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Voices for Safer Care

Insights from the Armstrong Institute

Dreaming the dream

Susan BoyleThe video of Susan Boyle’s debut on Britain’s Got Talent is well worth watching. She walked on stage, wearing a frumpy dress, overweight and awkward. Members of the audience snickered and rolled their eyes as this 47-year-old told the judges that she wanted to be a singing star. I suspect she had her own doubts. Yet she had the courage to try. She believed in herself and stunned the audience with her voice.

Susan’s story is typical of so many personal journeys. We face skepticism from others, and we are filled with self-doubt. Sometimes we listen to those little voices whispering: You cannot do this. Yet when we overcome the doubts, we are often successful. If we give into those voices, we will surely fail.

This same self-doubt exists in patient safety. I know because I had plenty of uncertainty about my ability to reduce patient harm. More than a decade ago, we decided to reduce central line-associated bloodstream infections on one intensive care unit. We doubted it was possible and whether we could have a role in reducing harm. Most of the physicians thought it couldn’t be done. Sick people get infected, they said. These infections just happen. In our own way, we felt frumpy and awkward.

Initially, we did not debate whether we could stop these infections. We focused on consistently following those practices shown by evidence to reduce them. We had been complying with those practices just 30 percent of the time. Our clinicians agreed that we would follow a checklist to help ensure 100 percent compliance and then see what happened to our infections. As compliance rose, the rates went to nearly zero, and the doubts disappeared.

Read More »Dreaming the dream

Why can’t the ICU be more like a cockpit?

cockpitIn the world of patient safety, we’re constantly reinforcing the importance of teamwork and communication, both among clinicians and with patients. That’s because we know that patient harm so often occurs when vital information about a patient’s care is omitted, miscommunicated or ignored.

Yet for all we do to improve how humans work together, clinicians compete against an environment in which there is very little teamwork or communication among the technologies that they need to care for patients. And there’s little that clinicians or hospitals alone can do about it.

Take, for example, the plethora of alarms from cardiac monitors and other devices that compete for clinicians’ attention. Vendors act as if we are in an alarm race, with each making their devices’ beeps more annoying but no clear prioritizing of the most important alarms. A study on one 15-bed Hopkins Hospital unit a few years ago found that a critical alarm sounded every 92 seconds. As a result, nurses waste their precious time chasing an ever-growing number of false alarms—or becoming desensitized to false alarms and ignoring them. Across the country, this has had tragic consequences, as patients have died while their alarms went unheeded. (Read a 2011 Boston Globe series about this issue.)

In most other high-risk industries, such as aviation and nuclear power, technologies are integrated. They talk to each other, and they automatically adjust based on feedback. Indeed, because of systems integration, pilots fly a small amount of a flight, and even in some treacherous situations, they hand over the reins to the autopilot. Although Southwest Airlines or the U.S. Air Force can buy a working plane, you cannot buy a working hospital or ICU. You must put it together yourself.Read More »Why can’t the ICU be more like a cockpit?

To gauge hospital quality, patients deserve more outcome measures

Central LinePatients, providers and the public have much to celebrate. This week, the Centers for Medicare and Medicaid Services’ Hospital Compare website added central line-associated bloodstream infections in intensive care units to its list of publicly reported quality of care measures for individual hospitals.

Why is this so important? There is universal support for the idea that the U.S. health care system should pay for value rather than volume, for the results we achieve rather than efforts we make. Health care needs outcome measures for the thousands of procedures and diagnoses that patients encounter. Yet we have few such measures and instead must gauge quality by looking to other public data, such as process of care measures (whether patients received therapies shown to improve outcomes) and results of patient surveys rating their hospital experiences.

Unfortunately, we lack a national approach to producing the large number of valid, reliable outcome measures that patients deserve. This is no easy task. Developing these measures is challenging and requires investments that haven’t yet been made.

Read More »To gauge hospital quality, patients deserve more outcome measures

What I learned from listening to a patient

ListeningI was reminded again recently of how important it is to sometimes just sit back and listen to what our patients have to say. Every month, as part of our hospital-wide patient safety efforts, I meet with staff and interview patients, seeking to learn how we can improve the care we provide to them.

A young patient shared two stories with me, one telling me how we get it right and one reminding me how we sometimes get it wrong, even without realizing it. She was nervously awaiting a procedure in Interventional Radiology when a nurse sensed her anxiety and called in a child life specialist. The specialists came and significantly helped relieve the patient’s suffering. She listened to the patient, offered a comforting touch, and provided her age-appropriate reading material and Sudoku puzzles, a brilliant though infrequently used intervention. If anything could take your mind off of your illness, it is Sudoku.

