Having spent the majority of my life living in Chicago and being a big basketball fan, I had the great pleasure of watching the Chicago Bulls during the Michael Jordan and Phil Jackson era. For basketball junkies like myself, it couldn’t have been any better. While the athleticism of the basketball played on the court was always a great attraction, the leadership examples set by Jordan and Jackson resonated with me both personally and professionally. From Jordan, it was his passion for the game that was his life’s work–leaving everything on the court, every game. From Jackson, it was his ability to pass on the love of the journey in the midst of ten team championship seasons across a career.
Michael Jordan had a “Love of the Game Clause” written into his contract. It gave him the ability to play in a pick-up basketball game, anywhere–anytime, because he loved playing basketball. He didn’t want the Bulls to keep him from playing the game he loved whenever he wanted. Today’s athletes aren’t allowed to do this because teams and owners fear they might hurt themselves – their contracts forbid them from participating in non-professional athletic activities unless first approved. Sightings of Michael Jordan playing basketball with neighborhood teens in Chicago parks and schoolyards were common in the early days of his basketball career. In my mind, Jordan’s passion for the game, and the artistry with which he graced the court was second to none.
Phil Jackson’s reference to the Chinese saying, “the journey is the reward” throughout his career stuck with me throughout mine. After each of the six NBA championships he won with the Bulls, and four more with the LA Lakers, Phil would relate that the work put in every day–coming together as a team, creating an offense that flowed smoothly, almost intuitively and a defense that capitalized on each players’ strengths, drawing out the weaknesses of the opponent, was far better than an NBA championship trophy. When I reflected on things in my own life, I thought his comments were always right on the mark.
So how does basketball, the Bulls, Phil Jackson and Michael Jordan connect to the Malcolm Baldrige Quality Award? When I met with Bill Neff, Ric Detlefsen and Stan Gunstream, members of the Poudre Valley Health System (PVHS) leadership team last week, they unknowingly echoed Phil Jackson’s words numerous times. The journey far exceeded the award, they shared. Less than a dozen hospitals have been awarded this prestigious award, given by the president of the United States and considered the nation’s highest honor for innovation and performance excellence, and they were telling me the journey was more rewarding than the award? Only a Bull’s fan would understand. Or maybe Phil Jackson fan.
Hard to believe, but Bill Neff explained. When their CEO announced PVHS was going to apply for the Baldrige Award, leadership all thought, “great idea – this will be fun. Since we already provide high quality care it will be easy”. Their leadership team all believed they would win the award the first year they applied…if not the first year, the second year for sure. They were already picking out where the trophy would be displayed in the hospital’s lobby. When the evaluation came back that first year, not only had they not won the award, their quality score was not even close enough to warrant a site visit. As Bill shared with me, PVHS leadership’s first reaction to the rejection was “the Baldrige reviewers didn’t understand healthcare quality. We’ll reapply next year and get reviewers who get it.”
The following year, they did a better job of addressing issues in their application, reapplied, and guess what? Their quality score was lower than the first year. This phenomenon is common in medicine. Don Berwick and others often reproduced this same self-aggrandizement when they would ask audiences of physicians to raise their hands if they believed they were in the top half of their discipline. Every time they asked this question, all the physicians in the audience would raise their hands. So leadership at PVHS looked in the mirror and said “we aren’t as good as we think we are”. That single reflection and honest assessment led them on their road to high quality patient care, and one of the most fulfilling journeys of their professional careers.
The mission then became improving how they provided patient care each day by using the annual Baldrige quality assessment report as a guide, completed by an independent expert quality assessment team without any personal agendas or motivations. They decided to use it as a tool to improve their patient care and make their organization better. It took four years before they finally qualified for a site visit by the Baldrige team, and another four years before they won the award. But as Bill Neff shared, an amazing thing happened on the way to the award. The culture at PVHS had changed. Everyone now looked forward to the annual Baldrige assessment report because it became the driver for them to refocus energy and effort in areas that were cited for improvement by the assessors. Over the eight years, the focus had changed from winning the award, to pushing their patient care to a higher level each year. For PVHS, like Jordan and Jackson, the journey was truly much more important than winning the award .
Yesterday, I introduced the multi-disciplinary team at MedStar Health System led by Terry Fairbanks MD/MS, Director of the National Center for Human Factors Engineering in Healthcare and his team’s proposal for an Integrated Patient Safety Transformational (PST) Model to prevent and mitigate harm to patients. A description of the model, and a proposed plan for dissemination, follow. Comments are always welcome!
The team’s PST model is based on the clinical concept of primary, secondary and tertiary disease prevention–where interventions are first targeted at disease prevention, and then finally at mitigating disease if/when it occurs. The example the team provides is for Cardiovascular Disease Prevention:
- Primary prevention includes things like encouraging a healthy lifestyle or smoking cessation programs.
