Harvard MOOC: Patient Safety and Quality with Ashish Jha

Ashish Jha

Last year, about 43 million people around the globe were injured from the hospital care that was intended to help them; as a result, many died and millions suffered long-term disability.  These seem like dramatic numbers – could they possibly be true?

If anything, they are almost surely an underestimate.  These findings come from a paper we published last year funded and done in collaboration with the World Health Organization.  We focused on a select group of “adverse events” and used conservative assumptions to model not only how often they occur, but also with what consequence to patients around the world.

Our WHO-funded study doesn’t stand alone; others have estimated that harm from unsafe medical care is far greater than previously thought.  A paper published last year in the Journal of Patient Safety estimated that medical errors might be the third leading cause of deaths among Americans, after heart disease and cancer.

While I find that number hard to believe, what is undoubtedly true is this:  adverse events – injuries that happen due to medical care – are a major cause of morbidity and mortality, and these problems are global.  In every country where people have looked (U.S., Canada, Australia, England, nations of the Middle East, Latin America, etc.), the story is the same.

Patient safety is a big problem – a major source of suffering, disability, and death for the world’s population.The problem of inadequate health care, the global nature of this challenging problem, and the common set of causes that underlie it, motivated us to put together PH555X.

It’s a HarvardX online MOOC (Massive Open Online Course) with a simple focus: health care quality and safety with a global perspective.

I believe that this will be a great course—not because I’m teaching it, but because we have assembled a team of terrific experts.

But, let me be clear:  putting this MOOC together is unlike any educational experience I have ever had before.

First, you get to assemble the faculty – and here, I had almost no constraints.

Want to learn about quality measurement?

We have Jishnu Das (World Bank economist whose ground-breaking work includes sending trained, fake patients into doctors’ offices in Delhi) and Niek Klazinga (a Dutch physician who led the creation of the Health Care Quality Indicators for the OECD).These two guys have thought more deeply and broadly about quality measurement than almost anyone else in the world.

What about the role of leadership?

We have Agnes Binagwaho (Minister of Health, Rwanda) and Julio Frenk(former Minister of Health, Mexico and current dean of the Harvard School of Public Health) speaking about what leadership in quality looks like from a health minister’s perspective.

We have T.S. Ravikumar, the CEO of a massive public hospital system in Pondicherry, India talking about how his decision to prioritize quality transformed his institution.

Sometimes, when you want the best people in the world, you don’t even have to go very far. On patient safety, we only had to cross the street for David Bates, Chief Quality Officer at Brigham and Women’s Hospital and patient safety maven. When we wanted to learn about the empirical basis for the role of management in improving quality, we went across town to Harvard Business School to spend time with Rafaella Sadun.

And when we wanted to learn about quality improvement, we only had to cross the Charles River to find Maureen Bisognano, CEO of IHI.

Beyond getting to assemble an excellent, world-class faculty, the MOOC is a completely different approach to education.  Because this course has never been offered before –we had the freedom to write a fresh syllabus specifically for online learners. This is not a live course copied onto a web platform. These are not hour-long lectures videotaped from the back of a classroom.

Our lectures are short, pithy conversations on pressing topics.  Instead of asking Professor Ronen Rozenblum, an Israeli expert on patient experience, to lecture about how and why we might measure patient-reported outcomes, we are having a meaningful discussion – back and forth, where I get to challenge his assumptions and let him articulate why patient experience should be considered an integral part of quality and more importantly, why he cares.

Beyond the discussions, we have interactive sessions where students create content.  One of my favorites? Through this course we will crowd source the first global “atlas” on healthcare quality.  Lets be honest, it’s one thing for me to point to individual studies on hospital infections in Canada or India, but right now, we have no place to turn to if we want to really understand key issues in healthcare quality around the globe and how they compare to one another.

The goal of this exercise is as simple as it is ambitious. By the end of the course, we will draft a resource that maps out where the world is on the journey towards a safe, effective, patient-centered healthcare systems.  It will be created by the collective energy and creativity of people in the course – a range of students, providers, policy folks and people just simply passionate about improving the delivery of healthcare. It will be a public good for us all to use and improve.

Finally, we have a few enticements to keep everyone engaged.  The attrition rate in these courses tends to be high, so we have a few carrots.  First, half-way through the course we will have a series of live discussions in which expert faculty will help students solve pressing quality and safety problems in their own institutions.

Have a problem with high infection rates in your ICU?

We will get an expert on nosocomial infections to help you think it through and figure out how to begin to solve it.  Wondering how to keep your family members safe during their hospital visit?  We will have healthcare consumer experts help you navigate those waters.

Finally, at the end of the course, students have the opportunity to submit a 1200 word thought piece on the importance of improving quality and safety in their own context whether as a clinician, patient, or health policy expert.  The top three pieces will be published in the BMJ Quality and Safety, arguably the most influential global quality and safety journal.

