Saturday, July 12, 2014

Good progress, but work remains

Here's a superb article by Helen Haskell on the AHRQ site.  It provides a compelling retrospective of the patient safety movement in the US, from 1981 to the present.

Her conclusion is right on target, in my view:

It should be axiomatic that without safe and effective health care, other reforms have little meaning. Yet despite decades of work by patient safety advocates, both inside and outside the health care system, our systems are still far from safe. The topic preoccupying this patient safety advocate is that in the rush toward inclusiveness, population health, and integrated care, the vital unfinished business of safety may be pushed to the margins.


Medical Equipment Solutions LLC said...

Great blog and excellent article.

Michael said...

The patient safety movement lacks case-controlled clinical studies. As a result there is a continuous piling on of "patient safety" measures without knowing if these measures actually improved safety. I can tell you in the case of the surgical "time out," it has become so larded with items that it takes away from the focus on caring for the patient. It is a major distraction for those of us who have always taken patient safety on as our personal responsibility as the physician.

All physicians know who the bad actors are that are responsible for bad outcomes such as wrong site surgery. Little if anything is done when these problems occur. Physicians should take the lead in policing themselves and not leave this to our patients.

It will be a challenge going forward to prevent mistakes caused by the ever increasing burden imposed by documentation requirements of the EMR. Errors are bound to increase.

Paul Levy said...

Wow, Michael, I barely know where to start disagreeing. You've given me fodder for an entire blog post. Another day.

Initial Truth said...

I agree with Paul - I don't know where to start disagreeing. But one small point of logic: even if you were right, and you are not, that doctors know "all the bad actors," the problems that time-outs and other systemic interventions are designed to prevent, and do prevent, are ones that can happen to "good doctors" and "good nurses." They would be a hazard even in the utopian world where all doctors policed themselves.

Would you want to fly on an airline that did not systemic safety checks, but merely relied on "good" pilots weeding out bad ones? Airplanes are way too complicated for that; health care even more so.

You provide no evidence that safety interventions are ineffective because the evidence supports the intervention you cite.

Michael said...

I've always done a "timeout" even before there were timeouts. I interview every patient in the preoperative area before going to the OR. I take my charts to the OR, review my notes, review applicable tests and radiology studies. My "preflight" checklist in other terms. Good surgeons have always done this and I've never had a wrong site surgery as a result.

In many cases of wrong site surgeries that I have reviewed in QA processes a "timeout" was done. The problem is the data presented was incorrect or ignored, i.e. no one noticed the films were put up backwards. The nurse or anesthesiologist has no prior encounter with the patient, so other than verify this patient is who we say it is how do they improve safety by participating in a "timeout"?

Physicians by not policing themselves have left this task to others and so now a one-size-fits-all policy is imposed. I would say the bigger cause of errors in the OR is a lack of routine. There should be more focus on routines and less on time-outs.

e-Patient Dave said...

Michael, what's your point? More important, what's your job? What experience do you have in the areas where you're asserting knowledge?

If you won't publicly answer those, then I imagine you're an anonymous complainer, aka a troll. But I hope you can shed light on your experiences that give you credibility in the issues.

These really are important. I personally know people who've had major disasters happen to a family member, including death. I hope you're not asserting that it's not possible to do anything about it, because as I'm sure you know, some provider organizations have produced radical and well documented improvements.

So please - what is your role in healthcare (surgeon? attorney? nurse?), and what experience do you have in the subject at hand? Then we can talk.

nonlocal MD said...

I would like to encourage commenters not to 'pile on' to Michael as one of the 'patient-safety haters.' His attitude is entirely typical of physicians (mostly surgeons) presented with these patient safety principles, often in a 'here's this list, just shut up and follow it' manner by hospital administrators. Of course they feel insulted and demeaned since they have always taken care to try their best.
It is incumbent on the patient safety movement to address the powers that be in hospitals who are ruining their best chance to educate and losing advocates, even creating 'haters,' as a consequence. This problem is being overlooked and is a critical component of creating real change.

nonlocal MD said...

Having posted my previous comment, I'd like to address Michael's comment of 10:43 pm, since I was in his shoes before I understood the point of all this. The critical flaw in your comment, Michael, is the "I". The culture of personal responsibility is one of "I" do all these things and if everyone would only do what "I" do, care would be safe. The problem is, everyone has their own "I" procedures and they are all different, and of varying efficacy, and they are often defensive procedures against an unreliable system. Care is not safer as a result.The point is to create a system that is safe which EVERYONE agrees upon and follows without exception, not to make up your own routine.

e-Patient Dave said...

Michael, thanks for your reply - I think i get it - and Bev, thanks for your addition.

For what it's work, along Bev's line:

Before my cancer 7 years ago I watched what Paul was doing at Beth Israel Deaconess about standardizing work on central line insertions; 25% of infections there lead to death, he wrote, and the Lean approach of standard work reduces it. If I recall correctly, that method has produced insanely good results in, for instance, Cleveland's county, where Cleveland Clinic shared its methods and experiences, and I think I heard they whole county had ZERO central line infections in more than a year. (I might be off in details but the story was widely reported a couple of years ago.)

Then (back in '07) I discovered that I would have my treatment delivered through four central line insertions. Cool, I thought; and I talked with the surgeons abou tit as they did them. The first one grumbled at some length about how all this "standard work" stuff was for doctors who don't know what they're doing.

