Search our Site
Reflections on Safety
Blog Home All Blogs
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.


Search all posts for:   


Top tags: leadership  culture  diagnostic error  patient safety  patients  public health  transparency  AHRQ  ambulatory  Health IT  IOM  workforce safety  2016 NPSF Congress  2017 Patient Safety Congress  board certification  collaboration  communication  communication and resolution  CRP  diagnosis  education  emotional harm  families  flu  health communication  health literacy  IHI  measurement  medical education  medication 

Five Notable Developments in Patient Safety in 2015

Posted By Administration, Monday, December 28, 2015
Updated: Sunday, December 27, 2015

As the year comes to a close, it's time to reflect on some of 2015's most important
patient safety stories.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


It’s hard to believe that the final days of 2015 are upon us. It’s been an incredibly busy and productive year for NPSF and for the broad patient safety community. As the year winds down, here in no particular order is a look at some of the most notable developments in patient safety this year.

  1. Reductions in patient harm. Earlier this month, the Agency for Healthcare Research and Quality (AHRQ), reported a 17% reduction in patient harm in hospitals over three years. The report quantified the efforts of the Partnership for Patients and as well as Medicare payment incentives, estimating that 1.3 million fewer patient harms and 50,000 fewer deaths occurred between 2010 and 2013 than would have been expected had hospital-acquired conditions continued at the 2010 rate. While this is good news, the report also noted that incidents of harm are still too high, with 1 in 10 hospitalized patients experiencing a hospital-acquired condition.

  2. A new focus on diagnostic error. In September, the Institute of Medicine released a consensus report pointing out the depth of the problem presented by diagnostic errors. By some estimates, diagnostic error affects 1 in 20 patients, or approximately 12 million people in the U.S. each year. The IOM report’s recommendations include enhancing culture and teamwork, improving health care professional education and training in the diagnostic process, ensuring health IT supports the diagnostic process, and increasing research into identifying and learning from diagnostic errors. The report launched an important conversation about a serious patient safety issue with broad impact across the continuum of care.

  3. Public interest in measurement and transparency. Over the summer, ProPublica, a nonprofit news agency, issued the Surgeon Scorecard, which calculated complication rates for eight relatively low-risk surgeries at the hospital and surgeon level. While some may argue about the accuracy of the risk-adjusting and the use of claims data to assess outcomes, the ProPublica reporters did an admirable job of trying to be fair and measured in their approach. Love it or hate it, the Surgeon Scorecard makes my list simply for the discussion it sparked around the need for greater transparency about outcomes in health care. Was it perfect? No. Was it a step in the right direction? Absolutely.

  4. A growing appreciation that harm is not just physical. Over the past few years, NPSF has focused a lot on disrespect within the health care workforce and the emotional and psychological harm it breeds. But the truth is, even patients—those who are at their most vulnerable state—can be the victims of emotional and psychological harm during care. A recent viewpoint article calls emotional harm the “neglected preventable harm.” We need to continue discussing, learning about, and preventing emotional harm to patients and families.

  5. Recommendation for total systems safety. My final pick is one close to my heart: the new NPSF report, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. While we’ve seen pockets of improvement in patient safety, it’s time for a new approach. Our report provides eight recommendations for achieving total systems safety and a culture of safety. I urge you to download the report and share it with your leaders and teams. We’ll be focusing on many of these themes as we embark on 2016.

It is gratifying to see movement and achievement in patient safety, but there is still much work to be done. Whether you are a patient, a clinician, an executive, or a consumer who will someday be a patient, it’s your business to be engaged and involved as part of the solution. Let’s accelerate progress in 2016. 


What would you choose as the most notable development in patient safety this year?  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.

Back to top

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  emotional harm  transparency 

Share |
PermalinkComments (0)

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 

Share |
PermalinkComments (0)

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 

Share |
PermalinkComments (0)
more Calendar

10/24/2019 » 10/30/2019
Patient Safety Executive Development Program

Copyright ©2019 Institute for Healthcare Improvement. All Rights Reserved.

Membership Software  ::  Legal