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Voices for Safer Care

Insights from the Armstrong Institute

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”

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

Doctor Who?

One of the most exciting things about working in patient safety and health care quality is that it’s not solely about advancing science or applying performance improvement methods. It is also about the excitement of being part of a social movement that is changing the culture of medicine—putting patients at the center of everything, sharing errors in the hopes of preventing future ones, and confronting hierarchies that stifle communication and innovation.

Kate Granger, a physician in the United Kingdom who is living with terminal cancer, has tapped into that sort of enthusiasm in a big way. Last summer, reflecting on a recent hospital admission, Granger remarked in her insightful blog that some members of her care team never introduced themselves when approaching her. She wrote:

As a healthcare professional you know so much about your patient. You know their name, their personal details, their health conditions, who they live with and much more. What do we as patients know about our healthcare professionals? The answer is often absolutely nothing, sometimes it seems not even their names. The balance of power is very one-sided in favour of the healthcare professional.

She asked that health care professionals make a pledge to introduce themselves to every patient that they meet, and share the challenge with others across the National Health Service. Thus was born a movement that went viral, aided by the Twitter hashtag #hellomynameis. More than five months since her post, there is a steady stream of tweets every day. Some clinicians wear lanyards with the hashtag, a show of support and a reminder to introduce themselves. Last week, NHS Employers released a video celebrating the #hellomynameis campaign.

More than anything, introducing yourself to patients is an issue of providing compassionate care. But it is also a patient safety issue. We know that faulty communication so often lies at the root of medical errors. How many adverse events might be prevented if all clinicians introduced themselves, making them more inviting to questions and concerns?Read More »Doctor Who?

A cure for ‘initiative fatigue’?

Frontline caregivers across the United States—and in many other countries, no doubt—are bombarded by multiple quality improvement (QI) projects. A clinical unit might simultaneously be engaged in efforts to reduce readmissions, eliminate hospital-acquired infections and other complications, increase hand-hygiene compliance, improve performance on core measures, and enhance the patient experience. The demands brought by participating in all of these efforts risk overwhelming health care professionals, who are already stretched thin in an environment of reduced reimbursements and health care reform.

So what are the ingredients that help some quality improvement projects succeed in this atmosphere? How do we avoid “initiative fatigue”?

These were among the questions that sociologists from the University of Pennsylvania and Harvard University sought to answer as they interviewed 150 hospital workers across six states who were involved in two large-scale quality improvement projects. Targeting surgical site infections and ventilator-associated pneumonia, respectively, the projects were funded by the Agency for Healthcare Research and Quality and led by Johns Hopkins’ Armstrong Institute for Patient Safety and Quality, with the sociologists as key members of our project teams.

They summarized what they have learned in a March 7 Health Affairs blog post. I encourage you to read the piece. Here are a few of its key points:

  • Safety must be embedded into daily work. Participating in QI efforts should not be treated as “an additional administrative burden,” as the blog authors write. Certain steps, such as giving staff protected time to participate in these projects “shows a commitment of hospital administration to QI, as opposed to viewing it as another activity that staff must add to their already stressed days.”
  • Small wins go a long way. Frontline staff can usually identify simple, inexpensive changes that can reduce the hazards that they have identified. These quick, early wins can show frontline providers that their team is capable of improving safety, and help to generate momentum.
  • Do it with feeling. It’s not enough for a care team to simply use a tool, such as a checklist. Observing teams in their use of a pre-surgical timeout, the sociologists found that some care teams used it only “symbolically”—often without any eye contact between providers, while other care processes were going on. For others, it was a “genuine safety practice,” as clinicians used the tool to identify potential risks. They revised the tool continually to meet their needs.

Read More »A cure for ‘initiative fatigue’?

Re-engineering health care for safety and cost savings

Long-time intensive care nurse Rhonda Wyskiel (left) and engineer Alan Ravitz represent just a couple of the 18 professional disciplines involved with Project Emerge.

Despite spending $800 billion on technology last year, health care productivity is flat and preventable patient harm remains the third leading cause of death in the U.S.

One reason is that health care is grossly under-engineered: medical devices don't talk to each other, treatments are not specified and ensured, and outcomes are largely assumed rather than measured.

Other industries rely much less on heroism by individuals and more on designing safe systems and using technology to support work. Today a pilot’s cockpit is much simpler than 30 years ago; it is far more error-proof, and built-in defenses enhance safety. By comparison, hospital intensive care units, which contain anywhere from 50 to 100 pieces of separate electronic equipment, appear unchanged.

Changing this will require unprecedented collaboration between health care’s many stakeholders. That’s one reason why this fall the Armstrong Institute and the World Health Organization convened health care leaders, consumers, providers, regulators and private-industry partners to discuss such topics as how to design safer systems at the Forum on Emerging Topics in Patient Safety held in Baltimore.

One effort to design safer systems at Johns Hopkins is Project Emerge. Supported by a $9.4 million grant from the Gordon and Betty Moore Foundation, Emerge is tapping into the wisdom of a diverse team of engineers, nurses, doctors, bioethicists, and patients and family members — 18 disciplines in all from across Johns Hopkins University— to design safer care in ICUs.

Read More »Re-engineering health care for safety and cost savings

A blueprint for high reliability

Ensuring that patients who take beta blockers receive their heart medication before and after surgery is a best practice to prevent future problems. A workgroup at The Johns Hopkins Hospital is one of 40 teams across JHM focused on delivering such best practices.

Across health care, organizations constantly struggle with the challenge of achieving patient safety and quality successes on a large scale—across a hospital or network of hospitals. Too often, they are doomed at the start, because staff don’t even know what the goals are. In other cases, staff have limited capacity to carry out improvement work and few resources available to help them. Subpar performance is allowed to continue without any accountability, assuming that they know how well they are performing in the first place.

At Johns Hopkins Medicine, we are proud of an effort that has not only improved patient care, but has also provided a blueprint for how we can tackle any number of challenges in improving patient care—such as eliminating infections or enhancing the patient experience—across complex health care organizations.

Last week three hospitals within Johns Hopkins Medicine were recognized by the Joint Commission as “Top Performers” in patient safety and quality, for consistently following evidence-based practices at a very high level. Those hospitals—The Johns Hopkins Hospital in Baltimore, Sibley Memorial Hospital in Washington, D.C. and All Children’s Hospital in St. Petersburg, Fla.—benefitted from an organization-wide approach that enlisted local teams in problem solving, directed core resources to support those teams, and made units, departments and hospitals accountable for their performance.

Read More »A blueprint for high reliability