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Voices for Safer Care

Insights from the Armstrong Institute

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

“Just like me”

Recently in one of The Johns Hopkins Hospital's intensive care units, a patient was dying from cancer and sepsis, and there was nothing that I, nurse Mandy Schwartz or anyone else could do to stop it. Yet as the patient’s family—two daughters and a husband—suffered at her bedside, Mandy saw their need for comfort, and she responded. Although she was busy with nursing tasks, she delved into the inner life of the patient and family. She helped the mother look as good as possible—hair combed, face washed, a clean gown and sheets. She made sure the patient was pain-free and not anxious. She hugged one daughter who was “a hugger” and avoided embracing the other daughter who wasn't. She sat with the family, listened and supported them in their anguish.

Schwartz gave comfort to the family because she cares and has true empathy.  There’s no way that we could train her to care more. Yet too often, efforts by hospitals to improve the patient and family experience approach it purely as a technical challenge. For instance, we provide scripts to health care professionals to help them navigate various situations, from what to say when walking into a patient’s room to service recovery when things haven’t gone as they wished.  We try to identify and broadly implement the practices that will best enhance patient experiences, such as rounding hourly in patient rooms to address pain management, bathroom visits and other needs.

These are well-intentioned and needed efforts to improve the patient experience. But they could very well backfire if we don’t simultaneously embrace the human element and tap into clinicians’ desire to be empathic healers and comforters. I fear that we send the wrong message, for instance, when we simply hand detailed scripts to staff in low-performing units or hospitals. Subtly, we’re labeling them as someone who does not care adequately for patients, and that they need to be taught how to do better. Here, we say, mouth these words and the patient and loved ones will believe that you care. Likewise, hourly rounding and other interventions will not be effective if we simply treat them as a box to be checked off.

Words are important, of course. And caregivers can certainly learn how to insert key words and phrases into their conversations with patients to show they care and open the door to more meaningful dialogue. However, health care is too complex and nuanced for a lengthy script to be useful.

Clinicians witness the extreme highs and lows of other people’s lives, yet like any job this becomes our everyday reality, with mundane documentation, meetings and bureaucracy. It’s easy to forget that “just like me” someone may be in the hospital for the first time, that their family members must take off work for an extended period of time to be with them, or that the outcome of their stay is a turning point in their family’s future.

When we lose sight of the connection with our common humanity, with our patients’ suffering, we can fail to connect with our patients’ needs for empathy as well as healing.  We can get so caught up in the tasks that we need to do that we don’t stop to care. While we think we are still delivering good care, patients perceive our frenzied state and decide it’s wiser not to raise valid concerns.

What can help us to reverse this?

There’s more than a single thing, but one powerful approach involves coaching caregivers on their interactions with patients and loved ones. On a surgical unit in The Johns Hopkins Hospital, scores on HCAHPS—the national post-discharge survey sent to patients after discharge—were far below national averages. In their written responses, some patients said that they felt unwelcome to raise concerns, or that staff made them feel like a burden.Read More »“Just like me”

Hospital-acquired infections: How do we reach zero?

This week, the U.S. Centers for Disease Control and Prevention issued two reports that are simultaneously scary and encouraging.

First, the scary news: A national survey conducted in 2011 found that one in every 25 U.S. hospital patients experienced a healthcare-associated infection. That’s 648,000 patients with a combined 722,000 infections. About 75,000 of those patients died during their hospitalizations, although it’s unknown how many of those deaths resulted from the infections, the CDC researchers reported in the New England Journal of Medicine.

On the bright side, those numbers are less than half the number of hospital-acquired infections that a national survey estimated in 2007. And a second report issued this week found significant decreases in several infection types that have seen the most focused prevention efforts on a national scale. Noteworthy was a 44 percent decrease in central line-associated bloodstream infections (CLABSI) between 2008 and 2012, as well as a 20 percent reduction in infections related to 10 surgical procedures over the same time period.

These infections were once thought to be inevitable, resulting from patients who were too old, too sick or just plain unlucky. We now know that we can put a significant dent in these events, and even achieve zero infections among the most vulnerable patients. At Johns Hopkins, we created a program that combated CLABSI in intensive care units through a multi-pronged approach—implementing a simple checklist of evidence-based measures while changing culture and caregivers' attitudes through an approach called the Comprehensive Unit-based Safety Program (CUSP). The success was replicated on a larger scale across 103 Michigan ICUs and then later across most U.S. states, with impressive results.

