New Bloggers, New Name, Same Mission
More than a decade ago, a team of Johns Hopkins safety and quality scholars began meeting in a small office building along the Baltimore waterfront… Read More »New Bloggers, New Name, Same Mission
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
Health Care Shouldn’t Judge Itself by Flawed Tests
As standardized exam scores increasingly define success for students, teachers and schools, parents worry about the dangers of “teaching to the test”—and of their children being judged by tests with low or unknown validity. We want our children to perform well on tests, of course, yet only if they measure something that students, patients and teachers believe really matter. We also want the education system to inspire students develop into well-rounded people, not just skilled exam-takers.
In health care there is a similar danger of focusing on improving our “test scores” at the expense of real improvement in patient safety—and in this case, the exams have serious flaws. The federal government uses a composite measure of patient safety to help determine whether hospitals are penalized under two programs. One of those programs, the Hospital-Acquired Conditions Program, in December reduced Medicare reimbursements by 1 percent for 721 hospitals for their rates of preventable harms, such as serious blood clots, pressure ulcers, and accidental punctures and lacerations.
Serves them right, you might think. These hospitals are unnecessarily harming patients. That might be true if the test of their patient safety performance was scientifically sound. However, these programs have a serious methodological flaw: Many of their component measures are not based on reviews of the clinical record, but are rather derived from billing information, which produces a high rate of false positives. Indeed, for some of these measures, more than half of the incidents identified as preventable harm turn out to be false, once we review the clinical documentation. There can be many reasons for this. For instance, a patient may have had a pressure ulcer before admission that was not documented. Or a clot in a small vein might be mistakenly coded as a more serious clot known as a deep vein thrombosis.Read More »Health Care Shouldn’t Judge Itself by Flawed Tests
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
The Value of Safer Care
What is it worth to be treated in a hospital with a stellar patient safety record rather than one with lower performance? For a large… Read More »The Value of Safer Care
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
New Ebola Training Modules Will Help Safeguard Patients, Providers, and the Public
Your body is covered from head to toe in protective equipment, and it’s 115 degrees Fahrenheit inside your outfit. Your hands sweat under two pairs of gloves. An ill-fitting hood creeps down your forehead and nearly covers your eyes, but you cannot touch your head to shift it back up. To top it off, the exterior of your protective garb is partially covered with bodily fluids from a patient with Ebola.
The time comes to leave the patient’s room without leaving a trace of the virus on you or carrying it outside the room. You are anxious and tired but careful to follow infection-control protocols as you remove a disposable face shield, hood, mask, booties and other garb. Yet as you do, a piece of hair falls down over your eyes. In a split second and without thinking, you brush it back, and an infected glove glances across a misty eye. The virus is in you.
In a health care world where infection control methods are part of daily practice, Ebola requires a new level of vigilance. Even scrupulous health care providers could get infected without the proper training and support on how to put on and take off personal protective equipment, or PPE.
The new Ebola protection guidelines for PPE use issued this month by the U.S. Centers for Disease Control and Prevention are a critical step in protecting patients, health care professionals and populations in the United States and abroad. Highlights of these new guidelines include leaving no skin exposed and requiring a trained observer to actively help the health care provider to follow the protocols for donning and removing their protective equipment. Because there is very little that one can do to prevent infection after exposure to this unforgiving virus, it is essential that clinicians know this guidance inside and out, become competent in putting on and removing PPE and have a “buddy” to coach them to ensure that they adhere to each and every step.
But like many clinical guidelines, following them is like following the directions for assembling an IKEA chair. They need to be translated into something that providers can easily absorb, that points out the most important steps and provides guidance for implementing them in real time, under real-world constraints. We need to create systems that help health care workers to follow these guidelines, and clinicians need to practice until they are competent. Health care workers also need to know how to respond in those instances when something doesn’t go according to plan.
With that in mind, the CDC asked the Johns Hopkins’ Armstrong Institute for Patient Safety and Quality to convene a team to produce a series of interactive, online training programs on following the new PPE guidelines. Released this afternoon, the videos provide guidance for putting on and removing PPE and allow users to select training specific to the type of respirator and body covering that they will be wearing. Another video module, which guides trained observers on how to be effective in their roles, will be available in days. The free course will also be available on iTunes U.Read More »New Ebola Training Modules Will Help Safeguard Patients, Providers, and the Public
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
Changing The Conversation About Patient-Centered Care
Earlier this year, our hospital staff was weighing a new 24/7 family presence policy to allow immediate family members to stay with patients 24 hours a day. We knew this was a step in the direction of delivering patient- and family-centered care.
We presented the proposal at a meeting of our Patient and Family Advisory Council. One of the members of the council told a story that drove home the importance of this decision. When her son was battling a fatal illness in the hospital, she had to leave him when visiting hours ended. She couldn’t stand the thought of being far away, she told the group, so instead of going home she slept in her car in the hospital’s parking garage.
It’s hard to gauge exactly how her story ultimately affected The Johns Hopkins Hospital’s new 24/7 family presence policy. But one thing is clear: Involving patients and family members in decision-making fundamentally changes the conversation for the better, whether the issue involves an individual treatment decision or a hospital-wide policy. Charlene Rothkopf, a former patient who sits on two of our health system’s safety and quality boards, puts it so eloquently. “Many times our health care professionals get so caught up in the day-to-day press of business, that they may lose sight of the real meaning of what they’re there for,” she says. “Patients help bring that to light.” Patients appreciate the importance of simple things, such as discussing their concerns about an upcoming surgery or providing a compassionate touch, she says.
Sadly, the status quo in health care does not always engage patients and their loved ones, and we are all less healthy for it. We don’t always ask patients what their goals are for their care. We sometimes forget to introduce ourselves by name when we walk into a room. We deliver aggressive and expensive treatments to prolong life, without always having conversations with patients to determine whether they want these well-intentioned steps. We confuse patients with a stream of physicians and nurses that leaves them wondering who, if anyone, is overseeing and coordinating their overall care. We send patients out of the hospital without a clear understanding of how to provide self-care or without hard-wiring the connection to their outpatient physicians.Read More »Changing The Conversation About Patient-Centered Care
“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”