Getting to Zero Harm

“There’s nothing in the high reliability literature that demonstrates how to move a hospital or health system from low to high reliability in the real world,” according to Mark R. Chassin, MD, FACP, president of The Joint Commission and the Joint Commission Center for Transforming Healthcare.

This is the second most challenging fact about patient safety in 2013.  We have no roadmaps, other than those we invent and test ourselves.  But the biggest obstacle is that it is hard for healthcare professionals to remember how lost we really are.

I have a love/hate relationship with the term "patient safety."  We tend to think of it as getting from good to great, like Volvo building better airbags to protect passengers in case of a high speed crash.  But there's a big difference.  Automotive safety protects passengers from threats "out there" - bad weather, another driver's error.  Patient safety is about protecting patients from the very healthcare we are providing.  A closer analogy would be Volvo announcing that it has reduced the number of times its cars spontaneously catch fire and explode, noting with pride that their vehicles now do so a bit less often then those of their competitors.  Imagine that.

That's how healthcare leaders have to see things if we are going to get to anywhere near zero harm from healthcare - making medication errors, hospital infections, "failure to rescue" events and wrong site surgeries problems of the past.   

In a recent monograph on high reliability in healthcare by the American College of Healthcare Executives (Healthcare Executive, Mar/April 2013), the author pointed out that we need to aim for the total elimination of "defects" (which in our world means harm to patients) if we are to really move the bar.  This admittedly flies in the face of "realistic" goal setting, given the difficulty of the work and our industry's track record to date.  

How do we engage our professional workforce - physicians and nurses, pharmacists and therapists, from housekeepers to hospital administrators - in a sustained, heartfelt rejection of the status quo and the heavy lift of transforming the way we do...everything?  As medical scientists, we like data.  But it is clear that data, business intelligence, report cards - call them what you will - are not nearly enough.  We need the human stories, and the closer to home the better.  We need the spirit of renewal and a vision of the possibilities before us.  And while on the topic of renewal and possibility, a happy Easter and Passover to all.    

Doctor please, not in front of the patient: interdisciplinary teamwork in healthcare

In today's New York Times, oncology nurse and author Theresa Brown highlights the sometimes fraught and always complicated relationship between physicians and nurses.  By drawing attention to the "hierarchical" interaction between these intertwined but very separate professions, she exposes some weighty issues.  These are matters with real consequences - both for those who provide, and those who consume contemporary, high-tech healthcare.  I want to talk about what she leaves out.

But first, here's what I think this accomplished nurse is saying that physicians have to hear. Medicine, if it was ever a solo act, isn't one anymore.  The hospital is a dangerous place.  We need to "expect" one another to make slips and errors - not so we can excuse ourselves, but so that we can see these events coming - before they harm a patient, and help one another by heading them off.  This is the essence of teamwork on behalf of patient safety.  

Changing the culture of an organization is hard work, but changing that of a whole profession is like steering an ocean liner.  Where do we come from, as physicians?  A longstanding "culture of accountability" means that doctors expect perfection of themselves and their colleagues.  That they, alone, must shoulder the burden of hard decisions.  That making a mistake is not merely a technical problem, but also a significant moral failure.  We are in many ways so different from our nursing colleagues that we have trouble understanding one another. Physicians focus on the mechanisms of disease and fixing what is broken.  Nurses respond to the patient who owns the disease, and that individual's overall needs.  Hospital leaders expect nurses, nowadays, to "stop the line" for safety.  They rightly complain that some of us physicians never go the memo.

On the other hand, many hospitals and Health Systems like ours have embraced team training.  We study and practice the language and techniques of highly effective teams...we call "huddles," we use checklists, and check backs and safe words that mean "I think we have to pause and figure this out because we're not on the same page." This is a framework adapted from aviation, nuclear power and the military, and applied in the Emergency Department, Labor Suite and Operating Room.  It is slow work, but there is reason to believe that it is stemming the tide of medical errors, a little at a time.

 

In her Times essay, “Healing the Hospital Hierarchy,” Brown describes an intimating encounter with a senior physician who “seethed” at her, eyeball to eyeball, when she proposed that a bone marrow procedure be delayed until her patient’s potentially serious heart problem could be evaluated.  She adds that “there is no established way for a nurse to resolve” such serious concerns. 

But here’s what Ms. Brown has left out.  First, escalation procedures in many hospitals absolutely encourage and protect the professional who speaks up.  In fact, they demand as much.  Second, intimidating behavior by any team member is verboten.  As a matter of fact, our Code of Conduct refers to it in great detail.  Physicians in our facility have been disciplined for it and privileges have been revoked. 

Finally, mutual understanding must be, well, mutual.  What I mean is that just as doctors need to understand the nurse’s role and hear her perspective, so nurses need to appreciate that most physicians, like most nurses, really ARE there for the patient and that they are committed to doing the right thing.  Therein lies the path to real teamwork – respect all around, and the patient at the center.