These and similar successes have changed caregivers’ beliefs about what is possible, and inspired more efforts to reach zero infections.

What will it take to attain this goal—or at least get much closer?

We need policymakers to continue providing support so that we can mature the science of improving patient safety. We need their help to create valid and widely accepted performance measures, as well as advance implementation science so that we can learn how best to translate medical evidence into everyday bedside practice.

Hospitals have a big role, of course. As organizations, they must focus on the safety and quality of care with the same rigor and accountability that they bring to their financial performance. Almost without fail, hospital CEOs can tell you if their organization is meeting its budget goals. There are financial specialists at various levels of the organization, and there are consequences for poor performance. When it comes to patient safety, however, those structures rarely exist, even when the desire to reduce harm is strong. Some hospital CEOs I've met didn't know the infection rates at their facilities. Sometimes those rates are known only by the infection prevention department.

What we need are chains of accountability that link everyone in a hospital—from the board to the frontline staff—so that everyone has a shared understanding of their organizational goals, knows their role in meeting them, and gets feedback (such as dashboards) on how they are performing. Those organizations also need the internal capacity—health care professionals with the appropriate training—to carry out their roles in this chain. It sounds simple, but clearly it’s not. Over the past year, Armstrong Institute researchers worked with the VHA hospital engagement network on a demonstration project that sought to create those accountability structures at 10 U.S. hospitals. The initial results are encouraging, with 92 percent of participants reporting that they felt their organization has made improvements in targeted areas, such as surgical site infections (SSIs). It’s breathtaking what we can accomplish when everyone is working toward the same goal.Read More »Hospital-acquired infections: How do we reach zero?

The Ripple Effect

The doughnut shop I pass on my drive to the hospital isn't the kind of place where you might expect to see outpourings of random kindness. It sits in the shadow of a raised highway, a few doors down from a bail bond business and a block away from a prison complex that resembles a medieval castle. One Sunday before Valentine’s Day, the line to get served there was long, checkered with homeless people—some of whom sleep under the highway to stay dry and protected from the wind—and more well-off people getting breakfast or bringing bagels or doughnuts to work or church.

A homeless couple stood ahead of me. Their clothes and hair were dirty, and the undersides of their fingernails were caked in dirt, as if they had just come in from gardening without gloves. They appeared very much in love—standing close, gently touching and smiling. She wanted a heart-shaped doughnut, and he wanted the same. They reached deep into every pocket counting their change, hoping to find enough.

They were a nickel short. Sheepishly, they turned to me and asked for help. I had a feeling of injustice: Here I was bringing doughnuts to doctors, nurses and staff who did not need them, yet this couple would not have breakfast without help. Not wanting to shame them, I softly told them that they could order whatever they wanted and that I would be happy to buy them breakfast.

When they ordered, the cashier looked at them judgmentally. Perhaps she had been stiffed before, or maybe she knew they did not have the money. The woman spoke up, stating that I had offered to pay. The cashier looked at me and I nodded.

That is when the cascade started. “What a great idea,” said a woman behind me, who was picking up doughnuts for Sunday school. She offered to buy breakfast for the homeless person next to her. The nurse behind her did the same, as did the police officer further back. The nurse and Sunday school teacher discussed how they were going to come back the following Sunday to do this again.

I was also moved by their generosity and handed the homeless couple more money to cover lunch and dinner and perhaps pay for a stay at a shelter. They wept, and I sat down at the table with them. They spoke excellent English, as if they had graduated college or higher. The man explained how they never intended to be that way. They hit some “rough patches” and made a couple bad decisions, he said. “We are something,” the woman told me. I told them that I believed them. My only request, I said, is that when they got back on their feet, they “pay it forward” to someone in need.

For weeks, I reflected on that day not quite understanding what exactly had happened. Then I read a New York Times article on the science of paying it forward. Cornell University sociologists Milena Tsvetkova and Michael Macy explained how we are much more likely to perform a kind act when we experience or witness one. Experiencing a small kindness is more potent than observing one, though in the case of the doughnut shop, observing proved a potent pill. They describe how chains like I observed are not rare at all. At a drive-through coffee shop in Manitoba, Canada, one customer paid for the person behind them, and the chain progressed to 226 people. At a Chick-Fil-A drive-through, there was a 67-customer cascade after one generous customer paid for the person next in line.Read More »The Ripple Effect