Yesterday, we talked broadly about Patient Safety Awareness Week in order to provide more context around the movement. Today, we’re going to go a little deeper. Recently, I sat down with HCA’s Chief Medical Officer Dr. Perlin and the President of the National Patient Safety Foundation, Diane Pinakiewicz to discuss patient safety. I wanted to hear their thoughts on how far we’ve come, what’s on the horizon and the roles that both patients and their providers (nurses and doctors) play in improving patient safety. We recorded the conversation and separated the audio by each question, below.
This is a great discussion and I think you’ll get a lot out of it. I encourage you to listen and let me know your thoughts or questions in the comment section. We’ve also posted the transcript below the audio if you prefer to consume the information that way.
Question 1: A lot of people are talking now about electronic health records. How do you think electronic health records will impact patient safety?
Question 2: We mark the beginning of the modern patient safety movement from the landmark Institute of Medicine report To Err Is Human that was published at the end of 1999. What progress do you think that we have made as a country since the release of that report?
Question 3: This year, the National Patient Safety Foundation gave us a theme for Patient Safety Awareness Week which was “Be Aware for Safe Care.” The emphasis in that theme is on the importance of effective communication between patients and providers. How do partnerships between patients and their health care providers contribute to safety?
Question 4: Both of you have been long-time leaders in patient safety, what is your greatest source of motivation?
Download the transcript or read it below:
Patient Safety Discussion with Dr. Jon Perlin (HCA) and Diane Pinakiewicz (NPSF)
Jane: Hello everyone. This is Jane Englebright. I’m the chief nursing officer and the patient safety officer with HCA. This year National Patient Safety Awareness Week is March 4-10th. And today we’re going to discussing patient safety, specifically, we want to talk about some of the innovations on the horizon that hope to improve patient safety and also the role that patients play in improving patient safety.
I have with me today Dr. Jonathan Perlin, HCA’s chief medical officer and president of clinical and physician services group and Diane Pinakiewicz who is the President of the National Patient Safety Foundation. So Dr. Perlin and Diane, welcome.
Dr. Perlin & Diane: Thank you very much Jane.
Jane: I’d like to jump right in with a few questions, so let’s go ahead and get started. So the first question is a lot of people are talking now about electronic health records. How do you think electronic health records will impact patient safety? Dr. Perlin, let me turn to you first on that one.
Dr. Perlin: Well, thank you very much. In your role as chief nursing officer and as our chief patient safety officer, Dr. Jane Englebright, our moderator, you’ve seen and you know as someone who began her career as a bedside nurse, how information intense healthcare is. And in the absence of the tools that have made every other modern industry more productive and more reliable, we as caregivers and patients, have to make decisions in the absence of having the right information. Electronic health records really make sure that we have the right information at the right time, and that really means at the time of decision, and all the time. They correct information across circumstances of care, hospital perhaps, a physician’s practice or or even in the home.
If you think about it, it’s kind of ironic that healthcare has been behind and we’re making great strides to redress that. And I’ll talk a little bit later about what we’re doing across HCA to be completely electronic, but paper’s dangerous. If you take your car to the shop, there’s a very well known oil change place, where they have a commercial where the spouse finds out that someone had an oil change in Las Vegas. Well, does your doctor’s office know the last time you had a doctor’s visit or what the last test was or what the results of that were? And the answer is, well, not reliably. So, electronic health records really provide the glue to create the necessary information and complete the story that allows patients to make good decisions and their care providers to make good care decisions across the different care environments and over time.
It also allows care team and patients to experience more seamless care when, for example, they transition from one care environment to the other. For example, from a hospital or home or a hospital to a rehabilitation center. Electronic health records of course also do things that the humans don’t do so well, which is manage multiple pieces of information simultaneously. So, if you have a number of drugs, the potential for interactions, it really can melt very quickly into thousands, hundreds of thousands or millions. And well, I might remember as a physician some of those interactions, a computer can check every last one of those interactions, making sure that two drugs that might be administered are in fact compatible and don’t have a bad reaction when administered together. What if there is not a lab that says a particular drug shouldn’t be used? Or that the drug isn’t prescribed to which a patient’s allergic? It also provides the information that helps a care provider understand what drug or what therapy might be most beneficial. That’s called decision support. And across our organization, we’re a large organization of hospitals, and office practices and surgical centers, and all the pieces in between. I’m very proud of the fact that as the president has challenged the country to go electronic, 145 of our district hospital sites have hit the requirement for the meaningful use of electronic health records. And I know that in 2011, only about 600 hospitals hit that goal. So really proud of the fact that we’re getting behind this, because electronic health records offer one of the best opportunities to improve patient safety and care.