- Secondary prevention encompasses screening for risk factors and then controlling those risk factors.
- Tertiary prevention includes strategies employed post heart attack or optimizing congestive heart failure management.
The PST model for patient safety improvement takes a novel approach by shifting the typical focus of healthcare’s medical error management from “after the fact” to the primary and secondary areas of opportunity. The model is designed to proactively identify existing hazards and marginalize them before error occurs, and enhances the management of error if it does occur, through transparent disclosure when appropriate (tertiary prevention). These efforts will not only protect patients from preventable harm, but also have the potential to provide considerable cost savings to the health system.
Five “best practice” modules were selected to address these three areas of prevention with the ability to design additional modules if a need arises. Each module will be measured for its individual efficacy, as well as the efficacy of the model as a whole. The flow of the proposed PST model will include:
- Primary prevention: Module 1 (Proactive Risk Assessment), Module 2 (Enhanced Patient & Family Satisfaction), Module 3 (“Warm Handoff” including team dynamics and physician-patient communication strategies)
- Secondary prevention: Module 4 (Hazard Alerting Loop which reports hazards and collects, analyzes, trends, and feeds back hundreds of reports to staff)
- Tertiary prevention: Module 5 (Trains a “Go Team” to immediately address medical error through disclosure/apology/compensation (where appropriate), support staff involved and immediate initiation of systems-safety based event review)
The team is striving to apply the model within MedStar health operations, but is awaiting AHRQ’s review of their grant proposal which, if awarded, will allow an intensive implementation in the emergency medicine setting. Of importance to note, is that MedStar has a unique proving ground within their system. The five EDs where they hope to test the model reflect the diversity and breadth of the urban, suburban and rural areas in Maryland and the District of Columbia. Several of MedStar’s community hospitals, along with the larger teaching and tertiary care centers, serve diverse patient populations and present an opportunity to provide research that is inclusive of many patient populations.
Hundreds of near misses occur for each adverse event in complex industries, according to James Reason’s research, yet many health systems continue to try to solve the medical error problem by focusing on the proverbial needle in the haystack, which still occurs all too frequently. So frequently in fact, that the World Health Organization recently reported the odds of dying due to a medical error to be 1 in 300 compared to the likelihood of dying in an airline crash, which they estimate to be 1 in 10 million.
But the MedStar Health System in Maryland and Washington DC is increasing their odds of finding a new way to prevent medical errors before they occur. Leadership at this innovative health system is successfully collaborating across multi-disciplinary lines with safety scientists, innovation researchers, safety & quality leadership and their simulation center, SiTel, coming together to move patient safety into the 21st century. Instead of waiting for a medical error to occur, Terry Fairbanks MD, MS (Director), Zach Hettinger MD, MS and their team at the National Center for Human Factors of Engineering in Healthcare are taking into account the opportunity those hundreds of near misses present, and the team is looking to test their Integrated Patient Safety Transformational (PST) Model which provides a proactive approach to medical error prevention, catching errors before they occur.
If medical error should occur, the PST model also includes the same tenets of disclosure and transparency the 7 Pillars approach is based upon, and which received a $3M AHRQ grant in 2010. David Mayer MD, our blog host and now VP of Safety & Quality at MedStar, is co-Principal Investigator on the 7 Pillars grant, along with Principal Investigator Tim McDonald MD/JD at the University of Illinois-Chicago Medical Center. With Mayer’s arrival at MedStar in May of this year, it was apparent that Fairbanks’ human factors work raised the 7 pillars to new heights (and vice versa). The model was now complete by providing an organized and optimized advanced response to adverse events with an emphasis on improving safety and reducing liability risk before error occurs, but also having a progressive approach to work with patients, families and caregivers if events do occur.
A description of the PST model, and the origin of its genesis will be provided in tomorrow’s post. In the meantime, please share your innovative ideas around preventing medical error and keeping patients safe.
Another hospital performance evaluation was released last week – this one by the Joint Commission (JC), having announced its Annual Report on Quality and Safety. A list of Top Performers was included in the report. The amazing thing to many of us working in quality and safety is that there seems to be little consistency between the evaluation outcomes of this newest assessment and those released over the last few months, such as: The Leapfrog Group, US News & World Report, Consumer Reports, and HealthGrades. While all these organizations use somewhat different criteria to choose their Top Performers list, one would hope some consistency would exist among those anointed top performers–at least to reassure all of us that the conclusions drawn are valid. For instance, not one of the top ten hospitals in the US News & World Report is included as a top performer by JC. HealthGrades’ list of the top 50 hospitals in the country, with over 75% of their grading based on quality and safety measures, looks quite different from the JC top quality and safety performers. It makes many wonder why organizations that have access to the same metrics all come up with quite different results when evaluating performance.
