Saturday, March 30, 2013
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.