The Richard and Hinda Rosenthal Lecture 2011 New Frontiers in Patient Safety (2011) / Chapter Skim
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Discussion
Discussion
Pages 9-32
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From page 9... ...
If I could invite Don Berwick, Carolyn Clancy, Brent James, and Paul O'Neill to please come with me and we will sit together in the seats appointed. This is the conversational, informal part of our program, and we look forward very much to the opportunity to interact with you in the course of this part of our conversation together.
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From page 10... ...
Brent James, who is the Chief Quality Officer for Intermountain Health Care and also serves as the Executive Director for the Institute for Health Care Delivery Research, has been an incredibly successful leader in reshaping and guiding improvements in the processes of care that have benefited patients and has been a model for many institutions and professionals throughout the country and, indeed, around the world. And on my far left, Mr.
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From page 11... ...
I thought that we could drive central line infections to zero in hospitals for years, year upon year, or that ventilated pneumonias could essentially be abolished, or pressure ulcers cut 95 percent as dissension is done. Seton Northwest in Austin, where the Secretary will visit, has now, last year, 10,000 consecutive deliveries with only one birth injury.
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From page 12... ...
I'm starting to think that in terms of lists, pressure ulcers, ventilator pneumonia, central line infection, it's the adolescence of safety. Safety, as Jim Reason teaches, is a continually emerging property of a dynamic system.
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From page 13... ...
The second is simply a reinforcement of what I regard as one of the central tenets of the To Err Is Human report, and that is that the workforce is on the same side of the net as all of us. They don't want to hurt anybody, anytime.
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From page 14... ...
The Patient Safety Bill, which enabled the creation of patient safety organizations -- huge excitement there -- actually gave the Secretary the authority to disseminate common ways of defining events, extensively vetted through the National Quality Forum, which has really been fantastic. Right now, electronic health record vendors are trying to build them into their products.
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From page 15... ...
One of the first things we showed her comes from a project about reengineering the discharge process and recognizing that many hospitals are struggling to keep up nurse staffing levels, and it makes the discharge process very chaotic. This team at Boston Medical Center is actually testing a computer avatar.
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From page 16... ...
Fineberg, in the sense that coming after Secretary Sebelius, Don Berwick, and Carolyn Clancy, I feel that everything I'm going to say is just redundant.
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From page 17... ...
Number two, health care is inherently dangerous. Since the healing professions adopted the scientific method back in about 1910, we have massively improved our understanding of the human organism in health and disease, and we've devised literally thousands of ways that we can intervene to change a patient's future.
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From page 18... ...
He was looking at adverse drug events, over 200,000 consecutive inpatients across 8 years. He was tracking human error, CDC definition being parallel with confirmed events, 3,996 confirmed ADEs, 138 of them track back to human error as their primary cause, 3.5 percent.
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From page 19... ...
I hadn't actually thought about it for a long time, but Ken Shine was here when the To Err Is Human report was released. And he and I'd been colleagues on the RAND Board.
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From page 20... ...
So I would propose that caregiving institutions around the country, at eight o'clock every morning local time, post in cyberspace the lost workday injuries that occurred to caregivers in every caregiving institution in the country. They would collectively be horrified to see the below-the-horizon, unnoticed injury rate to caregivers.
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From page 21... ...
The size of the opportunity related to American caregiving institutions, getting to be habitually excellent, is a trillion dollars a year. And I know $50 billion sounds like a lot of money.
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From page 22... ...
And I'd like to ask Don or Carolyn: in the health care domain, are you aware of health care institutions that have taken this message really to heart and put front and center at the forefront of their aspiration safety for everyone who works in this institution? Anyone in the audience hear that?
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From page 23... ...
I know the National Quality Forum came out some years ago with the "never events list," and that list was used to decide what events Medicare would not pay for when they were clearly preventable. And I think a bunch of private insurance companies have done the same; they followed suit.
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From page 24... ...
Suddenly, people who were leading quality efforts in hospitals, who had to have conversations with CFOs and the Grenache guys about liberating resources for some of this work, found a newly receptive audience.
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From page 25... ...
Berwick's comment, if here, why not everywhere, I would like this to be applied to medical education. Right now, there is currently no substantial evidence that supports the notion that the current assessment industry used in medical education correlates with good patient outcomes.
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From page 26... ...
DR. BERWICK: The Lucian Leape Institute, which is sponsored by the National Patient Safety Foundation, several years ago picked five themes that we -- Paul and I and Carolyn are on that Institute -- were on the Institute group.
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From page 27... ...
Oh, there he is. The AAMC has recently launched a big quality campaign, and I will say that I got up early last Saturday morning to spend some quality time with some of their folks.
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From page 28... ...
The first is, if you get really down to the roots of what it means to be a physician, well, a committed healing professional in general, it was just one way of implementing it, this belief we have about medical professionalism. Frankly, quality improvement taught us better ways of implementing the same ideas that are just as congruent, just as energizing to our core professional commitments as the others that we learned when we were going through our training.
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From page 29... ...
The 98,000 came from the original Harvard Medical Practice Study. Now, when we were doing this most recent assessment of the IHI global trigger tool, which is so far the most sensitive instrument we found, you have to understand that at least for the 325 charts that came out of Intermountain, I personally reviewed all of those, and it took a
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From page 30... ...
And one of the reasons Bill Munier and my colleagues are so excited about building a better system is that we can focus on the harms, and people can actually begin to see that, because this preventability introduces in a way, a reliability issue, where Don and I might not agree if we're looking at exactly the same information, what's preventable. But if the goal is actually eliminating harm, it becomes much, much easier, I think, to be straightforward about what's the opportunity here and how far do we need to go in our efforts.
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From page 31... ...
I created a base with you, and hopefully you all thought that every caregiving institution ought to hook up the Internet at eight o'clock in the morning and report every lost workday case that happens to their employees. See, that's really just a foundation, because what I'd really like to do, having created that capability, is ask every caregiving institution to post every morning those cases of new nosocomial infections identified in the previous 24 hours, patient falls, and medication errors.
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From page 32... ...
I've learned how precise we have to be with language, that some of the words we have used, like error and preventability, we have to rethink, because we need to cast in the positive goals rather than in the negativity and the false question of avoidability. I have learned that we need to make institutional excellence, habitual excellence, an absolutely central institutional attribute, that we can only very effectively, if we standardize systemically, a very important lesson, that the right culprit to focus on is system failure, that the right focus is on all causes, that zero is the right number, that everywhere is the right place, and that now is the right time.
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