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Reflections on Safety is a monthly column presenting the insights of Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement (IHI). Dr. Gandhi was president and CEO of the National Patient Safety Foundation prior to its merger with IHI in May 2017.


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Improving Health Literacy: One Key to Improving Health Care Safety

Posted By Administration, Friday, October 9, 2015

October is Health Literacy Month. There's no better time to start learning more about how we can become better health communicators. 

By Tejal K. Gandhi, MD, MPH, CPPS

  Tejal K. Gandhi    


If you’ve ever misheard a conversation or misread directions, you know the pitfalls of written and spoken language. Messages are not always clear, even to those who are normally considered proficient communicators.


Think, then, of the complexities involved in health literacy, which requires not only understanding words, but also following instructions, using numbers, and reasoning. By some estimates only 12% of English-speaking adults in the U.S. are proficient in health literacy. At the same time, those of us in the patient safety field strongly advocate for greater patient and family engagement. It follows then, that we must identify good, useful tools to help patients become engaged and to help health care professionals communicate more effectively.


The National Patient Safety Foundation program Ask Me 3 is a patient education program designed to improve communication between patients and health care providers. It encourages patients to become active members of their health care team by asking their clinicians three questions:

  1. What is my main problem?
  2. What do I need to do?
  3. Why is it important for me to do this?

The newest report from the Institute of Medicine takes the patient’s point of view into consideration, defining diagnostic error as the “failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” The report comes down firmly on the side of patients being a central part of the solution to improving diagnosis, so it makes sense to view things the way a patient would.


In its “toolkit” of resources, the IOM report includes a secondary list of questions that NPSF developed several years ago in collaboration with the Society to Improve Diagnosis in Medicine. These questions specifically focus on the diagnostic process:

  1. What could be causing my problem?
  2. What else could it be?
  3. When will I get my test results, and what should I do to follow up?

Question 2 — What else could it be? — is particularly important, because it can lead physicians to think twice, potentially avoiding “premature closure.” A 2011 review of research in ambulatory safety published by the American Medical Association defined premature closure as “the failure to continue considering reasonable alternatives after reaching an initial diagnosis.” Though the report found that most diagnostic errors occur through a combination of systems errors and cognitive errors, premature closure was the most common contributing cognitive problem.


October is Health Literacy Month, so there is no better time to start learning more about how we can become better health communicators. The Centers for Disease Control and Prevention offers robust resources to health professionals who want to learn more about health literacy. But there are also relatively simple tactics that clinicians can use to improve communication with patients right now:

  • Slow down your speech.
  • Limit, and repeat, information at every visit.
  • Avoid medical jargon (See Words to Watch).
  • Use illustrations to explain important concepts.
  • Use easy-to-read written materials.
  • Make visits interactive by encouraging questions.
  • Use “teach-back” to gauge comprehension.

What will you do this month to improve communication? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.


Tags:  diagnostic error  health communication  health literacy 

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Diagnostic Error in the Spotlight

Posted By Administration, Friday, September 11, 2015

As we anticipate the upcoming Institute of Medicine report on improving diagnosis, NPSF joins with other organizations to think about the next steps. 

By Tejal K. Gandhi, MD, MPH, CPPS

  Tejal K. Gandhi    


Later this month, I will be among the speakers at the Diagnostic Error in Medicine 8th International Conference, hosted by the Society to Improve Diagnosis in Medicine (SIDM). The theme of this year’s meeting — After the IOM Report: What's Next? — gets to the heart of what many of us have been anticipating: release of an Institute of Medicine report on improving diagnosis.


While we don’t yet know the report’s findings, early news reports indicate that it will build upon existing research and knowledge about diagnostic error:

  • There are multiple causes and reasons for missed, delayed or wrong diagnosis, from communication breakdowns and inadequate use of information technology to cognitive errors by physicians, such as confirmation bias. In fact, in a study published in 2006, my co-investigators and I found that most cases of diagnostic error involve both systems-related factors and cognitive errors.

  • More research is needed into how diagnostic errors occur and how we can help prevent them. A 2012 paper suggested interventions such as greater patient engagement, better use of information technology, and focused interventions to avoid specific, known pitfalls.

  • Missed, delayed, or wrong diagnoses are a neglected area of patient safety, and no one is really measuring the problem. The approaches we normally use to identify adverse events won’t work for diagnostic errors. Even the Global Trigger Tool, created by the Institute for Healthcare Improvement and widely thought to be the best tool available to identify adverse events in hospitalized patients, captures few cases of diagnostic error, because it is designed to assess treatment flaws.

While most patient safety efforts have been made in the inpatient setting to reduce treatment errors, far more care is delivered in outpatient settings, and studies of malpractice cases show that diagnostic error is the chief claim in ambulatory care. By some estimates, 1 in 20 adults in the US have been or will be affected by diagnostic error.


