Would your hospital allow a news reporter to follow along as the leadership team conducted WalkRounds? What does your hospital do to provide support to clinicians involved in medical errors? Would you ever hesitate to recommend your physician or hospital to a friend or loved one?
These questions may not come up in day-to-day patient safety work, with its focus on numbers, data, protocols, and checklists. But they are among the thoughts provoked by the presentations at this year’s NPSF Lucian Leape Institute Forum & Keynote Dinner, held in Boston last week. Leadership, culture, patient experience, and workforce safety took center stage as the event’s presentations demonstrated the value of transparency in health care and the importance of leaders in influencing behavior within our health care organizations.
The Institute’s most recent report argues that greater transparency in health care – at all levels – can fuel better, safer care. With that report as the backdrop, Dr. Darrell “Skip” Campbell shared experiences from his work as a surgeon, researcher, and chief medical officer as well as from his current role as director of the Michigan Surgical Quality Collaborative.
Dr. Campbell pointed to research that showed that staff who had participated in Leadership WalkRounds were more likely than those who had never participated to say they would speak up when faced with a potential or actual medical error. During his time at University of Michigan Health System, Dr. Campbell was so confident in the promise of WalkRounds to drive improvement, he invited a news reporter to observe the ritual.
In his role as director of MSQC, Dr. Campbell works on a different level of transparency—between providers. MSQC is certified by the Agency for Healthcare Research and Quality as a patient safety organization and is made up of 73 member organizations across the state that agree to share data on surgical outcomes and not compete on safety.
MSQC works to identify top performers through the analysis of data; visits them, talk to them, and figures out what it is that they are doing to achieve the good results; and then distributes that information to the other members. One of their early successes has been a state-wide decrease in surgical site infections after colectomy.
Dr. Gary Kaplan, chairman and CEO of Virginia Mason Health System and chair of the NPSF Lucian Leape Institute noted in his opening remarks that there are challenges and opportunities around the issue of transparency, as well as significant barriers. The Institute’s current focus is on translating its recommendations into action.
In breakout sessions, forum attendees discussed these issues. Rick Boothman, JD, chief risk officer at University of Michigan Health System and a member of the NPSF Board of Directors summarized the key points of consensus from the groups:
The single biggest area of concern is leadership’s role and the widespread failure to set expectations to create and support a safety culture.
Education is valuable, but it needs to be done correctly and embedded in the organization’s behavior.
Transparency can be powerful tool, but it needs to be used responsibly, with data that make sense and are delivered in useful ways.
There is a lack of appreciation for engagement by boards of directors in the issue of patient safety; board education on the issue is needed.
Provider-to-provider sharing of data and information is difficult to achieve, but is essential for progress.
Everyone in the organization needs to support the core mission of patient and workforce centricity – whether they are a housekeeper or a lawyer.
Information without action is not productive. It is the responsibility of the person reporting substandard care to be accurate, fair, and thorough, and the responsibility of the receiver to listen and understand the problem with the goal of fixing it if possible.
Dr. Alan Woodward was instrumental in starting MACRMI in 2005, when he was president of the Massachusetts Medical Society. “We were beating our heads against the wall with tort reform,” he said. “But we wanted to do something about patient safety.” He met with Rick Boothman at the University of Michigan, and eventually formed an alliance of hospitals in Massachusetts. Dr. Kenneth Sands, chief quality officer of Beth Israel Deaconess, served as principal investigator of MACRMI’s study, funded by the Agency for Healthcare Research and Quality, to identify the major impediments to apology and disclosure and strategies to overcome them. This work led to the MACRMI roadmap, known as CARe—communication, apology, and resolution following medical injury.
Dr. Woodward described CARe as a proactive process to review the case, advocate for the patient’s medical needs—and if the injury was found to be avoidable, their financial needs—and to render appropriate apology, which he said, "is therapeutic for both clinicians and patients.”
Dr. Sands facilitated a panel discussion of a case that was handled through the CARe process. In the case presented, a communication breakdown led to a delayed cancer diagnosis. Speaking via a video, the patient explained that she found out she had cancer only after persisting in telling her doctor that something wasn’t right after her gallbladder surgery. “Patients shouldn’t have to figure this out for themselves,” she said.
In an important part of the process, the patient met with the vice chair of the department of surgery, who explained what happened and how, and what the organization was doing to prevent it from happening again.
Pat Folcarelli, RN, PhD, director of patient safety at BI Deaconess said that “physicians usually leave such a meeting feeling very positive. We prepare them beforehand, [telling them] that it is a critical meeting to communicate openly about what happened. Despite anxiety, most leave thinking they’ve been given a gift in terms of interaction with the patient and family that they hadn’t had before.”
Dr. Jonathan Perlin, the evening keynote speaker, began his talk, "To Care Is Human," by asking the question, “Would you ever hesitate to recommend your physician or hospital to a friend or loved one?” A former, long-time member of the NPSF Board of Directors, current chair of the American Hospital Association, and chief medical officer of Hospital Corporation of America, Dr. Perlin argued that patient safety and patient experience go hand-in-hand. He told four patient stories, each through the lens of the HCAHPS survey (Hospital Consumer Assessment of Healthcare Provider and Systems).
Would you ever hesitate
your physician or
hospital to a friend or loved one?
Two of the cases involved breaches of hand hygiene. In one case, the patient, a retired nurse, did not speak up to the anesthesiologist because she knew “for the next four hours, my life would be in his hands.” In another case, speaking up to a clinician about hand hygiene led to a rebuke about how “disruptive visitors can be asked to leave.”
Apart from noting that the most common mode of transmission of pathogens is via the hands, and that there are roughly 80,000 hospital acquired infections each year, Dr. Perlin also fixed on the patient’s perceptions: how would those patients respond to HCAHPS survey questions such as “Would you recommend this hospital?” and “How would you rate the nurses’ response to concerns or complaints?”
A noted expert in health information technology, Dr. Perlin suggested that better use of data could also help providers improve care and safety. “If each of us read two articles per night, we’d only be behind by 10,000 articles,” he said. “Care informs care.” More effective use of the digital records we are creating can be part of a learning health system.
Making it personal, Dr. Perlin concluded by saying that each patient he had discussed was a member of his own family. “Patient experience isn’t just about being nice,” he said. “Patient safety is inextricably linked to patient experience. It involves culture and leadership, with the patient at the center.”