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Voices for Safer Care

Insights from the Armstrong Institute

Preventing Patient Harm

Ruling out the wrong diagnosis

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.

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Katie Couric, others keeping patient safety in the national spotlight

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.

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Connecting medical devices and their makers

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.

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Leadership qualities for a patient-safety turnaround

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.Read More »Leadership qualities for a patient-safety turnaround

Is this health care’s “man on the moon” moment?

For the past four years, Johns Hopkins patient safety researchers and our partners across the country have been working on an ambitious effort to reduce central line-associated bloodstream infections. The project spanned 44 states and included 1,100 intensive care units. On Monday, the Agency for Healthcare Research and Quality, who funded this project, released the preliminary results of this project. They report that our collective efforts have reduced infections by 40 percent, prevented 2,000 infections, saved 500 lives, and avoided $34 million in health care costs. Stunning!

Below are my prepared comments from a press conference hosted yesterday by AHRQ to share this news:

On a snowy night in February 2001, Josie King, an adorable 18-month-old girl who looked hauntingly like my daughter, was taken off of life support and died in her mother’s arms at Johns Hopkins. Josie died from a cascade of errors that started with a central line-associated bloodstream infection, a type of infection that kills nearly as many people as breast cancer or prostate cancer.

Shortly after her death, her mother, Sorrel, asked if Josie would be less likely to die now. She wanted to know whether care was safer. We would not give her an answer; she deserves one. At the time, our rates of infections, like most of the country’s, were sky high. I was one of the doctors putting in these catheters and harming patients. No clinician wants to harm patients, but we were.Read More »Is this health care’s “man on the moon” moment?

What health care can learn from corn milling

Some of the best ideas for improving health care come from outside our field. For example, we’ve adapted cockpit-style checklists from aviation to improve teamwork and communication on our clinical teams. We’ve turned to performance improvement methods from manufacturing to reduce waste and defects in care delivery.

A recent experience reminded of the value of seeking ideas and inspiration from elsewhere. As I wrote in an earlier post, I was among 15 executives from various fields who toured Cargill through a fellowship run by the Malcolm Baldrige National Quality Award Program. On a visit to Cargill Corn Milling, among the largest of the gigantic company’s 75 business units, I heard a story with unexpected parallels to health care. Cargill officials told us that their nine plants used to compete against each other. Often, two or more of their plants would submit bids to the same customer, usually with different prices. This self-competition was inefficient, didn’t meet customer needs, and cost them market share and revenue. Something needed to be done.

The Cargill leaders recognized that they needed to organize themselves around what they provide to customers (i.e. their product lines) rather than their geographically based plants. And that’s what they did. The three main product lines were human food products (largely sugar), animal feed, and fermentation such as ethanol. Rather than having each plant compete against each other, they worked together to meet customer needs.

To support this new structure, they set cascading goals in which everyone—from the employee to the plant to the product line—knew what they had to accomplish to meet corporate goals. They changed the incentive structure so that plant managers had greater motivation to ensure the company’s success, customer satisfaction, product line success and their plant’s efficiency. With this reorganization, they weren’t pitted against others at their own company.

As I listened to the presentation, my pulse quickened. I leaned forward anxiously feeling as if I took a double espresso to pull an all-night study session. The parallels between corn milling and health care were haunting.

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Company churns out burritos, French toast — and inspiration for health care

This year I am participating in an executive fellowship that is designed to expose leaders in various industries to the Baldrige Framework, a model for organizational excellence. As part of the program, the fellows visit companies that received the coveted Malcolm Baldrige National Quality Award, administered by the U.S. Department of Commerce. Recently, we toured Cargill, a large, Minnesota-based company that has about 75 business units, and spent time with two of them: Cargill Kitchen Solutions, which largely makes egg products for McDonald’s, schools and many other customers; and Cargill Corn Milling, a maker of corn syrup, animal food and ethanol.

We not only talked to leaders and reviewed their strategic plans, but visited the plant. We spoke to employees on the floor, as food was prepared on a massive scale: eggs being cooked by the thousands, breakfast burritos being assembled and placed on conveyor belts, French toast cooked, stacked and placed into boxes.

As we talked to leaders, toured the plant and reviewed their strategic plans, I was struck by three things.

First, everything and everybody was focused on the customer. The customer was at the center of every discussion, every decision and every strategy. From the CEO to the managers to people on the shop floor, they talked about meeting customers’ needs. Usually it was the first thing out of their mouths, and they used the impact on customers as a scale for weighing every decision. Indeed, many staff, from senior leaders to line operators making an hourly wage, said, We know who pays our paycheck; it’s the customer. If we want a paycheck, we better meet their needs.Read More »Company churns out burritos, French toast — and inspiration for health care

See one, do one, harm one?

Pronovost with groupI recently cared for Ms. K, an elderly black woman who had been sitting in the intensive care unit for more than a month. She was, frail, weak and intermittently delirious, with a hopeful smile. She had a big problem: She had undergone an esophagectomy at an outside hospital and suffered a horrible complication, leading her to be transferred to The Johns Hopkins Hospital. Ms. K had a large hole in her posterior trachea, far too large to directly fix, extending from her vocal cords to where her trachea splits into right and left bronchus. She had a trachea tube so she can breathe, and her esophagus was tied off high in her throat so oral secretions containing bacteria did not fall through the hole and infect her heart and lungs. It is unclear if she will survive, and the costs of her medical care will be in the millions.

Ms K’s complication is tragic—and largely preventable. For the type of surgery she had, there is a strong volume-outcome relationship: Those hospitals that perform more than 12 cases a year have significantly lower mortality. This finding, based on significant research, is made transparent by the Leapfrog Group and several insurers, who use a performance measure that combines the number of cases performed with the mortality rate. Hopkins Hospital performs more than 100 of these procedures a year, and across town, the University of Maryland tallies about 60. The hospital where Ms. K had her surgery did one last year. One. While the exact relationship between volume and outcome is imprecise, it is no wonder she had a complication.

Ms. K is not alone. Of the 45 Maryland hospitals that perform this surgery, 56 percent had fewer than 12 cases last year and 38 percent had fewer than six.

One day, after the ICU team—nurses, medical students, residents, critical care fellows and the attending—made rounds on Ms. K, we stepped outside of her room. We talked about what we could do to help get her well and to a lower level of care. But we also discussed the evidence for the volume-outcome relationship, highlighting that the hospital that performed Ms. K’s operation performed one in the previous year. Upon hearing this, the medical students cringed, quizzically looking at each other as if observing a violent act. The residents and fellows, the more experienced clinicians, stood expressionless; they commonly see this type of tragedy.Read More »See one, do one, harm one?