For all I know he's right (and Michael is), but I don't know if that's useful for the other 99% of clinicians.

And if standard work is mandated in a clueless, bureaucratic way, that in turn would suggest to me that the managers involved don't get it, which is another problem in itself. As CEO Paul always blogged that it all has to start from the top.

I'll note, too, btw, that BIDMC to this day hasn't come close to zero results; and I'll note that while Paul invited collaboration with other Boston hospitals, none of them were interested. I'm not a mind-reader but I'm guessing that since all those Harvards is smart, they must have other priorities than improving safety.

Here's to docs and everyone else who cares, is good at their job, and helps others too do well and avoid harm.

e-Patient Dave said...

[Michael, I hope you'll find this useful.]

I just had an exchange about this on Facebook with Henry Feldman, a hospitalist at Beth Israel Deaconess. The progression may be interesting - it starts with the concern others have expressed, and ends up with indeed calling for research to address the issue Michael raised. The thread:

Henry Feldman
Well while he does seem cocky, he is not wrong that there is poor evidence. The correct answer is not that it's useless, but that we need to systematically (not anecdotes) study each of these interventions in a scientifically valid way.

I've had cases where doing the checklist was the root cause of the problem rather than the solution, which is not to say checklists are bad or good, just that science and "what feels right" aren't always correlated.

E-Patient Dave deBronkart
Well said, Henry.

A revised view, perhaps: his initial comment strikes me as a mixture (as in "two intermingled different things") of a valid initial statement and a "Whattt???" inference, which, combined, sidestep the point that improvement is needed and inaction is unacceptable. (To me.)

Henry Feldman
Exactly dave. This should be a call to arms to researchers, not a rant on his part. The challenge is you can't use historical controls, as they aren't valid, so this has to be a randomized (obviously not blinded) trial set. It would seem that this would fall under AHRQ's bailiwick for funding.

FYI this would seem to be something you can attack, get more funding to figure out what quality stuff works, and what just churns out meaningless stats and gums up care, with well designed trials. Patients need to demand that we study (and fund) the quality measures/interventions the same as meds, etc!

Anonymous said...

Paul – thanks for sharing Helen’s thoughts. I did not read her article as a piling on of patient safety measures, but as a clear statement that we still have work to do.

I enjoyed this conversation more than I thought I would. When I first read your comments Michael I felt an immediate “pull” toward a reaction. My “fight” was engaged. As always, with a day or two to reflect, listen, and hear the clarity and opinions of others – my rush to judgment was exactly that, and I am sorry.

For the record, I am not an MD, RN, or an attorney. Early in my career I was a hotel executive, for the past 18 years I have been a hospital administrator. I consider myself an expert on organizational culture, patient safety and service excellence.

The conversation has raised some good points. e-Patient Dave captures well the risks and dangers of standardized work approaches and policies being heavy handedly mandated. Not helpful whatsoever. Michael, your mention of “routines” is critically important and a key component of operations committed to being highly reliable and safety.

What concerns me about your comments Michael is the statement about the “bad actors”, that we know who they are, and that they’re the ones that are responsible for the bad outcomes.
If we know who the “bad actors” are, have done nothing to mitigate, continue to work alongside them, and therefore permit the behavior; then this is a choice and a seriously worrisome one at that.

From what I have learned, and witnessed, the serious, otherwise preventable, harm happens for a wide variety of reasons. Sure, a small percentage is related to “bad actors”, but more often than not the system has failed. There is a series of operational variations, missed cues, poor communication and other elements that contribute to failure and ultimately patient harm.

This reality that you state (knowing and doing nothing), alongside your belief that “Physicians should take the lead in policing themselves” is I think at the crux of the unsafe, unreliable, expensive and inconsistent reality (healthcare) that we are living with.

We know and yet chose to ignore, we see and chose to turn away, we hear and we play deaf. There are very few examples (none) of high risk, human reliant industries where we leave risk mitigation, promulgation of best practice and the elimination of variation in practice to chance, or to “should”…

The word “should” is over used, not personally accountable, and quite frankly not very helpful. It implies that it’s someone else’s responsibility. We must stop should-ing on each other and start doing. The should-ing clearly hasn’t worked…

Thanks for your comments Michael and for sparking this conversation.

Douglas Wayne Hanto said...

I'm a little late to this conversation but I have a couple short comments to Michael. Full disclosure: I am a surgeon and was head of the Transplant Institute from 2001-2012 at BIDMC and worked closely with Paul while he was CEO.

First, of all I commend you for taking personal responsibility for your patients and going to the OR prepared. I have just written a Surgical Perspective that was published online ahead of print in the Annals of Surgery called "Patient Safety Begins with Me" that Paul has referenced before and I would be happy to send a PDF (there is no link yet); I basically suggest that the patient safety systems approach to errors is important but not sufficient and there needs to be a balance between our personal responsibility and attention to detail with system fixes.

Second, we don't know who the bad actors are, and that's part of the problem. Many errors are made by good people trying to do the right thing.

Third, if you truly believe that there is no evidence for much of what we do in patient safety then I challenge you to read Bob Wachter's book "Understanding Patient Safety". If you are not convinced that there is real controlled data, then I will buy you dinner. Not everything is a randomized controlled trial but there is a lot data and more coming every day.