Is the Patient Safety Movement in Critical Condition?

These should be the best of times for the patient safety movement. After all, it was concerns over medical mistakes that launched the transformation of our delivery and payment models, from one focused on volume to one that rewards performance. The new system (currently a work-in-progress) promises to put skin in the patient safety game as never before.

Yet I’ve never been more worried about the safety movement than I am today. My fear is that we will look back on the years between 2000 and 2012 as the Golden Era of Patient Safety, which would be okay if we’d fixed all the problems. But we have not.

A little history will help illuminate my concerns. The modern patient safety movement began with the December 1999 publication of the IOM report on medical errors, which famously documented 44,000-98,000 deaths per year in the U.S. from medical mistakes, the equivalent of a large airplane crash each day. (To illustrate the contrast, we just passed the four-year mark since the last death in a U.S. commercial airline accident.) The IOM report sparked dozens of initiatives designed to improve safety: changes in accreditation standards, new educational requirements, public reporting, promotion of healthcare information technology, and more. It also spawned parallel movements focused on improving quality and patient experience.

As I walk around UCSF Medical Center today, I see an organization transformed by this new focus on improvement. In the patient safety arena, we deeply dissect 2-3 cases per month using a technique called Root Cause Analysis that I first heard about in 1999. The results of these analyses fuel “system changes” – also a foreign concept to clinicians until recently. We document and deliver care via a state-of-the-art computerized system. Our students and residents learn about QI and safety, and most complete a meaningful improvement project during their training. We no longer receive two years’ notice of a Joint Commission accreditation visit; we receive 20 minutes’ notice. While the national evidence of improvement is mixed, our experience at UCSF reassures me: we’ve seen lower infection rates, fewer falls, fewer medication errors, fewer readmissions, better-trained clinicians, and better systems. In short, we have an organization that is much better at getting better than it was a decade ago.

So what’s the problem? I see two major forces slackening the response to patient safety: clinician (particularly physician) burnout and strategic repositioning by delivery systems to deal with the Affordable Care Act. Like a harried parent rushing out to the car to drive the school carpool, only to discover that he’s left his child in the house, we risk leaving behind our precious safety cargo if we fail to ensure that everybody is onboard as we rush headlong into the future.

Let’s begin with burnout. When the patient safety field launched in 2000, one might have expected that physicians would be natural foes. After all, say “medical errors” to a practicing doctor and the Pavlovian response is likely to be “malpractice.” This reflex made physicians unlikely patient safety enthusiasts, and it is axiomatic that nothing important happens in healthcare if physicians are not engaged.

Yet, by emphasizing systems problems – the “it’s not bad people, it’s bad systems” argument – many physicians felt validated, some even intrigued, and a few (like me) even inspired. Physicians turned from active resistors to, in many cases, real allies.

But the blizzard of new initiatives – all well meaning but cumulatively overwhelming – thrust at busy clinicians has created overload. The problem, of course, is that nobody freed up the time to do all this new stuff. When commercial airline pilots recertify every year on a simulator, they do this on company time. When they spend 30 minutes completing a pre-flight checklist, their salary is assured. But for many physicians, these new tasks – learning a new way of thinking, implementing a checklist, or surviving the installation of a new IT system – are usually obligations on top of an already jam-packed day. Even for nurses, who generally are salaried, new mandates to scan bar codes or even to wash hands ate up precious minutes in days that already lacked much white space.

Although many clinicians have been gratified by their work in safety and quality, I’m afraid this additional work has contributed to high levels of burnout. A recent study in JAMA Internal Medicine documented burnout rates significantly higher than those of the rest of the U.S. population – with nearly half of physicians displaying symptoms of burnout. Obviously, patient safety initiatives are not the only cause of this burnout. But the effects on the safety field are very real.

While the statistics are troubling (and, as chair of the ABIM this year, I certainly hear from my share of unhappy doctors), the impact on patient safety really came home during my recent interview of Prof. Bryan Sexton, the Duke sociologist and the world’s leading expert on patient safety culture. I had interviewed Bryan about culture six years ago for the federal website I edit, AHRQ WebM&M, and I thought it might be a good time to check back in. I approached the interview armed with a bunch of questions, covering things like Executive WalkRounds and teamwork training.

But within 10 minutes, I had scrapped all of my questions, because Bryan focused almost entirely on clinician burnout. In his work, he is seeing physicians and nurses so overwhelmed that getting them to think about anything else – safety, quality, teamwork – is nearly impossible. “It’s like Maslow’s hierarchy,” he said, in that people aren’t able to focus on higher needs until their basic needs are secured (the full interview will be published in the spring). Because of this, he has shifted his focus to improving “resiliency” – basically, helping docs and nurses restore joy in their work. As Dr. Richard Gunderman points out in a recent article in The Atlantic, while reducing dissatisfiers (hassles, bureaucracy, pay cuts, clunky IT systems) is an important part of addressing burnout,

… the key [to combatting physician burnout] is promoting professional wholeness, which flows from a full understanding of the real sources of fulfillment.

