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.