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Voices for Safer Care

Insights from the Armstrong Institute

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Organizational and Cultural Change

To Make Hospital Quality a Priority, Take a Page from Finance

When you are a patient at a hospital, you want to know that the executives who run that facility put the safety and quality of care above all other concerns. Encouragingly, more of them are saying that safety is indeed their number-one priority—a fitting answer given that preventable patient harm may claim more than 400,000 lives a year in the United States.

Yet when you look at the way that most hospitals and corporate health systems are organized, weak infrastructure exists to support that priority. True, some hospital boards of trustees have made safety and quality their first order of business. At meetings, they might hear directly from a patient who suffered a medical error, sit through a case study of a unit that reduced complications, or get an overview of various efforts to boost the patient experience and improve outcomes.

Stories can inspire culture change. Sustained improvements, however, require health care organizations to institute top-to-bottom accountability for performance.

What would it look like if safety and quality truly were addressed this way? It might be something like how most hospitals’ finances are managed, from the board level to the smallest unit.

With amazing precision, the finance department in Johns Hopkins Medicine can track virtually every dollar that comes in and goes out. These data can be segmented, sifted and filtered into well-established reports, showing us how our clinics, departments and entire hospitals are performing.

This financial data is used across our organization, all the way up to our board, which reviews consolidated financial statements. If a clinical service line falls short of its financial goals, there is a robust management structure in place—from the hospital to unit and clinic level--to ensure that we investigate and seek solutions.

Quality and safety lack a parallel infrastructure.  A health system typically has a chief quality officer, and so does a hospital. Yet the internal capacity within departments and clinics to contribute to improvement work is woefully deficient.Read More »To Make Hospital Quality a Priority, Take a Page from Finance

Change Day: An Overseas Concept for Patient Safety

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

Small Wins Line the Path toward Zero Harm

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

Grandmothers Advancing Patient Safety

Last Thursday, I made a presentation about patient safety to about 200 senior citizens at The Women’s Club of Chatham. My mother lives there, a picture-perfect town at the elbow of Cape Cod, with an old-fashioned main street that hosts a Fourth of July parade. For a while she had been asking me to give a talk to the group, and when she provided possible dates, I couldn't refuse.

When I told the audience that preventable patient harm is the third leading cause of death in the United States, the highly educated crowd seemed shocked, as if they just heard that their family was the focus of the latest town gossip.

But as usual, I probably learned more from them than they did from me. One by one, they told stories of harm: a granddaughter who died from a pain medication overdose; a spouse who died from a misdiagnosis; a women’s club member who suffered a blood clot that went to her lungs; a daughter who had multiple operations and still is very ill, a year after acquiring a drug-resistant infection.

They also told stories of communication errors and of doctors who don’t like to be questioned. They remembered experiences of leaving the hospital scared, confused and uncertain. To be fair, they also told stories of excellent care delivery.

Like many patients, they wanted to know how to select an excellent doctor and hospital. I emphasized the importance of doing their homework, such as finding out how many times the doctor or hospital has performed the procedure the patient is considering. I pointed them to several websites that post transparent, valid measures of patient safety and quality, such as the federal government’s Hospital Compare, Consumer Reports, the Leapfrog Group and some state health departments. We discussed how perhaps the biggest red flag is a doctor who does not welcome being questioned, is reluctant to seek a second opinion or doesn't encourage patients to participate in their care.

Beyond making their own health care choices, these women wanted to mobilize and raise the profile of the patient safety problem. One woman, a member of Grandmothers Against Gun Violence, asked if we could start “Grandmothers Against Preventable Harm.”

As we talked and their energy soared, mine did too, though with a bit of shame. These women want safe, patient-centered care and they are willing to advocate for it. Yet the patient safety movement has not mobilized this army, tapped their wisdom or channeled their energy. Today, fifteen years after the Institute of Medicine issued To Err is Human, this group was unaware of this report or the extent of the patient safety problem that it exposed. Perhaps they saw their own personal experiences with health care as aberrations or strokes of bad luck, rather than products of larger systemic problems. They all suffered alone.

Those of us leading patient safety have been too insular. We have talked to each other but not to the public. The victims of preventable patient harm often die silently, one at a time. With some exceptions, we don’t have the high-profile disasters that grab headlines and spur policymakers to take action, such as airplane crashes. And although this public health problem is equivalent to two Boeing 747 airliners crashing every day, research funding for improving the safety and quality of care delivery remains paltry.Read More »Grandmothers Advancing Patient Safety