Preventing Patient Harm

Part II: ISO clinician leaders in patient safety and quality

by Peter Pronovost
November 8, 2011June 10, 2015
9 Comments

I recently gave a talk to the American Medical Student Association. The energy in the room was palpable. The students were excited, passionate and hopeful. We spoke about the urgent need to reduce preventable harm and to enhance value, and we discussed that they will need to be the ones to lead these efforts.

Yet, in speaking with them, I had to confront the sad reality that most of them will graduate ill-prepared to lead the improvements of quality and safety our health care system needs. They no doubt will know chemistry, biology and physiology, but they may not know about human factors, implementation science or performance measurement—the language of quality improvement. They will know orthopedics and genetics but they won't know teamwork and systems engineering. They likely know about German scientist Rudolph Virchow, the father of cell theory, yet they do not know John Kotter, the father of change theory whose model for leading change is highly effective and widely used. Without a doubt, these students will need to lead change.

Translating safety in Spain

by Peter Pronovost
November 1, 2011June 10, 2015
1 Comment

Caregivers’ potential to reduce preventable harm and improve patient outcomes is profound. Consider the news that came out of Spain last week from a collaborative… Read More »Translating safety in Spain

ISO clinician leaders in patient safety and quality

by Peter Pronovost
October 27, 2011June 10, 2015
1 Comment

Simulation 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.

Live the values

by Peter Pronovost
October 24, 2011June 10, 2015
1 Comment

In creating the Armstrong Institute, we reviewed the Johns Hopkins Medicine values, trying to see if these were sufficient for our new endeavor and considering if we might need some new ones. Much to my surprise, no one among the 50 people in the room - myself included - could state the values off top of our head. So we looked them up:

Johns Hopkins Medicine Core Values

Excellence and Discovery
Leadership and Integrity
Diversity and Inclusion
Respect and Collegiality

We then realized that the words themselves were not important. What was important was what the words meant to each of us. We asked everyone to describe how they would behave if they lived these values. The answers, understandably, varied whether the responder was a researcher, a community physician, a nurse, a member of the patient safety staff, an administrator, a house keeper. Yet, if Hopkins is to advance patient safety, all of us must live these values in our own way.