I cling to the hope that improving systems of care will bring fulfillment to clinicians (both from the work itself and the fruits of the labor), as it has for me and many of my colleagues. But it is important to recognize that for many clinicians (and not just the pre-retirement folks), this work is yet one more thing that stands between them and professional satisfaction.

The lack of evidence that all our hard work is paying off is also contributing to burnout. Several influential papers (such as here and here), using the IHI’s Global Trigger Tool methodology, have documented continued high rates of harm; one study of 10 hospitals in North Carolina showed no evidence of improvement between 2002 and 2007. On top of that, a steady drumbeat of studies (beautifully chronicled by Brad Flansbaum) demonstrates that nearly every policy intervention that we thought would work (readmission penalties, “no pay for errors,” pay for performance, promotion of IT, resident duty-hour reductions) has either failed to work, or has led to negative unanticipated consequences. For people who have given their hearts and souls to making the system work better for patients, the result is more demoralization.

My second major concern about patient safety stems from the Affordable Care Act (ACA), one of whose main goals, paradoxically, is to place a premium on value over volume. You’d think that the patient safety field would benefit from such a law (which also includes significant new spending on safety), and perhaps it will… eventually. But in the short term, the ACA is yet another speed bump on the road to a safe system.

Just as physicians are overwhelmed and distracted, so too are hospital CEOs and boards. As the healthcare system lurches from its dysfunctional model to a (God willing) better place, healthcare leaders are scrambling to be sure that their organizations have seats when the music stops. The C-suite and boardroom conversations that, a few years ago, were focused on how to make systems better and safer now center on whether to become Accountable Care Organizations, how to achieve alignment with the medical staff, what the insurance exchange will mean for our reimbursement, and the like. To the degree that people remain interested in improved value, here too the emphasis has shifted from the numerator of the value equation (quality, safety, patient experience) to the denominator: cutting costs.

Dr. Gary Kaplan, CEO of Virginia Mason Health System in Seattle and probably the most admired hospital leader in the country, recently reflected on the state of patient safety in a note to the board of the Lucian Leape Institute at the National Patient Safety Foundation (we’re both on the LLI board). Gary wrote,

[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.

We simply must reorganize our healthcare systems to deliver the highest-value care. Of course, this will require big picture, strategic planning – new relationships, new institutions, new IT systems, and more. It will also depend on the creation of a bottom-up culture that allows those who deliver the care to improve it. Together, this is an awfully full agenda for both leaders and clinicians, and it is a noble one.

But as we proceed, we must remember that healthcare is delivered by real humans, working in organizations that are led by other real humans. Ignoring the pressures that both groups are under may lead us to create lovely systems and dazzling org charts for organizations that continue to harm and kill. In other words, we risk the dystopian world that the great healthcare futurist Ian Morrison has warned of, one in which our hospitals and clinics have the anatomy of high-performing organizations, but not the physiology.

Robert Wachter, MD, professor of medicine at UCSF, is widely regarded as a leading figure in the patient safety and quality movements. He edits the federal government’s two leading safety websites, and the second edition of his book, “Understanding Patient Safety,” was recently published by McGraw-Hill. In addition, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine and is chair of the American Board of Internal Medicine.  His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

18 replies »

  1. The risks to patients during the provision of health care, and the harm to be prevented and minimized. Patient safety is fundamental to delivering quality health services.

  2. Heya! I’m at work surfing around your blog from my new iphone 3gs!

    Just wanted to say I love reading your blog and look forward to all your posts!
    Carry on the outstanding work!

  3. This is an excellent article. Patient safety should give more priority in every health organizations and hospitals. Thanks for this helpful article.

  4. The most important thing is the safety provided to the patient while moving him to the hospital or any health care organization because this is a basic yet critical mode of health care but now a days there are organizations such as the orthohealing center which possess a very good patient shifting module enhances safe and reliable movement of the patient.

  5. Yes, the IOM report was a sham, utilizing two small studies to extrapolate to millions of people. Wachter should no better.

    The study was trumpeted by those who had a monied interest in controlling medicine, including Leapfrog that was run by big business.

    That Leapfrog pushed CPOE on the Bush adminstration, who in turn bragged on how safe it was, started the greatest scandal in the US Government since Teapot Dome.

    How the Congress was duped by SeeChit of the HIM$$ family is beyond many thoughtful academics.

  6. Patient safety should be give more priority in every health organizations and hospitals. Therefore people are getting reliable source of healthcare systems through various healthcare plans and policies.

