BB&T Contributing Writer

CHICAGO – A standing-room-only crowd of more than 700 hospital administrators, surgeons, nurses and other administrative personnel gathered at a Joint Commission on Accreditation of Healthcare Organizations (JCAHO; Oakbrook Terrace, Illinois)-sponsored conference in November to learn from healthcare leaders the strategies and methods that work best in modifying an organization toward improving patient safety.

In the opening keynote presentation, Atul Gawande, MD, assistant professor of surgery at Harvard Medical School (Boston) and author of “Complications: A Surgeons’ Note on an Imperfect Science,” posed the question: “Which will save more lives? Research in a laboratory or research on how to improve safety?” He said he believes that improving areas we already understand will save more lives than research into those things we don’t understand such as stem cells, genomes, cancer, etc.

Gawande said, “At the core of patient safety there are two sources of error: one of ineptitude and one of ignorance. The first is when the knowledge is available but the individual fails to apply it correctly, and the second type of error is when we just don’t have the knowledge.” He said that “science has given us more information, but the more it has given us, the more human we have become. The gap between what medicine can do and what we actually do is where the errors exist.” Gawande said he believes that perfecting our current performance will save more lives today than gaining new knowledge in research on things we don’t understand. He said, “we need metrics to know where to look for improvement and create action on what we learn.” By studying each component of care, identifying sources of error, quantifying those errors and then applying methods to correct those errors, we can produce better results and save more lives on a daily basis.

He used a study on “Reducing Deaths from Battle Wounds” to demonstrate the application of this principle. Gawande studied the lethality of war wounds from the revolutionary war in 1775 through the next 10 wars in which the U.S. was involved. War wounds had remained at a 24% lethality rate for years since World War I, regardless of the millions that had been spent on blood substitutes, new burn agents, and other new technologies. But once the deaths were analyzed, and methods applied to address the findings, they were able to reduce the lethality rate to 9%. It is this method that Gawande supports in order to improve patient safety in hospitals throughout the U.S. For instance, although Kevlar vests were available to soldiers since the 1980s, only 10% wore them regularly. By making the wearing of Kevlar vests mandatory, they significantly reduced the number of wounds inflicted. Researchers found that only 3% of the soldiers in Vietnam died if they had reached a surgical care unit, while those who did not receive surgical care in the field had a 24% death rate. By adding more surgical care units in the field, followed by shipping soldiers to the next level of care if necessary, they could further reduce the percent of lethality. The dramatic reduction in lethality of war wounds was due to researching and identifying the areas of error and applying specific corrections to those areas – something hospitals can and should do.

In another study performed in 1999 and published in Surgery, a review of charts from 15,000 admissions to 28 different hospitals showed that there were 3% adverse events with serious complications. Of these, 47% were preventable and 53% were unpreventable. “Even these statistics fail to show how much we fail,” Gawande said. “When we study individuals performing a specific protocol, we find a bell shaped curve, where some perform better, some worse, and most are in the middle. The difference between the performance of the best and the worst is what we are trying to learn. Once learned, this excellence must be achieved on a daily basis.”

In a presentation on the improvements that Vanderbilt University Hospital (Nashville, Tennessee) has achieved by implementing aviation practices into its lines of communication, given by Richard Clark Jr., vice president of LifeWings Partners and Rhea Seddon, MD, assistant chief medical officer at Vanderbilt Medical Group, they said they found that by using aviation’s best practices they could improve patient safety and quality of care. As a former aircraft carrier jet pilot and commercial flight pilot, Clark shared what the aviation industry learned years ago: “No matter how advanced the technological system, if humans are involved error is inevitable. Aviation recognized that 70% of accidents are based on human error in a team setting and that the key to safety is managing error.”

His question to the audience was “Can lessons learned from aviation be transferred into healthcare?” Between 44,000 and 98,000 patients are killed in U.S. healthcare systems annually; the equivalent of one large jumbo jet crashing daily, Clark said. Both industries are complex and require intense training, and both can succeed in reducing risk and error by applying systems to manage error. Seddon, who was one of the first women astronauts, understands the criticality of risk reduction and elaborated on her “Lessons learned from NASA,” which are: 1) use precise standardized communication, 2) teamwork must be impeccable, 3) prior planning is mandatory, 4) utilize well-developed and well-practiced procedures, 5) leadership must be focused on safety, and 6) safety procedures must be embedded in daily operations. What she learned in space she now applies to her hospital-wide risk reduction system, which has resulted in 619 continuous error-free days since the last surgical error. Can healthcare learn from aviation? The answer is an with emphatic “Yes!”

Although the way to reduce liability exposure is to improve patient safety, there are those unpreventable events that result in a poor outcome. In a panel discussion on what to do after an adverse event has occurred, George Lee, MD, president and CEO of the Physician’s Reimbursement Fund (San Francisco), shared the company’s “apology and disclosure” policy that has been at the root of its success in reducing malpractice claims, resulting in the ability to maintain low premiums to their insured physicians. Inherent to the program is that in the case of an adverse event, “the attending physician meets with the patient and accepts responsibility, apologizes for the outcome, discloses the facts and makes restitution for the losses,” Lee said. Also, “the patient will not experience an economic loss from a bad medical outcome.” The staff contacts the patient and identifies financial or other resources necessary to prevent an economic loss and the patient is then reimbursed for out-of-pocket additional support resources. In addition, the patient is not required to sign a release.

The implementation of full and immediate disclosure, coupled with an up-front solution, has allowed the Physician’s Reimbursement Fund to offer premiums significantly lower than competitive insurance companies while remaining more profitable than most of its competitors (Table 9). But that is not why they do what they do – they do it because “it’s the right thing to do,” says Lee, “If someone asks how much it costs to implement a safety program, we respond with: ‘That’s not the right question to ask.’”

When an adverse event occurs, it is critical that lines of communication between the hospital, its staff and the patient and his or her family remain open – however, it can be very difficult to discuss the situation. Jeannette Ives Erickson, MS, RN, senior vice president for patient care and chief nurse at Massachusetts General Hospital (Boston), discussed the barriers to disclosure and the four steps to communicating a poor outcome. She said that “the reasons it is difficult for a hospital staff member to disclose their error are because they are ashamed, they feel that the outcome may have been the same, that they have no legal protection if they disclose, they fear retribution from the patient or colleagues, and that they have a feeling of failure toward themselves, their team and towards the patient.” Because of these feelings, Mass General requires staff to take training in “Four Steps to Full Communication” which are: tell the patient and family what happened, take responsibility, apologize and explain what will be done to prevent future events.

JCAHO closed the three-day seminar by saying that it is beginning to see broad-based interest in patient safety directed at achieving a greater good and that hospitals are thinking in creative ways to make these advances. A good safety program provides skills training coupled with safety tools and a commitment to safety; these then create a changed attitude towards safety that leads to changed behavior which results in improved outcomes. JCAHO said it has found that those institutions that have put systems in place making it easy for their staff “to do the right thing” are enjoying higher patient safety with reduced risk exposure.