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The Evolution of the The Evolution of the Patient Safety Movement:Patient Safety Movement:
Reflections on a Decade of Successes, Reflections on a Decade of Successes, Failures, and Surprises Failures, and Surprises
For more information about today’s webinar,Feel free to contact me at
To learn more about AccessMedicine, visitAccessMedicine.com
The Evolution of the The Evolution of the Patient Safety Movement:Patient Safety Movement:
Reflections on a Decade of Successes, Reflections on a Decade of Successes, Failures, and Surprises Failures, and Surprises
James ShanahanAssociate Publisher
McGraw-Hill Medical
The Evolution of the The Evolution of the Patient Safety Movement:Patient Safety Movement:
Reflections on a Decade of Successes, Reflections on a Decade of Successes, Failures, and Surprises Failures, and Surprises
Robert M. Wachter, MDProfessor, Associate Chairman, and Chief, Division of Hospital Medicine,
University of California, San FranciscoChair, American Board of Internal Medicine
I am not in the office at the moment. Please send any work to be translated.
Successes, Failures, Surprises and Successes, Failures, Surprises and Epiphanies in Patient SafetyEpiphanies in Patient Safety
The Pace of ChangeThe Limitations of Top-Down ApproachesIT is Harder Than it LooksThe Importance of CultureThe Need to Balance “No Blame” and
AccountabilityLooking Ahead and Dealing with Change
2000: The Patient 2000: The Patient Safety Field BeginsSafety Field Begins
The Healthcare The Healthcare World of 2000World of 2000
Quality/safety assumed to be quite goodNo business case to improve safety/qualityNo local expertise, research or best practicesLittle concerted effort by healthcare
leaders or physicians to improve quality/safety
2000
2002
2004
2006
2008
2012
2010
Successes, Failures, Surprises and Successes, Failures, Surprises and Epiphanies in Patient SafetyEpiphanies in Patient Safety
The Pace of ChangeThe Limitations of Top-Down ApproachesIT is Harder Than it LooksThe Importance of CultureThe Need to Balance “No Blame” and
AccountabilityLooking Ahead and Dealing with Change
The Checklist: The Checklist: A Bottom-Up A Bottom-Up
Innovation in USInnovation in USDr. Peter Pronovost develops checklist for
CLABSI (evidence->bundles->checklist)– Tries it at home (Johns Hopkins): it works– Puts together a state-wide study in Michigan– Demonstrates effectiveness in NEJM study
Popularized in article, book by Atul Gawande, extended to surgery (WHO surgical checklist)
Diffuses through US, with govt support
Arrives in UK via Federal MandateArrives in UK via Federal Mandate
“Another top-down mandate.” One UK surgeon
The Surprise: Healthcare is a The Surprise: Healthcare is a Complex Adaptive SystemComplex Adaptive System
System and external environment constantly changing– Uncertainty and paradox are inherent properties
Problems cannot be solved in a machine-like fashion (but can sometimes be “moved forward” that way)
Individuals are independent – but highly interdependent – creative decision-makers
Solutions often emerge from minimal specifications and simple rules; overspecification can get in the way
From Brenda Zimmerman
Successes, Failures, Surprises and Successes, Failures, Surprises and Epiphanies in Patient SafetyEpiphanies in Patient Safety
Healthcare IT: Some Surprising Healthcare IT: Some Surprising Problems EmergeProblems Emerge
Getting better, but juxtaposition with breathtaking state of IT in the rest of our lives ever-more jarring
Early glowing studies not generalizable to vendor-built systems
Unforeseen consequences– Growing literature on IT-related safety hazards
That said, we must computerize, and it’ll probably help
“The patient is still at the center, but more as an icon for another entity clothed in binary garments: the ‘iPatient.’ Often, emergency room personnel have already scanned, tested, and diagnosed, so that interns meet a fully formed iPatient long before seeing the real patient. The iPatient’s blood counts and emanations are tracked and trended like a Dow Jones Index, and pop-up flags remind caregivers to feed or bleed. iPatients are handily discussed (or ‘card-flipped’) in the bunker [the team’s conference room], while the real patients keep the beds warm and ensure that the folders bearing their names stay alive on the computer.”