  7. I remember when the bright idea of refusing to pay for certain conditions that occurred in a hospital came into vogue, under the concept that they were avoidable. What struck me was the irony – most of the conditions listed were “avoidable” if there had been more staff to do something as simple as getting the patient out of bed and walking him/her around – but the result of “refusing” to pay meant that with “decreased revenue” – management had to “decrease overhead” and that of course meant less staff and on and on we go …

  8. Dr. W, fine piece.

    First, the IOM report was bunk. Here is a note I recently publishe in our local newspaper:
    “… panic that gripped the nation [and MN occured] when an Institute of Medicine (IOM) report in 1999 claimed that hospital medical errors caused 44,000-98,000 deaths—a “fact” advertised as something like 5 crashes of 747 airplanes weekly yet allegedly ignored by a delinquent “establishment”. When repeated like a mantra for over a decade, a bogus statistic becomes “true” by repetition.

    Since Minnesota has 1/70th of the U. S. population, we ought to have 1,400 such adverse hospital deaths. However, when MN began tabulating 12 month results each October, there was only modest variation, no trend, and no mayhem. For example, the reports showed 12 deaths in October 2005, 24 in 2006, 13 in 2007, five in 2011, and now 14 in October 2012—typical statistical variation. And 14 not 1,400 deaths! Why?

    The original IOM report was based on death being the adverse event in a small subset of seriously ill patients amongst 31,429 hospital admissions. C. J. MacDonald from the University of Indiana noted that the IOM report was based on two old studies not designed to find a causal relationship between an adverse event and the deaths—and indeed that there was none noted. The 98,000 deaths were an extrapolation from the very sick subset, while the percentage of deaths per total admissions in the two studies, 3.4, was no different from all state of New York hospital admissions—sick folks do die in hospitals but very rarely from an adverse event.”

    Second, we’ll have to discuss burnout is a subject for another day. A serious problem.

    Bob Geist

  9. “But in looking at the system in its totality, it’s evolving and is better off than it was ten years ago”

    Disagree completely. There have been technological advances, but the “system” is getting much worse very rapidly. Doctors and nurses are distracted, confused, overworked, and demoralized. It’s a recipe for disaster.

    If an airline wanted to improve its safety record, would they tell a pilot that she: needs to fly 25% more flights; cut turn-around time in half; take liability for and manage the actions of the flight attendants and the baggage crew; have their salary determined in part by ratings for the in-flight movies; and, also, go back in the cabin to serve drinks before take-off?

    No, they’d remove every distraction that interferred with the pilot doing her job. Why don’t we give that a try?

  10. This is an excellent article. Your points are echoed and song in concert by my colleagues daily who complain of burnout and feeling overwhelmed. Safety issues are a work in progress often being lost in the shuffle of poor staffing, poor morale, and customer satisfaction surveys. Quality initiatives are often staff by uninformed personal that mean to improve system problems but who forget to tie in the human factor of the clinician and the time constraints of the day. But in looking at the system in its totality, it’s evolving and is better off than it was ten years ago. Somehow we have to capture the joy and idealism that the clinician once felt in order to continue improve this system of safety.

  11. Has the move to use hospitalists for hospital care made transitioning from home to hospital to home more difficult for patients and families? No matter how hard we try, I think it’s hard for patients to do all the “coordinating” needed when a hospital discharge occurs. Even if an appointment with a physician is made, if the patient isn’t up to getting to a clinic in a timely way (perhaps not enough support at home and discharged before recovery was well enough established), it’s difficult for the clinic to have enough info to reach out to the patient – even if that was within their capabilities. It doesn’t entirely make sense to me to create an entirely new hospital-based follow up system, either. It seems more likely that if your primary care physician saw you and gave you instructions at discharge, they would have greater reason to know if your missing your post-hospital visit was something to get alarmed about – am I missing something?

  12. Let’s not forget or ignore culturally safe practices as an enabler in establishing trust in the clinician/care receiver encounter. Culturally safe care empowers care recipients because it reinforces the principle that each person’s knowledge and reality is valid and valuable. It facilitates open communication and allows the patient to elaborate on what Professor Arthur Kleinmann calls their explanatory model. It realigns disproportionate power by the clinician to a more balanced, shared decision making process. There are 125 million (legal) residents in the US who were born outside the US and whose perspectives on wellness are rooted in their history. Clinicians, particularly physicians, should be able to appreciate this since 24 percent of all physicians were also born outside the US. It’s refreshing to note the current healthcare safety sensitivity has emerged from its slips and falls confines. How did we survive pre 1999?

  13. Surprise surprise, many things do not pan out as intended, including electronic care managing devices. That is why we have the FDA, and IRB boards, and randomized controlled trials. There are many robber barons getting rich selling safety. You do not have to look any further than your HIT vendor.

  14. ‘every policy intervention that we thought would work (readmission penalties, “no pay for errors,” pay for performance, promotion of IT, resident duty-hour reductions) has either failed to work, or has led to negative unanticipated consequences’

    You need to get out of the bubble more often.
    None of us in the trenches thought those interventions would be anything but more hassles preventing us from concentrating on patient care.