. There can be many reasons for this. For instance, a patient may have had a pressure ulcer before admission that was not documented. Or a clot in a small vein might be mistakenly coded as a more serious clot known as a deep vein thrombosis.Read More »Health Care Shouldn’t Judge Itself by Flawed Tests
Often, when giving talks to health care professionals about the urgent need to improve patient safety and quality, I ask them to do an exercise. At the beginning of the talk, they write down “I will…” on a piece of paper. As the talk comes to a close, the audience is urged to complete that sentence—saying what they will do to make the patient experience safer, better and more respectful. The goal is not just to have an interesting talk, but rather it is to change something that leads to improvement.
Hopefully, this leads some people to adopt new behaviors and change their approach to care. But it is really on them—they have to hold themselves accountable.
In the United Kingdom, there is a program that takes a similar concept, but on a nationwide scale. It is called Change Day, it began in 2013, when the National Health Service asked health care professionals across the nation to pledge one thing that they would do to improve care. It’s an opportunity for people to commit to improvement, as well as a chance for participants across the country to share ideas. In a twist, this year’s Change Day, on Wednesday, is asking people to share one action that they have already done to improve care. They can submit their actions to the Change Day website, and are then encouraged to use social media to share what they have done.Read More »Change Day: An Overseas Concept for Patient Safety
What is it worth to be treated in a hospital with a stellar patient safety record rather than one with lower performance? For a large… Read More »The Value of Safer Care
The safety concerns that keep clinicians awake at night often aren't issues that you could fit onto a safety and quality dashboard. They aren't the kinds of things that feed metrics on the CMS Hospital Compare website or any of the other sources of publicly reported quality measures. They are intensely local, and no less important for being so.
This reminder came to me last week during a quarterly meeting of Comprehensive Unit-based Safety Program (CUSP) teams from across Johns Hopkins. This meeting is a chance for these teams to share successes, learn from one another and discuss common challenges. For instance, one team was concerned that improper handling of insulin pens might lead patients to be injected with a pen that had already been used on another patient. These pens must be kept in a patient-specific drawer in a medication room between administrations. Yet frequent interruptions and the distance to the medication room make it hard for nurses to follow this consistently. They might be tempted to place an insulin pen in a coat pocket and move on to another patient's room, where they could mistake one patient's pen for another. So the unit has formed an interdisciplinary group that will be pilot testing a solution — a clear lockbox in each patient's room that holds only these pens — in four units across the hospital.
This was but one example of how local units were identifying hazards, owning problems and coming up with system fixes for them. Another unit presented its investigation into a malfunctioning device, the findings of which will go to the Food and Drug Administration.
Today, health care faces pressure from all fronts to prevent harm and demonstrate high-quality care. We track and publicly report health care-acquired conditions such as infections, patient safety indicators like accidental vein lacerations and adherence to evidence-based care processes known as core measures. We measure harm in patient experience by whether patients felt respected and had their needs met though the Hospital Consumer Assessment of Healthcare Providers and Systems survey.
Increasingly these measures are shared online, tied to reimbursement and hospital reputation. They can be tracked, and they can help our health care organizations to see how they are performing compared to their goals and to other hospitals. These metrics are important, of course. But they paint an incomplete picture of what constitutes preventable harm.
Patients suffer harm when they receive disrespectful care, or when we perform invasive treatments at the end of life that are not in line with their goals. They are harmed when we waste their money by increasing their out-of-pocket expenses on therapies they do not need, when a provider orders lab tests out of fear of being second-guessed by an attending physician and when we order an intravenous drug when a less expensive oral medication would do just as well.
No doubt, it is overwhelming to commit to zero harm, especially when we define it so broadly. There are just so many ways that we can fall short of patients’ expectations and needs. Certainly there aren't enough months in the year for each harm type to be a "flavor of the month," even if that were a wise approach to begin with.Read More »Small Wins Line the Path toward Zero Harm
Your body is covered from head to toe in protective equipment, and it’s 115 degrees Fahrenheit inside your outfit. Your hands sweat under two pairs of gloves. An ill-fitting hood creeps down your forehead and nearly covers your eyes, but you cannot touch your head to shift it back up. To top it off, the exterior of your protective garb is partially covered with bodily fluids from a patient with Ebola.
The time comes to leave the patient’s room without leaving a trace of the virus on you or carrying it outside the room. You are anxious and tired but careful to follow infection-control protocols as you remove a disposable face shield, hood, mask, booties and other garb. Yet as you do, a piece of hair falls down over your eyes. In a split second and without thinking, you brush it back, and an infected glove glances across a misty eye. The virus is in you.
In a health care world where infection control methods are part of daily practice, Ebola requires a new level of vigilance. Even scrupulous health care providers could get infected without the proper training and support on how to put on and take off personal protective equipment, or PPE.
The new Ebola protection guidelines for PPE use issued this month by the U.S. Centers for Disease Control and Prevention are a critical step in protecting patients, health care professionals and populations in the United States and abroad. Highlights of these new guidelines include leaving no skin exposed and requiring a trained observer to actively help the health care provider to follow the protocols for donning and removing their protective equipment. Because there is very little that one can do to prevent infection after exposure to this unforgiving virus, it is essential that clinicians know this guidance inside and out, become competent in putting on and removing PPE and have a “buddy” to coach them to ensure that they adhere to each and every step.
But like many clinical guidelines, following them is like following the directions for assembling an IKEA chair. They need to be translated into something that providers can easily absorb, that points out the most important steps and provides guidance for implementing them in real time, under real-world constraints. We need to create systems that help health care workers to follow these guidelines, and clinicians need to practice until they are competent. Health care workers also need to know how to respond in those instances when something doesn’t go according to plan.
With that in mind, the CDC asked the Johns Hopkins’ Armstrong Institute for Patient Safety and Quality to convene a team to produce a series of interactive, online training programs on following the new PPE guidelines. Released this afternoon, the videos provide guidance for putting on and removing PPE and allow users to select training specific to the type of respirator and body covering that they will be wearing. Another video module, which guides trained observers on how to be effective in their roles, will be available in days. The free course will also be available on iTunes U.Read More »New Ebola Training Modules Will Help Safeguard Patients, Providers, and the Public