A 7-year-old Girl’s Depiction of her MD VisitA 7-year-old Girl’s Depiction of her MD Visit
Toll E. The cost of technology. JAMA 2012
The The ““Glass Cockpit SyndromeGlass Cockpit Syndrome””: : The Tragedy of Air France 447The Tragedy of Air France 447
Successes, Failures, Surprises and Successes, Failures, Surprises and Epiphanies in Patient SafetyEpiphanies in Patient Safety
Teamwork level felt to be Teamwork level felt to be ““highhigh””
Sexton, British Medical Journal, 2000
Believe that decisions of the Believe that decisions of the ““leaderleader”” should should not not be questionedbe questioned
Sexton, BMJ 2000
Safety Culture is Unit-BasedSafety Culture is Unit-Based
Safety Climate Across 100 Hospitals
Safety Climate Across 49 Units in One Hospital
Pronovost/Sexton, QSHC 2005
Successes, Failures, Surprises and Successes, Failures, Surprises and Epiphanies in Patient SafetyEpiphanies in Patient Safety
Balancing Balancing ““No BlameNo Blame”” and and AccountabilityAccountability
The “No Blame,” “It’s the System, Stupid” approach has been crucial– Most errors are “slips” – expected behavior by
humans, particularly when engaged in “automatic behaviors”
– Can only be fixed by improving systems (checklists, double-checks, standardization, IT, other new technology…)
At the Junction, the Message Gets At the Junction, the Message Gets a Little Garbled…a Little Garbled…
NoBlAccoblantabimety
James Reason Understood James Reason Understood This Tension in 1997This Tension in 1997
A ‘no-blame’ culture is neither feasible nor desirable. A small proportion of human unsafe acts are egregious… and warrant sanctions, severe ones in some cases. A blanket amnesty on all unsafe acts would lack credibility in the eyes of the workforce. More importantly, it would be seen to oppose natural justice. What is needed is a just culture, an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information – but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior.
Reason, Managing the Risks…
Individual Accountability:Individual Accountability:The Hand Washing StoryThe Hand Washing Story
Typical hand hygiene rates circa 1999: 10-30%Over last decade, tremendous push to improve (via
transparency, social pressures, and more)Many organizations now at 40-70%,
and stuck “It’s a Systems Problem”:
Education, dispensers every 3 feetA systems problem? Really?
Wachter and Pronovost, NEJM 2009
Who Decided that a 60% Hand Washing Who Decided that a 60% Hand Washing Rate is a Rate is a ““Systems ProblemSystems Problem””??
The Bottom Line: Clinicians, leaders The Bottom Line: Clinicians, leaders and organizations and organizations will will be held be held
accountable for safetyaccountable for safety
“ ‘No blame’ is not a moral imperative (even if it seems so to providers, it most definitely does not to patients). Rather, it’s a tactic to achieve ends for which
providers and healthcare organizations will be held accountable. ”
Wachter and Pronovost, NEJM 2009
Successes, Failures, Surprises and Successes, Failures, Surprises and Epiphanies in Patient SafetyEpiphanies in Patient Safety
[The] reduction in reimbursement and increasing consolidation threatens to make the focus on economics, size, and market competitiveness take precedence over getting better in terms of quality and safety. This will be in part because the ‘line of sight’ from senior leaders to the front lines of care will be even more distant.
Gary Kaplan, MD CEO, Virginia Mason
Health System
Could this be worse?Could this be worse?
“We think that the anxiety, demoralization, and sense of loss of control that afflict all too many healthcare professionals today comes not from finding themselves to be participants in systems of care, but rather from finding themselves lacking the skills and knowledge to thrive as effective, proud, and well-oriented agents of change in those systems…. A physician equipped to help improve healthcare will be not demoralized, but optimistic; not helpless in the face of complexity, but empowered; not frightened by measurement, but made curious and more interested; not forced by culture to wear the mask of the lonely hero, but armed with confidence to make a better contribution to the whole.”
Don Berwick, Acad Med 2010
The Evolution of the The Evolution of the Patient Safety Movement:Patient Safety Movement:
Reflections on a Decade of Successes, Reflections on a Decade of Successes, Failures, and Surprises Failures, and Surprises
For more information about today’s webinar,feel free to contact me at
To learn more about AccessMedicine, visitAccessMedicine.com
Thank You for attendingThank You for attending