Jane: Diane, would you like to add anything to that discussion?
Diane: I would, although it’s hard to add anything to what Jon said, other than to say a couple things and that was that I couldn’t agree more with what he’s saying. You know certainly, healthcare isn’t the only complex industry in the world, but it is right up there with the most complex of them. And in every decision point in the healthcare process, the amount of information that needs to be distilled and synthesized in order to make the best decision on behalf of the patient is just enormous. I think there are probably few other industries in the world that have to take so much into account at any individual decision point in their processes. And of course the stakes are much higher in healthcare than they are in other complex industries, because we’re talking about the health and lives of human beings. So, as Jon had said, it is, actually it’s almost unbelievable that we’re so far behind other industries in our adoption of technology to facilitate the exchange of this information and at a point beyond that, in integrating shared decision tools and processes into the information flow to assist us in making the best decisions for our patients.
From the very first point of diagnosis through the design of the optimal care plan, the necessity to have as much accurate, current, complete information about the patient at hand is critical. And we have done a poor job of adopting modern tools to make that easier for us. And in doing so, that also by definition provides us with some safety nets around the process of information capture and exchange that can help mitigate what we know as causes of error in the healthcare system. So we’ve known for some time that communication is the key reason, lack of communication is the key reason, for medical error. We’ve known for some time that we fall down in transitions of care, whether it’s provider to provider within an organization or whether it is organization to organization, care point to care point. And that the ability to use technology to help organize this information, and also prompt us to ensure we are getting and looking at a complete set of information before we make a decision, is something that we absolutely have to avail ourselves of in a manner that is effective.
The movement to accountable care organizations or whatever the construct ends up being, as we head down the correct path of organizing ourselves to deliver value in healthcare and raise the health of the population to a higher level, improve the patient experience, and contain the costs associated with delivering care,that will require of us that we are able to have a facilitated flow of clinical information across care settings. And of course the point of constancy in the entire process is the patient. So the electronic health record is an absolute must for us to be able to do this effectively, but so is the eventual development of an effective way to allow patients access to information and to connect some form of the personal health record into that process so that the information can effectively flow with the patient across the system.
Jane: Thank you Diane. You brought up an interesting point about progress. We mark the beginning of the modern patient safety movement from the landmark Institute of Medicine report To Err Is Human that was published sort of at the end of 1999. What progress do you think that we have made as a country since the release of that report?
Diane: It’s hard to measure progress because as you know the denominator was hard to discern back then and I’m not sure if we even know what it is now. I would say that to me the most significant thing that has happened is that the healthcare industry has really gotten to the point where there is almost ubiquitous acceptance of the fact that there is a necessity for us to go about our work in a different way than we have prior to the patient safety movement and has adopted tools and approaches from other complex industries, safety sciences, human factors, engineering which have really changed the face of our process improvement work. And I was in the field for some time before the patient safety movement started and I believe that the anchor of the movement, when you are talking about patient safety versus quality improvement, is a much more tangible anchor for the improvement work than quality improvement had been, not that that work was not valuable and isn’t still valuable, and not that I see them to be all that different. But it is a lot more poignant to think about not hurting an individual than it is to think about what degree of quality improvement you may have achieved on scale that people often times have difficulty coming to agreement on.
So, I think the adoption of the systems approach to process improvement in healthcare which has come through this movement, the use of all the tools that we borrowed from other complex industries and used from safety sciences, human factors engineering, has been valuable and what it has allowed us to do is really take a look at our systems with a different lens. Once we started doing that, and used the systems approach and recognized that it isn’t just about a singular process improvement against a particular clinical issue or condition or error set, it is about creating a safety culture that has a number of embedded tenets in it that includes teamwork and transparency and proactively searching out errors and near misses, or near errors as people call them, so that we can learn from our flaws, which prior to that we were pretty good at turning our heads on. I think we have learned a lot about who we are from this work and it has allowed us to target our process improvement activities a lot more effectively than we had been doing previously. It has allowed us to understand why it is important to reduce variation and adopt evidence-based practices.
