When we board a plane we put our lives in the hands of others.
We fly based on the belief that airline employees are well-trained, conscientious, and careful. We understand that it’s not just the knowledge and skill of the pilot and co-pilot that matter. Our lives also depend on the work of flight attendants, ground crew, air-traffic controllers and a host of others. In particular, our lives depend on all of those people communicating well.
When patients enter our hospitals they put their lives in our hands.
They enter based on the belief that hospital employees are well-trained, conscientious and careful. They understand that it’s not just the knowledge and skill of the physicians and surgeons that matter. Their lives also depend on the work of nurses, pharmacists, technicians, and a host of others. In particular, their lives depend on all of those people communicating well.
That analogy was the basis of Cleveland Clinic’s Chief of Staff, Dr. Joseph Hahn’s introduction of Peter Pronovost, M.D., Medical Director, Center of Innovations in Quality Patient Care at Johns Hopkins Hospital, the key-note speaker at our 2008 National Patient Safety Week Forum.
Dr. Pronovost opened with the statement that quality initiatives often fail because we do not view (or fund) the delivery of healthcare as a science.
He shared the sobering observation that around the nation all of our investigation, tracking and trending is not making an appreciable, measurable, difference in patient safety. Despite thorough investigation and root cause analysis, Sentinel Events continue to happen.
So what steps can we take to treat the delivery of healthcare as a quantifiable science?
A few of Dr. Pronovost’s recommendations:
- Take a lesson from industry: identify and learn from defects.
- Translate evidence to practice.
- Ask the front-line staff: Based on the action we’ve taken, do you think the risk of this happening again has been reduced? Why, or why not?
- Base change initiatives on credible, scientifically sound data, while not ignoring local wisdom. (A difficult balance.)
- Connect technical resources with culture change to continuously move toward improved patient safety.
- Develop central data management, but local ownership. (In other words, don’t assign your front-line staff data collection duties, but allow them ownership of the results.)
- Develop bi-directional communication between front-line staff and leadership.
He reminded us that without valid measurement tools we believe that we are safer than we are, and advised that we regularly ask, "How is the next patient going to be harmed?"
Could these ideas from Johns Hopkins work in your hospital?
- New physicians are assigned to round with a nurse for two hours, with the expectation that they will report back on issues they observe regarding safety and communication.
- At the beginning of a new OR case everyone in the room introduces themselves by first name and role. It was noted that initially some physicians needed reassurance that being called by their first names does not diminish their authority. All team members are encouraged to value open communication and work to overcome barriers to that goal.
Evidence shows that one of the strongest predictors for clinical excellence is whether caregivers feel comfortable speaking up if they perceive a problem with patient care.
Toward the end of his presentation Dr. Pronovost reminded us that healthcare organizations must not compete on issues of safety. Healthcare organizations must partner and collaborate with one another to develop better tools for safe patient care.
Additional patient safety information is available from the Johns Hopkins Bloomburg School of Health: http://www.jhsph.edu/ctlt/training/patient_safety.html
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