The good news is that the IOM report is sure to bring much needed attention to this area of vulnerability for patients. NPSF recently joined the Coalition to Improve Diagnosis, which is led by SIDM and comprises a number of organizations committed to bringing awareness, attention, and action to the problem of diagnostic error.


As we await the IOM report, I encourage you to read Myths and Facts About Diagnostic Error, which NPSF and SIDM prepared jointly for Patient Safety Awareness Week 2014.


Have you experienced missed, delayed, or wrong diagnosis, either as a clinician or a patient? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.

Tags:  diagnosis  diagnostic error  IOM 

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When We Share Data, Patients Win

Posted By Administration, Thursday, August 13, 2015
Updated: Thursday, August 13, 2015

Hospitals and clinicians should be thinking about what comparative analysis of data can do for patients and for improving the safety of care. 


By Tejal K. Gandhi, MD, MPH, CPPS

  Tejal K. Gandhi  


Fifteen years ago, an Institute of Medicine report estimated that 98,000 people die every year in the US as a result of medical error. Today, while there is greater awareness of safety science in medicine, studies continue to estimate that thousands of avoidable deaths and injuries occur annually in medical settings.

One outcrop of the attention to this problem has been greater scrutiny of health care organizations and providers. Consumers have grown accustomed to seeing hospitals and physician practices ranked by various state, federal, and private report cards. At considerable effort, these organizations wade in to what was once a void—information about the safety and quality of our nation’s health care.

Yet even with these resources, consumers are not fully informed—and health care is still not as safe as it could be.

Now, the nonprofit news outlet ProPublica has entered this arena, releasing results of a years-long investigation into surgical complications at both the hospital level and the surgeon level. That’s right: they look at, and report on, the outcomes of individual surgeons.

Many consumers probably don’t realize how difficult it is to capture, analyze, and compare this kind of medical information. For starters, the data ProPublica used are not readily available to health care institutions, and even if they were, hospitals would need to employ statisticians to translate the data into useful information. There are services that provide analysis of a hospital’s own outcomes data, but if a patient is discharged from Hospital X and readmitted two weeks later to Hospital Y across town, Hospital X has no way of knowing about it. But if Medicare is paying for that patient’s care, Medicare knows.


Some hospital CEOs who review the ProPublica database (called the Surgeon Scorecard) may be surprised to find a surgeon with a low complication rate (a good thing) working alongside another surgeon with a much higher complication rate (a not-so-good thing). The refreshing angle here is ProPublica’s stated goal that these data should be used as a means to drive improvement. Let’s get Dr. A to talk to Dr. B and explain exactly how those good outcomes happen. And let’s get the hospital where these doctors work to improve and standardize its processes, training, and oversight to drive down variation.

To be sure, there are limits to the value of the ProPublica analysis. Using Medicare claims data, the investigative team narrowed their review to a group of relatively low-risk, elective surgical procedures and searched for two kinds of complications: death, or a readmission to the hospital within 30 days of discharge with a “likely complication of surgery.” They did, however, enlist the help of biostatisticians and noted researchers to control for confounding circumstances and try to perform appropriate risk adjustment.

There are those who argue about the validity of ProPublica’s methodology. Others may seek to point fingers and assign blame for higher-than-average complication rates. But those responses are misguided. What we need now is for hospitals and surgeons to think about what this kind of comparative analysis can do for patients and for improving the safety of surgical care. And we need to expand this kind of data sharing beyond Medicare and beyond surgery.

Earlier this year, the National Patient Safety Foundation’s Lucian Leape Institute issued a report calling for greater transparency throughout our health care system, as a fundamental precondition to patient safety. Only by openly discussing errors and problems with care can we get better. Greater transparency has the potential to facilitate better partnership with patients and improve learning between providers, across health care organizations, and with the public.

But health care organizations cannot do this work on their own. This level of data, and a useful analysis of it, needs to be more readily available and more timely for organizations to be able to effectively use it for improvement. We need Medicare, private payers, and health care systems to help move the needle on greater transparency so that it doesn’t require an outside news organization to shine the light on these kinds of issues.

Would greater openness about outcomes harm the reputation or finances of lower-performing hospitals and physicians? Perhaps, but what better incentive is there to work on improving? Variation between providers or organizations is not about shaming or blaming; it is ultimately a way to drive improvement and create better systems of care. By learning from high performers, we create best practices. By creating best practices, we drive out the variation. By driving out variation, we improve care, make health care safer, and reduce the toll of medical errors on patients and families.


What do you think of ProPublica's Surgeon Scorecard? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


Note: Marshall Allen, one of the reporters who worked on the ProPublic project, moderated an interactive discussion of transparency around health care outcomes with the public at the NPSF Congress earlier this year. The Executive Summary of this session at Congress can be downloaded here.


Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.