This is a grand experiment in a new way of teaching, engaging, and creating information on quality and safety of healthcare.  I’m sure there are parts that won’t work, but we will learn along the way.  I’m also sure that the pressing issues facing the US – healthcare that is not nearly as safe, effective, or patient-centered as it should be – are similar to issues facing not just other high-income countries, but also low and  middle -income countries.

Thinking globally about these issues, and their adaptable solutions, can help us all deliver better care.

Quality needs to be on the global health agenda.  Don’t believe me?  Take the course.

Ashish Jha, MD, MPH (@ashishkjha) is the C. Boyden Gray Associate Professor of Health Policy and Management at the Harvard School of Public Health. He blogs at An Ounce of Evidence where this post originally appeared. He is also the Senior Editor-in-Chief for Healthcare: The Journal of Delivery Science and Innovation.

22 replies »

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  4. Hello. I’m working in Primary Care. Is this course also thought to this area?
    Here in Portugal there is a huge amount of quality parameters (many of them are too much bureaucratic and distract us from our patients). Perhaps this course might be interesting for me as a GP trainee.

  5. Pathetic conclusions. EHR CPOE systems are killers of more patients than any other etiology. These systems represent emerging disease. Better watch your loved one 24/7 if CPOE and CDS is involved!

  6. I like what Dr. Sibert has written about challenging the status quo when it comes to value and quality. I was skeptical when I was looking at the relationship between,”defensive medicine” and, “medical errors.” I think that whatever the outcomes from practicing medicine or regulations. I think the key is measurement or as Dr. Sibert says, “Scientific rigor and prudence.” I believe that cost, can, while it may not be the final determinate in measurement, be an indicator.

    I look at things from a slightly different perspective. I don’t see how these technologies or new techniques translate into better bargains for the consumer. I can understand from a practitioner standpoint one wants to deliver the best care possible. But, the best care possible might not be the most affordable healthcare. As a consumer of such services, I would like to see a bridge between the, “best” and what is “affordable.”

    I believe that the MOOC is groundbreaking in the experts that are going to be discussing the effects of quality and safety. It looks like T.S. Ravikumar is a proponent of leveraging medical health technologies in ways that makes sense. Sounds exciting. I also think that Jishnu Das has some interesting perspectives on primary care structuring as he has extensive research on the care in India.

  7. Aside from some of your examples, Paul, there’s always the non-compliant patient. My brother-in-law was just released from the hospital for a colon resection done 4 days ago. By the second day, he was up walking as much as he could tolerate. Many of the other patients stayed in their beds, watching TV instead of getting up and moving around to increase muscle strength and decrease the chance of DVT and pneumonia.
    Additionally, one of his roommates brought in a truckload of family members
    who no doubt did not wash their hands before touching the hapless patient family member.
    Do you think these episodes just MIGHT have something to do with bad outcomes?

  8. Karen — it’ll be terrific to have you engaged. Please share the course info with colleagues or others who you think might find it valuable.

    Our goal is indeed to share how the world is thinking about these issues — and I think you’ll find that while the U.S. has a lot to offer, we also have a lot to learn.

    This course is meant as the launching point for building a community of people around the world who can engage in meaningful discussions around these topics.

  9. In conclusion, until those concerned quit calling every “adverse event” a “medical Error” and fail to recognize that adverse events are all just a part of that very dangerous episode of medical care that CAN lead to death, the discussion is skewed to detract from the very real and necessary discussions around the fact that everyone dies and healthcare on the HEALTHY is already dangerous. We are N OW treating people with multimorbidities, most of which have been caused by a very bad choice of lifestyles regarding drugs, alcohol, gunplay, sports injuries, obesity…….. I see ASA 4 patients every day for elective surgeries where an adverse outcome is virtually expected, but Momma wants a new Knee with stage 3-4 renal failure!
    Get real America- you can buy healthcare-you cannot buy health! You must keep it and nurture it, not expose yourself to operations that MIGHT make you “better” only after they surely make you very much more “worse”!

  10. I am saying since the “to Err is human” publication hit the streets, which called anything that was less than the EXPECTED 100% outcome an “adverse event” (which has been subsequently translated to mean medical errors because of the title) there has been frank hysteria which is then turned on the physicians as being the cause of multiple jumbo-jets full of unnecessary deaths each year. Of course these “studies” were all retrospective chart reviews-which at best document “associations” and not proof, are totally subjected to investigator bias (and these people are out to find adversity) and of course are from the 1990!
    So I as about the relevance, the political motivation and frankly a very sincere lack of science in the matter.
    The press will focus on any singular (and often very disturbing misadventure) and use these ancient and questionable reports to blow it out of proportion. Let’s talk facts! 20-50% of ICU admissions DIE in the hospital. These MUST be adverse outcomes and no one comes to the hospital to die! That is the job of Hospice! But Hospice is NOT an American acceptable outcome for too many patients or families-even if it IS appropriate! In Other counties 90-100% of ICU deaths are MANAGED outcomes. No one gets out alive and death is the final episode of life-this is a message that is neglected in the conversations!
    A suicide in the hospital is a “never event”. But is totally caused by the patient. Most errors are minor, NOT caused by physicians. Going into the hospital for the majority of procedures ENTAILS the basic risk of bleeding , CNS damage or death as KNOWN complications. A very certian % of all surgeries, appendectomies WILL have wound infection even if all procedures are followed! The SCIP protocols have NOT decreased any of this significant. IT is time to focus on recognition of adverse outcomes as PART of the very dangerous encounter of that thing called MEDICAL care. All patients are reassured to the hilt of a good outcome after explaining the very real BAD things that can happen-and then get the lawyers to sue when the EXPECTED low incidence of adverse events is THEIR reality. We are wasting money in healthcare by neglecting the reality of getting yourself cut open in the name of “better health”. The better is down the road AFTER you miss the complications-which are indeed CAUSED by medical care, not as a failure but as an expected component of the very real danger!