We are still challenged; we see reports all the time about the level of error that people find alarming. I think that we have a long way to go, but we have really made a big difference with the way we look at ourselves, the way we practice what we have done in our culture. Prior to the reports and all this work, it was unheard of to disclose an error to a patient and apologize to a family. That alone is an amazing accomplishment given the number of decades that the culture did not allow for that, changing the culture is not a short-term project. So, we have a lot to do ahead of us, I think, integrating the improvements that have been proven into every day work and adopting them ubiquitously across the industry, and finding ways to sustain the improvement is proving to be a challenge. But every day we see progress in another area. And every day we see providers doing great work to correct things that have been discovered to be imperfect that are causing undue harm to our patients. And so, I would have to say that the energy, the focus, and the improvement work is measurably better than it was prior to this report being introduced.
Jane: Thank you. Dr. Perlin, do you have some specific examples?
Dr. Perlin: Well thank you. First, let me agree with Diane. The report from the Institute of Medicine, To Err Is Human, was so hugely important because it changed the discussion from “bad things happen” to really asking the question “what causes bad things to happen?” and “how do we build systems to avoid bad things from happening?” Coming from a patient’s perspective, the only acceptable rate of preventable harm is zero. And, from a care provider’s perspective, the question for us then becomes “are we using all possible and available evidence, all insight from other industries” as Diane said, “other industries that are high reliability, like aviation, to build systems that are tolerant to human beings and the failures that human begins can have?”, not because of bad intent but just, for example, as we discussed with electronic health records, because people can’t manage information in the same way that a machine might.
So, “are we doing all we can to prevent preventable harm?” is really the clear question. And I want to talk about 6 “tions”, 6 different areas of endeavor…starting with computerization, because there is a lot of information and very information-intense area like in healthcare, and that really helps in terms of error checking and supporting making the best evidence-based decisions, as we discussed. The other 5 shuns that I want to mention are: radiation, medication, gestation and preventing harmful outcomes either during the development of the fetus, or at the time of delivery, operations, and I don’t mean surgeries, I really mean the management of hospitals and infections.
So let me start with the first one: Radiation. Radiation is a modern technology to allow seeing things that for most of evolution and certainly the history of medicine were invisible. But radiation also uses a potentially harmful technology, that is, ionizing radiation can itself be dangerous. And so we have introduced a Radiation Right initiative really to image gently, that is used the least amount of radiation possible with any image that we might need to obtain, be it CAT scan (CT), or a moving x-ray called fluoroscopy, image wisely and that is really means to make the choice between other technologies that don’t use radiation if they did answer the question and to step gently, which is really to progress to additional radiation tests after exhausting all of the other alternatives. This is an approach to reduce the amount of radiation used and the amount of radiation that patients are exposed to both for diagnostic studies and also as therapy.
Let’s come over to the topic of medication for a moment. Imagine the importance of having error check and decision support at the time an order is placed for a medication. But it’s also important, particularly in the hospital for example, that the right medication be delivered to the right patient, in fact, in the right dose, by the right route and at the right time. And we call those the “five rights” and those are the things that secure point of care medication administration allow. We barcode all of our medications, we match that barcode with the barcode on the patients wristband so that we in fact know that it is the right patient getting the right medication in the right dose by the right route at the right time. I’m really proud that Dr. Englebright and her team received the Cheers Award for I-Trace, which was really as it sounds, a means for tracing IV lines for ensuring the right medications go into the patient by the right route. These are processes that increase the reliability of something that can be error prone, either because medications look alike or because patients have similar names, or lots of patients are getting lots of medications. Only about 1/3 of hospitals still have barcode medication administration or a secure point-of-care medication administration, though with the new agenda to advance electronic health records known as meaningful use, but that will be a requirement soon. But we were proud to be among the leaders in that.