Tags:  transparency 

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Transparency in Practice: Case Studies

Posted By Administration, Wednesday, July 15, 2015
Updated: Tuesday, July 14, 2015

By Tejal K. Gandhi, MD, MPH, CPPS


Tejal K. Gandhi

If you read this column on a regular basis, you may recall that earlier this year, the NPSF Lucian Leape Institute released a report called Shining a Light: Safer Health Care Through Transparency, outlining broad recommendations for greater openness in all domains of health care. The report includes case studies to demonstrate that this is not a theoretical proposition; some individuals and organizations are making significant progress in communicating openly with patients and in sharing outcomes data within their organizations and with their peers.


We took this discussion to the next level at the NPSF Patient Safety Congress in April, when some of those very innovators joined us to present their experiences at an all-day preconference program. If you were not able to be there in person, the next best thing would be to read the Executive Summary that we’ve just published and made available on the Congress web page.


One of the most compelling examples of the value of transparency can be found in the power of collaboratives. In the not-too-distant past, it would have been unthinkable for a hospital to share outcomes data or information about a medical error with another hospital across town. Now, peer organizations, such as those that make up the Indianapolis Coalition for Patient Safety, are doing just that. The leaders of the ICPS member organizations decide what issues the coalition will work on, then workgroups study the literature, develop best practices, and create implementation tools for the members to use in instituting changes in procedures.


The Michigan Surgical Quality Collaborative (MSQC) is an example of how, at the provider level, sharing information can drive improvement. One of the collaborative’s main functions is to serve as a registry for data that are risk adjusted to compare hospitals and surgeons as fairly as possible. Then, teams from the collaborative visit the high achievers to learn and share their best practices. Presenter Mike Englesbe, MD, pointed out that everyone has something they do better than someone else, and “If you ask, ‘Can you tell us why you’re so awesome?’ everyone wants to participate.”


This concept is key: transparency is necessary for learning and improving. Rick Boothman, JD, chief risk officer for the University of Michigan Health System, who led the preconference session, said that at his organization, it is acknowledged that “we should learn from our experiences and hard-wire improvement” into cases where there is an adverse event or unexpected outcome.

Transparency can help us learn, but it takes leadership and a strong commitment to a culture of safety to get to the level of transparency being practiced by our presenters. And, despite the case studies supporting transparency, we have a long way to go. In an informal poll conducted during the session, only 22% of those in attendance agreed with the statement: I’m satisfied with the degree of transparency at my medical institution.

If you are satisfied with the level of transparency in your organization, NPSF would love to hear from you. If not, I would encourage you to read the Executive Summary and the Institute's report to learn more about the individuals and organizations mentioned. And tell us what you think.

How satisfied are you with the level of transparency at your organization? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must be logged in to comment.

Tags:  leadership  transparency 

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A New Look at Root Cause Analysis

Posted By Administration, Tuesday, June 16, 2015
Updated: Tuesday, June 16, 2015

By Tejal K. Gandhi, MD, MPH, CPPS


Tejal K. Gandhi

In the almost two years that I’ve served as president of the National Patient Safety Foundation, one of the topics I’ve heard about a lot is the challenge of conducting an effective root cause analysis (RCA). Who decides when an RCA is needed? Who is on the investigatory team? How do we focus on systems and not appear to be on a hunt to assign blame?


With a grant from The Doctors Company Foundation, NPSF recently convened an expert panel to look at these and other challenges and to develop guidelines to help health care professionals and their organizations improve the way they conduct RCAs. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm is available as of today on the NPSF website, and I hope you’ll take the time to review this useful document.


This report provides a structure and brings together tools to help in the RCA process. In my estimation, the three chief recommendations to absorb are:


1. Use a risk-based case selection to prioritize RCAs. RCA is still most often conducted after harm has occurred. With a risk-based prioritization system, organizations can address hazards before they occur. Risk-based prioritization is consistent with the practices used in aviation and other high reliability organizations. A standardized method of assigning probability and severity also helps organizations determine where and when to utilize their (usually limited) resources.


2. Be sure to include strong actions. We named our report RCA2 (“RCA squared”), with the second A representing actions. When RCA is conducted after harm occurs, the chief question is often “how did this happen?” This new report emphasizes the need to take strong action to help ensure that it does not happen again. The document highlights examples of weak and strong actions and emphasizes that your RCA2 is not complete unless you have stronger actions.


3. Leadership involvement in oversight and review of effectiveness. Any RCA2 process can only be effective with support of the organization’s leaders, including board members. It is they who can commit the appropriate resources to establishing a robust system; approve or disapprove any actions recommended by the RCA2 team; and determine if the RCA2 findings and recommendations need to be shared widely within or outside of their organization.


If you’ve been involved with conducting an RCA for your organization, or even if you want to know more about why and when RCAs should be conducted, this report is worth a look. I hope you’ll take the time to review it and let us know what you think.


RCA2: Improving Root Cause Analyses and Actions to Prevent Harm will be discussed during an open webcast on July 15, 2015, from 1:00 to 2:00pm Eastern Time. Registration is free of charge. Learn more.


Comment on this post below (log-in required).


Tags:  RCA  risk  root cause analysis 

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