I really enjoy listening to Donald Berwick, the quality and safety maven who heads up the Institute for Healthcare Improvement. I think we have a lot to learn from him. (Careful, though: he can mesmerize you with a few non-evidence based claims and cause you to take the big leap that says quality equals single payer health care, and come out thinking they were all your ideas).
As I listened to his talk on the web archives of SHM 2008 I started feeling expansive about quality and safety. A few thoughts on the subject follow, some straight from Berwick’s talk along with others from my own random musings.
Although concern for patient safety is as old as the profession it began a 180 degree turn on October 4, 1984. On that evening an 18 year old college freshman was admitted to New York Hospital with fever and mental status changes. Cared for by sleep deprived and overworked house staff with no supervision, she died early the next morning. She was Libby Zion, daughter of powerful attorney and journalist Sidney Zion whose outrage set off a legal and media firestorm. Most readers are familiar with the case and know that it brought us the 80 hour work week rule for residents. Beyond that, it began a shift in the focus of patient safety.
The old notion was that a tireless and vigilant super doc hero was responsible for all details of the patient’s care, constantly intercepting dangers that lay at every turn in the treacherous hospital environment. If something went wrong it meant the doctor, ultimately responsible for everything, just had to work harder. I was trained in that culture. We could never do too much for the patient, even if we had to pass our own medications. A mentor who influenced me deeply, proud of the fact that he ran a very punishing residency program, once told us: “Each of you has the capability to be the best doctor in the world. If you’re not the best doctor in the world you need to work harder.”
Berwick was trained in that culture too, and it took him years to realize how wrong the thinking was. You won’t enhance patient safety by beating up on people to work harder. The new thinking? Systems and design. It’s Berwick’s first rule and it means that the safety nets and redundancies to intercept inevitable human error must be part of your system’s design. We’ve heard “systems approach” to patient safety until it sounds trite. But Berwick’s examples and arguments bring the concept to life.
Design is rule number 1. Rule number 2, my own rule, is to be proactive. Don’t wait for Joint Commission and CMS to tell you what to do. A corollary is not to limit yourself to what JC and CMS require you to do. The problem with the so called core measures is that hospitals, in their quest for good report cards, focus on them to the exclusion of quality improvements that matter more. The core measures as currently promulgated have been largely ineffective, not because they’re not evidence based (many are) but because unintended consequences of playing for the report card counterbalance benefits. Opportunities to put more robust measures into practice tend to be slighted. Examples are applied hypothermia after cardiac arrest and early goal directed therapy for sepsis, measures which have fallen short of widespread implementation years after publication of evidence. Getting a commitment from your institutional leaders, who no doubt want to “focus on the core measures”, may be a challenge.
Rule number 3 is not to get unnecessarily bogged down in your hospital’s committees. Your hospitalist group can brainstorm and formulate an initiative faster and more effectively than your hospital’s committee structure. Most proposals have to go through several committees, some of which may only meet once a quarter. If your proposal requires institutional commitment it will ultimately have to go through committees, but have the details and the supporting evidence ready to present first.