What was amazing was that after all the patient had been through—weeks in the hospital, countless procedures, scores of clinicians—what she remembered was the nurse’s act of kindness by caring enough to call the specialist. The patient reminded me that though we can cure disease sometimes, we can relieve suffering always, often with nothing more than a kind word, a gentle touch or a warm smile.

As I listened, the patient, along with her mother, went on to tell me more. They told me how the patient has complex allergies and that her mom knew her disease better than any clinician. They had lived with the disease for a decade. Yet at times, neither the patient’s mother nor the patient felt they were being heard by the doctors. The mom expressed frustration that clinicians often dismissed her concerns and discredited her knowledge.

Read More »What I learned from listening to a patient

A safety checklist for patients

checklistFar too many patients are harmed rather than helped from their interactions with the health care system. While reducing this harm has proven to be devilishly difficult, we have found that checklists help. Checklists help to reduce ambiguity about what to do, to prioritize what is most important, and to clarify the behaviors that are most helpful.

The use of checklists helped to reduce central-line associated bloodstream infections at The Johns Hopkins Hospital, in hospitals throughout Michigan, and now across the United States. Clinicians have begun to develop, implement and evaluate checklists for a variety of other diagnoses and procedures.

Patients can also use checklists to defend themselves against the major causes of preventable harm. Here are a few you can use:

Health care-associated infections

  • Ask about your hospital’s rates of central-line associated bloodstream infections in the intensive care unit. The best hospitals use the definitions provided by the Centers for Disease Control and Prevention and have rates less than one infection per 1,000 catheter days. A rate above three should cause concern.
  • Whenever clinicians enter your room, ask if they have washed their hands. Request that visitors also wash their hands often. Washing can be with alcohol gel or soap and water.
  • If you have any type of catheter, ask every day if that catheter can be removed.

Identification errors

  • If you are admitted to the hospital, check your ID bracelet to make sure all information is correct. Staff should use this bracelet to confirm your name before any treatments or tests.
  • If you are making an outpatient visit, staff should ask you to confirm your name and another unique identifier, such as your date of birth, before treatments or tests.
  • Verify that blood and other specimens taken from your body are labeled in front of you.

Read More »A safety checklist for patients

Health care needs greater accountability, not excuses

Hand washing

I recently spoke to an executive in the energy industry who had a joint replacement at a hospital in New York. His wound developed an infection, which required four additional hospital admissions and several operations. He asked me about hand hygiene in hospitals. Proudly, I told him that, at Johns Hopkins Hospital, we are at 80 percent compliance with hand hygiene, up from 30 percent not that long ago. I focused on the improvement. He focused on the failures. "So," he said pointedly, "one in five times you do not comply with basic hand washing rules, potentially causing infections—or even death." He asked what we are doing about it.

I told him how we try to learn from the high performers and to improve the poor performers, how we train staff on the importance of hand hygiene, how we report compliance rates to unit teams, how we put pictures of patients with the words “please wash” outside their rooms.

The executive said, "All that is great, but where is the accountability?" In any other industry, there is accountability to ensure staff comply with safety standards, standards that are often much less consequential than hand washing. Other industries help staff improve compliance; they also hold local managers accountable for poor performance. To get results, you must both support staff and hold them responsible.

Read More »Health care needs greater accountability, not excuses

Tell your story: Excellence in patient- and family-centered care

microphoneLast year, Sarah Andryauskas, then a new nurse in our emergency department, was caring for a patient with diabetes who had trouble maintaining healthy blood glucose levels. His disease had contributed to several hospital visits over the preceding months and years.

As health care providers, it’s tempting to attribute such repeat visits to patient noncompliance. But Sarah took the time to ask: Was there a barrier that kept the man from taking control of his health? Indeed there was, as the patient explained that diabetes-related sight loss had made it impossible to read his glucometer—and thus to manage his blood sugar.

Sarah’s story of this revelation, and the extraordinary steps that she and a colleague took to find a glucometer that reads results out loud, is the first in a new podcast series that delves into what it truly means to practice “patient- and family-centered care.”


From time to time, I’ll use this blog to highlight inspiring new stories—from caregivers, patients, or both—that have been added to the series. Visit the website for the project, called The Heart of Caring, anytime to see the full list of podcasts.

Read More »Tell your story: Excellence in patient- and family-centered care