Gestation – or assuring that we have healthy babies. We have a policy across HCA where we have done all we can to prevent early, elective, pre-term deliveries. It’s kind of interesting, over the last 30 years, the average length of time that a baby develops, or remains in gestation, has been reduced from around 39 weeks to about 37 weeks. It is really amazing. All of evolution led to 39 weeks in the last 30 years closer to 37. Why? Doctors and patients did not have a basis for thinking that there was any difference between 37, 38, or 39 weeks because there were no technologies such as ultrasounds to offer precise data. We have those technologies now and the question arose: are those 3 weeks the same? And it turns out they are not. If one can avoid early elective delivery, then they reduce the risk four-fold for complications if they move from 37 to 39 weeks, and twice lower rate of complications if they move from 38 to 39 weeks. So outside of distress by the baby, the fetus, or the mother, early elective pre-term delivery should be avoided. It reduces the rates of complication and leads to healthier take-home babies. We know a little bit about babies, we deliver almost a quarter million–more babies than the entire continent of Australia. That is why when the March of Dimes and others wanted the definitive answer, they came to us. But having created that evidence, our obligation has been to use it. I am very pleased that the secretary of Health and Human Services announced an initiative to use this as a basis for improving the health of new babies everywhere.
Let’s come to the topic of Operations– This may seem very straightforward, but no one wakes up in the morning saying, “gee I think I’d like to end up in the emergency room!” The stories of emergency room inefficiencies and overcrowding are almost a part of the daily news. We’ve halved the time in our emergency rooms and today our average time to being seen, outside of those things where someone is coming in with trauma or a heart attack when it is immediate, but the average time for everything else is down to around 26.5 minutes. And, that means that we can assure that conditions are recognized and that patients are treated in the timeliest fashion possible, preventing the opportunity for harm.
Finally, the last “tion” I want to talk about is Infection, and I just mention a couple of areas. First, hand hygiene is the area to prevent hospital or healthcare associated infections. It used to be thought that bad things happen; we now know that infections are increasingly preventable and our programs have reduced rates of MRSA and other hospital-associated infections to really moving towards industry leadership. The other is that we know other sorts of infections are preventable and one of the most important is the leading infectious cause of death in the U.S., and that is influenza, the flu. We don’t think of the flu as really something that is dangerous, but as mentioned it is the number 1 vaccine preventable cause of death in the United States. Wouldn’t it make sense that the last place you should catch the flu is in the hospital or in healthcare? Wouldn’t it make sense that in an environment that potentially concentrates individuals who have health risks, maybe lower immunity, maybe cancer, maybe just a patient for anything else, but the last place they should get infected is a hospital or health care environment? We think that is the case. And the National Patient Safety Foundation thinks that’s the case. That’s why together we adopted policies to assure that prevention of the transmission of the flu was the rule, not the exception. But it was a little bit out of the norm 3 and 2 years ago, but we went forward with a policy. To give you an example, in operation, across HCA facilities over 95 % of our clinical workers, that’s over 160,000 people, are vaccinated. The other 5% wear masks around patients during influenza season for 100% patient safety through prevention of transmission. I want to thank Diane and the entire NPSF leadership team, and board and membership for really having the fortitude to take on a policy which was the exception, but today is now the standard.
Jane: Thank you both very much. This year, the National Patient Safety Foundation gave us a theme for Patient Safety Awareness Week which was “Be Aware for Safe Care.” The emphasis is in that theme is on the importance of effective communication between patients and providers. So Diane let me start with you, how do partnerships between patients and their health care providers contribute to safety?
Diane: Well, I think we all recognize that we have not optimized on the value of patient engagement in our work. Our culture has historically been one of patients being passive recipients of care at the hands of the “experts.” While, there seemed to be nothing wrong with that all along, what we have come to understand over time, better than we did before, is that an informed patient and an engaged patient can offer added value to the process and it makes sense and stands to reason that in any healthcare situation, the one who knows the most about the patient is the patient. For us to not have taken advantage of that all along was something that compromised our ability to get to the best point of care. And very specifically with the patient safety work, we have come to realize, I mean one of the things that came out of our kind of taking a look outside of our industry and seeing what other high performing industries, high reliability organizations did, it was very evident that one of the keys to delivering safety and having an effectively safe culture is the emphasis on teamwork. And that directives issued by one individual to others are not necessarily the best way to function when you have more than one individual involved in a process. And that is why the airline industry, for example, adopted resource management and changed the way cockpits were organized and changed the rules for how people interacted in flight. So in the old days when a pilot was doing something that the co-pilot thought might potentially be wrong or could potentially endanger the flight, the co-pilot was not in a position to speak up. So they recognized that full team engagement and the ability for everyone on the team to have a say was a value and in fact, when they changed their culture to accommodate that, the result was that their safety profile improved quite significantly.
