, M.D., is internationally recognized as a leader of the patient safety movement. He is an adjunct professor of health policy in Harvard University's Department of Health Policy and Management, has published over 100 papers on patient safety and quality care, and was a member of the Institute of Medicine's Quality of Care in America Committee when it published To Err Is Human in 1999 and Crossing the Quality Chasm in 2001.
Q: One decade after To Err Is Human, how are we doing?
In some ways, very well; in others, not so good. There is a tremendous amount of activity in patient safety; everyone is getting engaged—individuals, health care organizations, professional organizations, and government. Patient safety is on everyone's agenda. On the other hand, proof that the risk of a medical encounter has decreased has been hard to come by. Annual surveys by the Agency for Healthcare Research and Quality (AHRQ) show little progress.
However, AHRQ conclusions are based on sampling only a few types of events and do not, I believe, fairly represent the true progress being made. We have many truly awesome examples of substantial gains, such as the impressive results of the Institute for Healthcare Improvement's "100,000 Lives" campaign, in which 3,100 American hospitals implemented various safe practices and reduced injury mortality by 122,000 lives in an 18-month period. In addition, overall mortality continues to decline nationally. I think we can take credit for some of that.
The work in preventing hospital-acquired infections in Michigan deserves special notice. With a collaborative effort, ICUs in 68 hospitals implemented new practices that totally eliminated central line infections and ventilator-associated pneumonia for six months or more. That experience was a game-changer. It showed that perfection is possible, that we can have zero defects. It set a new standard for all of us.
Individual institutions, such as Virginia Mason Medical Center and Cincinnati Children's Hospital Medical Center, have dramatically changed their cultures with significant improvements in safety. And health care systems, such as Ascension, have set audacious system-wide goals, and achieved unprecedented reductions in mortality and adverse events in their hospitals.
So, we have impressive examples of success. What we still lack is the ability to replicate those successes nationwide – in all hospitals. That is the agenda for the next 10 years.
One other bit of progress should be noted. When the IOM report came out, we called for systems changes, but we didn't have many to recommend. Hospitals were on their own. That is no longer true. With research support from AHRQ, the National Quality Forum has identified, validated, and certified 34 safe practices that can dramatically reduce iatrogenic injury and should be implemented by all health care organizations. That, too, is the next agenda.
Q: What trends in patient safety initiatives do you believe are most promising?
I find three trends most exciting: increasing transparency, emphasizing teamwork, and engaging patients. Transparency is the cornerstone of all improvement. Without full information, which is not available if people hide their errors, our ability to identify systems failures and correct them is seriously hampered. That is beginning to change. It's becoming safer to talk about our mistakes. Transparency with patients is even more important. Without honest communication, maintaining trust is impossible. We're beginning to see cracks in "the wall of silence." The move to full disclosure (and apology) is taking hold. Finally, institutional transparency is essential for maintaining the public's trust. That, too is beginning to occur, as more hospitals go public with their results, both good and bad.
The second trend, emphasizing teamwork, also has great potential. Teamwork has been the secret of success of every industry that has succeeded in achieving high levels of safety, such as aviation, nuclear power, etc. We now have powerful examples—such as the experiences in preventing central line infections and in implementing surgical checklists—that teamwork is also the key to patient safety. More and more hospitals are embracing it. In fact, team training in health care has become a growth industry.
Patient engagement, not just listening to patients, but actively enlisting them as meaningful partners in their care, and involving them in systems design and evaluation, is proving to be a powerful force for improvement. That is what "patient-centered care" really means. Advocacy groups, including ConsumerReports, are insisting on it, as they should.
I am also heartened by the fact that more and more people are accepting the concept of "getting to zero," the notion that complications are not inevitable but, with appropriate methods and diligence in their application, can be eliminated. Not just reduced, but eliminated. Zero. Believing it was possible is how we got to the moon; that's also how we'll slay the patient safety dragon.
Q: What are the biggest barriers to progress in patient safety?
Probably the biggest barrier is our perverse health care financing system that rewards individuals instead of teams and production instead of care. Work in teams, get a better result, and everyone loses money. One way to get incentives right is through use of global payments and the formation of accountable care organizations. Hopefully, the final health care reform package will address this, as we are trying to do in Massachusetts. Then, safety can begin to take precedence over doing more, and teamwork, the core of safety, will flourish.
I think a second serious barrier is the persistence of a blaming culture. For most of us it seems natural to want to punish an individual when they have made an obvious mistake, even when there are multiple systems failures. In recent years this response has even risen to criminal charges. That has to change. We need to do a much better job creating hospital cultures where people know the difference between error and misconduct, seek and remedy the systems failures behind the mistakes, and support the "second victim," the caregiver, when they err.
Finally, a persistent barrier is that we still fall short of obtaining the full commitment of hospital leaders and physicians. I don't believe we will be able to achieve safety in health care until physicians take ownership of it.
Q: What is the most constructive role states can play to promote patient safety?
States could develop much more constructive—and reciprocal—mechanisms of accountability to ensure that hospitals create safe environments and respond appropriately when things go wrong. Constructive by being partners in analyzing data and disseminating lessons learned, and by leading collaborative efforts (such as for reducing hospital-acquired infections). By reciprocal I mean that state governments have to be accountable to us as well. Practitioners—nurses, doctors, pharmacists, and others—have the right to expect the state to ensure that hospitals implement proven safe practices (such as bar coding, computerized ordering, etc.) that protect patients—and their providers—from errors. It's not enough to have standards; they have to be enforced. Why should a nurse lose her license—or go to jail!—for an error that could have been prevented by proper labeling and bar-coding a medication?
Similarly, licensing boards need to be much more proactive in helping hospitals monitor physician performance and helping substandard physicians improve rather than just calling them out when they fail. We need less emphasis on punishment and more on prevention. Same for nursing boards: why aren't they concerned about that bar-coding requirement being enforced so that nurses don't make mistakes? The driving concept of patient safety is that you don't get safe care by punishing people for making mistakes. You do it by creating safe systems. Isn't it time for the regulatory agencies to take some responsibility for making this happen? I think so.
Q: What advice would you give a governor who wants to improve patient safety?
I would recommend that he or she call on the hospital association, the medical society, and the department of health to work together to agree on a significant safety goal they would all commit to meet each year (e.g., reduction in hospital-acquired infections by 50 percent in 12 months). These campaigns should receive state financial support and be accompanied by public reporting of results identified by institution.
Q: One decade from now, what would you like to say in an interview like this?
That preventable injuries have decreased by 90 percent. That these dramatic reductions have occurred as hospitals and providers have learned to work together to turn health care organizations into learning organizations. That patients have regained their trust and are true partners in their care. That patients no longer fear going to the hospital. That health care really is becoming safe.