The Building Blocks of Better Care, 10 Years In the Making

This post is being cross-published today as part of The Blog of the Interdisciplinary Nursing Quality Research Initiative's commemoration of the 10th anniversary of To Err is Human.  You can find this contribution and other posts in two week series here.

Shortly after the second IOM report Crossing the Quality Chasm was published in 2001, Don Berwick authored a "users manual," a short document that clearly identified four broad stakeholder interests: the experience of patients; the functioning of the units where care is provided; the larger organizations in which direct care units reside; and the forces (policy, payment, regulatory, accreditation) that shape the performance of these organizations. Berwick described the model as necessarily hierarchical with the experience of the patient on top and other interests aligned to improve the health and functioning of the patients.

Berwick was probably wise to suggest that we begin crossing the quality chasm by holding on to the hierarchy. After all, no one understands hierarchies better than those who give and receive healthcare. By turning the hierarchy upside down, Berwick gave it a disruptive twist, one that helped re-establish the primacy of the care experience (and the outcomes attained) to the business of healthcare.

But I think Berwick was on to something better when he talked about the patient's experience being "true north." It's a construct that acknowledges the importance of the patient experience while seating all stakeholders around a common cause. 

The image of all stakeholders sharing space at the table works for me, especially since a decade's worth of study of system design and performance-shaping factors is dismantling the notion that strict hierarchies serve the interests of safety.

Ten years ago, the relationship between safety and strict deference to hierarchies—and other "soft" markers of dynamics that shape human performance—was not appreciated.  Cooperation, civility, and effective teamwork were seen as "nice to have's," the kind of behavior leaders might foster using sources like All I Really Need to Know I Learned in Kindergarten. Largely seen as social lubricants, behavior-based risk reduction strategies were given low priority in an increasingly technical healthcare domain.

A decade of studying what actually makes high-consequence industries reliable has sent healthcare stakeholders back to some foundational behavior-based learning. It turns out that things like speaking clearly, repeating words to be certain they have been understood; taking turns; using "inside" voices; and getting plenty of rest matter when individuals rely on complex processes to deliver intended outcomes. (Even "time-outs" have made a comeback!)

A series of recognizable standards and expectations are now visible on the frontlines of care. The Joint Commission’s National Patient Safety Goals is the most readily identifiable. But even more important to further progress are the larger studies and best practice recommendations linking elements of organizational culture to improvements in patient safety. Measures that support these relationships are plentiful, easy to locate, and increasingly integrated into forces that shape the performance of organizations.

The emergence of patient safety as a distinct discipline means the study of safety-sensitive processes and measures in healthcare now rests upon a conceptual framework, one that allows stakeholders to understand the science informing compliance measures in a way not possible before To Err is Human. We're poised to know, with increasing precision, not only who should be at the table but if what's being served is any good. 

Ten years spent building a table that so much rests upon is probably not too long. 

Glad you're here but there are other interesting places to visit, too!

The Tuesday redirect I normally reserve for Grand Rounds is being shared this week. This signifies a warm endorsement of the INQRI blog which today launched a 10 day series commemorating the 10th anniversary of the IOM report To Err is Human. But it doesn't mean that you shouldn't visit Health Technology News (where a good laugh is in store for those who remember Seinfeld & Co's patient adventures).

I've been surprised that the topic of patient safety--measures to prevent inadvertent harm to people who seek care--has received so little mainstream media attention in this very long season of talk about healthcare and reform. The INQRI To Err is Human series is a great place to hear how patient safety intention and outcome are converging, with some of the patient safety advocates who have led the charge taking time out to assess progress.

Check out INQRI in the coming days. There's something for everyone. (Florence herself is learning new things there!)

Thanks for speaking up

When I give talks about patient safety, I usually include a slide called, "Why Pilots Won't Nurse." It's an attention getter, one that draws smiles and sometimes fosters an "a-ha" moment for students, seasoned clinicians, and administrators.

I think that pilots won't nurse because, as a group, pilots are knowledgeble enough to reject systems that lack sufficient barriers, redundancies, and opportunities to uncover and rectify potentially lethal errors that have been set in motion. Commericial aviation isn't fool-proof, but the industry's 1 in 6 million crash rate shows what can be accomplished in high stakes domains when adequate barriers, redundancies, and recovery ops are in place.