So when we look at the way we have practiced health care all along, it’s not our fault, I mean our system grew up around an original journeyman model where the town physician did everything for the patient, but the more complex care got, the more specialties and affiliated care providers came to the fore, the less able a single individual has become to deliver the entirety of the care required by the individual patient. So we have come to recognize that it’s not just having more than one person involved that is important, it’s the way they all interact and it’s the significance and the value of having a team approach where everyone’s voice is important and everyone is contributing their individual expertise to the process that makes the process better. And when you think about it that way, and you start defining the team as being an important aspect of the culture and critical to delivering safe care, you cannot define a care team and leave the patient on the outside of the definition. We never, at NPSF, talk about a team without including the patient in the definition. So even to say the patient and his/her care team is something we don’t think is reflective of the mindset that we all need to have. When patients are involved and engaged, they bring to the table, obviously a complete understanding of how they are feeling and how they learn, and they also have responsibilities in the care process. You can’t move the patient to optimal clinical outcome without some participation on the part of the patient. They’re responsible for their own health, they have a role to play. As we allow them to do that more and more and respect their right to speak up and be involved, and informed effectively, what we start to see is that the process works better. So kind of the old days of the patient feeling that they aren’t allowed to say anything or the providers being non-receptive to questions we hope is in our rear view mirror. And although we still have quite a ways to go, the norm now is more along the lines of the expectations that the patient is going to be informed after all the information age. That they are going to come into the healthcare system having “Googled” their symptoms or their diagnosis, or whatever and curious about what it is that is going to be done to them and desirous of being a part of that decision process.
Lots of studies that show that shared decision tools are effective in helping patients go down a better path of care. We at NPSF 3 years ago during Patient Safety Awareness Week, put out into the field a compact, a patient compact, and the reason we did this was because we felt that the standard and very aged Patient Bill of Rights, while it was important at the time it was developed in the late 70’s, was no longer relevant. It is no longer relevant to the role of the patient in today’s healthcare market. It is important that we understand what patients want but it is divisive to have a Bill of Rights that essentially exists because one of the parties feels they need to defend themselves because they aren’t being listened to. So we specifically designed a compact between patients and providers and launched it 3 years ago and in fact take the opportunity every year during patient safety awareness week to reconfirm it and survey folks about whether it is still relevant. But that compact is a description of the goals for effective partnering between providers and patients.
Jane: Thank you Diane. Dr. Perlin?
Dr. Perlin: Well thank you. Our English colleagues have a saying that summarizes their aspirations for patient engagement; “no decision about me, without me,” no decision about me without me. That is a pretty inspiring aspiration but it is difficult to realize because there is the history of not having those sorts of conversations that fully engage the patient or fully engage the entire team. If you’re a patient in a hospital or a patient in the doctor’s office, it is sometimes hard to speak up and ask the question that is really on your mind. But sometimes that question has huge importance for patient safety, like: “Do you think you need to wash your hands before you put that IV in or wear gloves?” We need to really do a couple of things; first we need to make sure that we are very clear in terms of expectations about reducing infections by washing hands. But we also need to encourage the environment that really not only allows but facilitates the patient to speak up to be a part of and as possible lead the conversation. In internal medicine, my specialty, we say that 85% of the diagnosis is the history, it’s the listening. And the effectiveness of care, whether it is listening to the patient, whether it is communication across all the members of the team, nurses, doctors, pharmacists, all allied health professionals, administrators all come together, is so much better when the communication is really an active intent and not an afterthought. This is almost as revolutionary as the reframing of the question after To Err Is Human from “bad things happen” to “what can we do?” This is a resetting of a long standing culture and really moving to an environment that will better serve needs of patients likely more efficiently, certainly more effectively, and absolutely more compassionately. Our Chief Nursing Officer and Chief Patient Safety Officer, Dr. Jane Englebright, is really a leader in a topic that’s known as therapeutic communication, and I turn the question back to Jane Englebright, when you think about this next era and patient safety, can you comment on your thoughts on the importance of effective communication not only with the patient, but with the patient and with all members of the health team.