  11. I’ve already signed up! My frustration with the US version of “quality measures” for the surgical environment escalates daily. As does the physician and nurse burden of documentation associated with it. So much of what we are being pushed to do is based on flawed, fraudulent, or financially tainted data: for further explanation, see “The Dark Side of Quality”, http://wp.me/p2bC3h-g7

    It will be a pleasure to see a fresh point of view with an international focus, and I look forward to participating.

    Karen S. Sibert MD
    Associate Professor of Anesthesiology
    Cedars-Sinai Medical Center

  12. While no doubt culture and context matter, I’ve been surprised by the commonalities in both the causes of adverse events — and their potential solutions.

    I’ve found that high performing organizations in the U.S. have more in common in terms of culture with high performing organizations in India — than they do with poor performing organizations. Quality culture crosses national boundaries.

  13. Paul — while many of the deaths that occur in the hospital are indeed caused by the underlying disease, the studies have generally been very careful to try to tease apart deaths due to disease from the deaths due to medical care.

    Are these studies perfect? Of course not. But if you dig into the work that a lot of thoughtful people have done, you will find that the work is careful and measured.

    Patient safety really is a big deal — and needs a lot more attention — in the U.S., and across the globe.

  14. An important concept to remember on how a global perspective will improve patient safety and quality is the important concept of reverse innovation.

    One program at WHO is known as aPPS, the African PArtnership for PAtient Safety, which is a project that build sustainable patient safety partnerhsipss between hospitals in the WHO African region and counterparts in other rgions.

    Using reverse innovation, partner hospitals have the potential to identify local gaps and needs and aslo consider cost-effectiveness and the ability to create cost-neutral solutions towards preventable harm.

  15. I don’t know about globally, but here in the States, I keep hearing about local hospitals laying off or cutting back long-term staff (nurses, techs, etc) and hiring locums and new grads to cover. I suspect this practice would have a huge impact on patient safety, yet hospitals are concerned about saving money.
    Are there any studies about what exactly is contributing to these adverse events?
    Could also a greater emphasis on charting and paperwork take time away from valuable patient interaction?
    It’s great to have conferences on this, but are there some simple solutions we could try to implement in the meantime?

  16. I have seen where estimates put medical errors at a cost of $17 Billion Annually. I think that this can be seen as a larger issue depending on how medical errors are viewed.

    With my interests in a business perspective, I wonder how much implementing these steps to reduce errors, patient safety, and quality amount to. When looking at this from a global perspective I imagine cost is a factor for poorer countries. In the US right now we are in the midst of rising healthcare costs and in my opinion we have health care providers that are not accountable for costs.

    I look at these initiatives and wonder how can these goals be implemented in a cost effective method in order to reach a larger population.

  17. As of late, we’ve been hearing a great deal of emphasis being placed on global health security. Tom Frieden put it this way: “A threat [to health security] anywhere is a threat [to security] everywhere.”

    It would be inaccurate to say the same is true for quality and patient safety…right? It’s easy to say that there are similar systematic issues causing danger to patients worldwide, but where does cultural context fit into this conversation?

    How is understanding patient safety and quality from a global perspective going to tangibly help me challenge the status quo in my own nook of the world?

  18. @Paul–So are you simply disputing the stat or the idea that unsafe medical care exists and is a global health issue?

  19. If the care in hospitals was the #3 leading cause of death in the USA, Then no one would go to the hospital. In reality, sick and not healthy people go to the hospital and demand very dangerous “procedures” which would be dangerous to a healthy person and illegal under any other circumstance. As an anesthesiologist, I bring patients to deaths door daily, allow surgeons and others to do very dangerous things to them and send them home without nausea or pain as a basic reality.
    Most people die in the hospital. Anything less than 100% expected results is deemed “adverse event” and may well be expected in a given number of patients. If we continue to define reality to make the care responsible for anything less than going home 100% well, then this reality is nonsense. We can only address issues that are subject to improvements. The overwhelming amount of paperwork only distracts from this care which can be improved. Every patient cannot be made to be a government statistic.

  20. Bravo! This is incredibly exciting to learn about, not just because I conducted patient safety research as an undergraduate but because of the huge collection of experts from which to learn from and the potential to interact with them.

    Can’t wait start the course!