I could add another slide: why pilots don't practice pharmacy. And there's no better place to read why than Bob Wachter's thanksgiving day post about the tragic case in Ohio, one in which a little girl lost her life, a family dissolved, and a pharmacist went to jail. 

Late last summer, Mike Cohen, the president of the Institute for Safe Medication Practices, published An Injustice Has Been Done about what happened to pharmacist Eric Cropp in the aftermath of little Emily Jerry's death. Bob and Mike talked about what Eric's case means, for professionals and for patient safety in a CareFusion webinar (the recording is available here). Thanks for speaking up.

I am thankful!

People who check in at Florence dot com come from all over the world, united by a desire to see better, safer healthcare systems emerge. I'm happy my efforts are contributing to hard work being done by so many others and thought it would be interesting to share where visits to Florence dot com came from last month.  (The darker the green, the more visits from that region.)

In this season of thanksgiving, I want to say how grateful I am for the opportunity to share reflections and pass along resources I value with so many of you.

This week, I heard a physician leader in a large multi-system healthcare organization talk about progress her organization has made in patient safety. The gains were substantial, and hard won, coming not from gorging on cheap Happy Meals, but from putting safety and quality at the center of the table where bright, powerful, and connected people in the organization regularly convene. These people not only plan the meal, they're accountable for what's served.

Patient safety, a component of quality healthcare, isn't the same as quality. People struggle to understand their relationship, especially in complex and evolving arenas like healthcare. Safety doesn't prove which chemotherapy regime is the most efficacious. It's what allows the one selected to be delivered as intended.

Safety may not reveal God's perfect truth. But, done well, safety is what allows humans to facilitate the activities--some miraculous, some mundane--needed to heal. If therapy fails because the chemotherapy regime selected isn't the best match for a person's genotype or stage of cancer, more work on the quality side of performance improvement is needed. But if a person dies from an accidental chemotherapy overdose or doesn't receive the curative benefits because of less obvious dosing errors, there's work to be done on the safety side.

I learn the most when people who are well into the safety journey talk about where they're stumbling. The physician who shared inspirational data about the reduction of serious, preventable safety events in her organization shook her head when asked about the barriers that prevent further gains. "It's hard," she said, "to make humans perform as flawlessly as the healthcare system needs them to."

This means that even in healthcare organizations where demonstrable gains in patient safety have been made, there's still plenty of work to be done. Improving system design and actively shaping the choices made by people who use the system is how David Marx, a systems engineer, attorney, and the author of the Just CultureTM algorithm, describes the work leaders undertake when they gather to create and sustain a culture of safety.

This year, one of my best reads was Marx' book, Whack-a-Mole: The Price We Pay for Expecting Perfection. It's a resource I'm thankful to have and one I hope you'll find helpful in your journey toward safest care, no matter where you are (in the world or on your journey).

Oh, and thanks for checking in today and on so many other days this year. Come back soon!

Thank you, Grand Rounds!

A Thanksgiving edition of Grand Rounds is up this morning at Colorado Health Insurance Insider. One of my favorite posts comes from Laika's MedLibLog, where a web 2.0 savvy health librarian shares a list of scientific journals that she follows on Twitter.

Maybe Twitter lists like this speak to me because I remember what accessing quality medical information once looked like: finding time to go to the university library, scrounging around for change, countless hours spent looking for high-end resources, doing the bump and grind with a recalcitrant copy machine (so that the prized materials might be made readily accessible in places more welcoming than the nasty, drafty, dirty library). And leaving with the nagging sense that I probably missed the best things anyway.

People who think that Twitter is a place where bores report the outcome of their children's travel soccer games are missing it. There are bores in Health 2.0. (There are bores everywhere: The 2009 word of the year is unfriend and I suspect unfollow, what you do to bores on Twitter, will pop up next year.)

But the ability to piggyback onto lists used by medical librarians, gaining access to real time output from 90 (just a start, no doubt) scientific journals a health information practitioner relies on.... well, it's enough to make you drop your dimes.