Jane: Well thank you Dr. Perlin. You know that is a passion of mine. I think it does go back to my roots as a nurse where that time with the patient and that focus on the patient is so valued and so much a part of what nurses bring to the team. In today’s fast-paced world, as we work to give more care, it’s a thing that we often forget about. And it takes conscious intention on the part of all care givers to make sure that every moment with the patient is therapeutically rich and that our conversations, our thoughts and our attention are really focused on that patient for every moment of our interaction. This notion of involving the patient in their care is more than just being nice to the patient and it is more than just informed consent. It is really an ongoing collaboration that is laced with meaningful conversations that are focused on the patient.
I have asked you 3 big picture questions about what is going on with the national movements around patient safety, so let me ask a personal question now. Both of you have been long-time leaders in patient safety, what is your greatest source of motivation?
Dr. Perlin: Well this is really easy. First and foremost, the patients that we are privileged to serve. I think as I contemplate patient safety, I’d like to think that patients can get, and that we aspire building systems that can provide the kind of care that we want for ourselves, our families and our friends. We need to build the systems that ensure quality and safety for each individual. And that as a health professional, an individual who sometimes get called in to advocate for a patient’s needs when the dots don’t connect, that we can build systems that have the properties of safety, effectiveness, efficiency, and compassion without the need for an advocate. So, patient first and foremost, and secondarily, this is hugely important to recognize during national Patient Safety Awareness Week and frankly throughout the year, I’m inspired by the care providers, the nurses, pharmacists, the administrators, the physicians, all the members of the care team, who really bring their intellect, bring their passion, wake up every day with the intent of doing good things and doing good things well. And I’m inspired to give them the tools so that they can do their best in serving patients with safety, effectiveness, efficiency, and compassion.
Jane: Thank you. Diane, how about you?
Diane: First and foremost my inspiration is patients and patient care and taking care of people. And so, I came into the healthcare industry and I always knew that was where I wanted to be. The whole time I was growing up, but I came in not as a clinician; I came in on the other side of the equation and spent my early years in the provider system incredibly inspired by the care givers, by the clinicians, by the doctors, nurses, respiratory therapists, pharmacists, everyone who is committed to help make patients better. And my motivation was to provide the best systems and processes available to help them do what they were trained to do and were passionate about doing. I think that I became further motivated by the potential of making improvement on a larger scale across institutions which was what took me in a bit of a different direction. And doing this patient safety work which I find so compelling because it really is at the heart of it all about helping providers do what they want to do which is deliver the best care to their patients in the most effective, compassionate, and the safest way without the horror of potentially doing unintended harm.
Jane: Well thank you. Anything else that either one of you would like to add to this discussion as we come to the end?
Dr Perlin: Well let me add one other thing that inspires me. I am inspired by leaders like Diane Pinakiewicz, you Jane Englebright, and I don’t want this moment to pass without really thanking Diane and the leadership and the entire National Patient Safety Foundation for their leadership and helping to call the question but also bringing a lot of knowledge together to allow motivated, passionate, bright, committed healthcare providers and all those who are interested to really advance the quality of care and the safety. So, my thanks to National Patient Safety Foundation, Diane, and to you personally for your leadership.
Diane: Thank you Jon that means a lot to me. And all of the work that we do, and our boards and everybody who has been involved with NPSF since our inception, it would all be for naught if we didn’t have leaders like you and committed folks like you have across the HCA system to actually carry out the work and make a difference at the point of care. So I thank you as well.
Jane: Well let me conclude by thanking both of you, Diane Pinakiewicz from National Patient Safety Foundation and Dr. Jonathan Perlin from HCA. Thank you for today’s very stimulating conversation and a special thank you for your continuing work in leadership in advancing patient safety for the entire country.