When you let go of old ways of doing things, it's nice to find something as a useful as a "follow" button.

Welcome to Lake Wobegon!

Last Monday, over at the Wall Street Journal Health Blog, Jacob Goldstein was not kind to the residents of Lake Wobegon, calling out their leaders for believing that Only 1% of Hospitals are Below Average. Goldstein's piece shares findings from a study by Jha and Epstein published in Health Affairs this month, one that links knowledge and value ascribed to clinical quality on the part of not-for-profit board chairs to the quality measures their organizations post. [link]

Additional findings from Jha and Epstein's survey of 1,000 not-for-profit hospital boards chairs between November 2007 and January 2008 include:

• less than 1/2 of respondents rated “quality” as one of their “top 2” priorities
• 3/4 reported their hospitals had “moderate” or "substantial” expertise in quality of care
• only about 1/3 had received formal training in clinical quality measures
• when clinical quality training was included in education provided to the board, the mean amount of instruction time was 4 hours 
• less than 1% rated their hospital's performance as worse or much worse than a typical hospital's performance on standard quality measures (like The Joint Commission's core measures or other publicly reported measures)

When you dive deeper to find the "take-away" lessons from data like these, resist the urge to see the chairs' overly optimistic assessments as nefarious or necessarily careless. Their estimates are, in point of fact, consistent with what people do when they are asked to evaluate their performance relative to others. Cognitive psychologists call this bias illusory superiority, and it describes the tendency of people to overestimate the degree to which they possess desirable qualities relative to others or underestimate their negative qualities relative to others. It fact, illusory superiority is referred to as the "Lake Wobegon Effect."

The real take-away lesson here is that the Lake Wobegon Effect is proportional to the specific knowledge and skill a person is asked to rate. If you ask someone who plays ball how well he plays compared to others, he will provide a more accurate assessment than if you ask someone who has no experience with ball at all. Wildly optimistic estimates of performance suggest profound lack of experience.

This means that board chairs often don't know enough about quality to know whether the organizations they oversee reliably deliver quality outcomes. I don't fault them for their "glass half full" outlook (which likely serves them and their organizations well on other fronts). But I do worry who is in a position to tell the emperor about the problem with his clothes.

Two places where you'll find this being done, albeit a bit more genteelly, is the Institute for Healthcare Improvement's Boards on Board and creative partnerships, like the one housed at SafetyLeaders.org, that help make the National Quality Forum's Safe Practices expectations come to life through free webinars and web-accessible transcripts.

Closer to home, though, finding a credible champion for quality and patient safety becomes more challenging. What powerful community leaders know and believe likely mirrors the opinion of powerful people in the organization and the community. I'm sympathetic to where board leaders find themselves these days because for most of my career, I've lived in the same "small towns" they govern.

Healthcare culture values processes that rely on knowledge contained in human memory and devalues those that rely on more mundane performance shaping measures. For a very recent example of how this thinking shapes culture, consider this tweet I picked up from a PSO insider yesterday:

"I had one surgeon tell me that checklists are for the lame and weak"

If the chair of your local hospital's board (or one of her close family members) hasn't been the beneficiary of physicians, nurses, and pharmacists who hold similar opinions, you may indeed be somewhere very good. But it's a very different place from where the average American gives, receives, and oversees care.

Healthcare is a place where "intention" still trumps "outcome." Jha and Epstein reinforce the need for senior decision makers to become familiar with how desirable quality outcomes are fostered, then measured in healthcare.

Everyone else in town needs these lessons, too. It's easy to become lost under the standard normal curve out here.

Waiting for Rabbit Redux

Good stories are sometimes told across time, and so may be the case in telling the story of how healthcare gets healed.

I found this interesting interview, Medical Errors, 10 Years Post-Op, with two of the authors of the original IOM report. It's nicely bundled with a short history of the "hospitalist" specialty. (Don't miss the history of events that have informed the evolution of patient safety at the bottom of the piece.)

While we're waiting for Rabbit, here's a link to another snapshot of patient safety-sensitive performance measures: a 2009 report, commissioned by the American College of Healthcare Executives entitled, "Bad Blood: Doctor-Nurse Behavior Problems Impact Patient Care."

Maybe get a chair.