Which brings me to the Malcolm Baldrige Quality Award. I had the pleasure of visiting Poudre Valley Health System (PVHS) this past week. Members of their leadership team – William (Bill) Neff, Ric Detlefsen and Stan Gunstream – attended our Telluride Patient Safety Roundtable this past summer, and shared the story of their hospital’s commitment to high quality care, including having earned the Malcolm Baldrige National Quality Award in 2008 for their efforts. Their story, and their commitment to do the right thing for their patients no matter how difficult the journey, struck a chord in me this summer. I had asked if I could visit their hospital later in the year and observe the work they had shared with us in Telluride. Here is Rulon Stacey, CEO of Poudre Valley Health System, accepting the award:
My day began at 7:00am with their Quality Improvement Update meeting. When I entered the conference room, over 100 people including all members of their C-Suite were already in the room, eagerly awaiting the start of the meeting. Over the next sixty minutes, five teams presented Rapid Improvement Experiment (RIE) data in five different value streams. Each multi-disciplinary team consisted of 8-10 caregivers, who had been given a full week away from clinical responsibilities to redesign and trial the process improvement and was given 6 minutes to present their work. (The hospital bought out the time of MDs on each team during the week they worked with other team members on quality and safety innovations). These presentations were followed by five additional teams, who were given 3 minutes each to update data from RIE work completed the month before. Leadership provided feedback to each of the teams for the last 10 minutes of the hour-long meeting. The energy in the room was contagious, the sense of accomplishment palpable, and the commitment to quality improvement exciting to witness.
During the next few hours, Bill, Ric and Stan shared the story of their ten-year journey en route to winning the Baldrige Award, the nation’s highest honor for innovation and performance excellence awarded by the president of the United States. PVHS was one of three organizations to receive the award in 2008, and the only healthcare recipient, making it one of the best hospitals in America. What is most impressive about the team at PVHS is their modesty and business-as-usual attitude about the award itself. The challenges and dedication to the journey in the best interest of their patients is what they stressed the most–the award was the icing on the cake. In fact, the year they did win the award the caregivers were just looking forward to receiving the Baldrige evaluation report that came each year so they could see where they needed to focus their quality improvement energy for the coming year – the annual report had become their roadmap to high quality care. They were surprised and delighted they had won the award. It’s amazing to see what good people can accomplish when focused, and pointed in the same direction. A second post will follow on their lessons learned.
About the Baldrige Award
Congress created the Baldrige program in 1987 to promote quality awareness, to recognize the quality and business achievements of U.S. organizations, and to publicize these organizations’ successful performance strategies. Stand-alone hospitals, and large health systems nationwide can use the Baldrige criteria to improve their operations and sustain world-class results. Organizations being considered for the award undergo a rigorous review of:
- Their leadership
- Strategic planning
- Customer (patient) and staff focus
- Knowledge and process management
- Clinical, regulatory and financial results
When it comes to recognizing high quality healthcare, the Baldrige Award is one “High Performer” assessment model that uses stringent review criteria, incorporating site visit evaluation methodologies that are difficult to question.
From their website:
The Baldrige Criteria help health care organizations achieve and sustain the highest national levels of
- patient safety and patient loyalty
- health care outcomes for acute myocardial infarction, heart failure, pneumonia, and other conditions
- physician and staff satisfaction and engagement, especially among registered nurses
- revenue and market share
- community services
The Baldrige Criteria for Performance Excellence provide a system’s perspective for understanding performance management. They reflect validated, leading-edge management practices against which an organization can measure itself. With their acceptance nationally and internationally as the model for performance excellence, the Criteria represent a common language for sharing best practices among organizations. The Criteria are also the basis for the Malcolm Baldrige National Quality Award process.
Regardless of what other quality and safety rankings might tell us, I would give PVHS a top performer quality score. Can’t argue much with the Baldrige assessment methodologies when compared to many of the other models.
A review on the reasons why, and the methodology behind, incident reporting continues. We welcome your thoughts, and reference summaries as well.
Dr. R Lawton from the School of Psychology at the University of Leeds and colleague looked to better understand “the willingness of healthcare professionals (doctors, nurses, and midwives) to report colleagues to a superior member of staff following an adverse incident or near miss.” They also explored “the difference in reporting of events involving three kinds of behavior defined by (James Reason)–compliance with a protocol, violation of a protocol, an improvisation where no protocol exists.” Lawton theorized that the culture of medicine, along with the increasing fear of litigation, would likely constrain healthcare providers from reporting.
And that is almost exactly what he found, as results showed:
- Doctors were less likely to report a colleague across the board, even when a colleague deliberately went around protocols.
- Nurses were the group most likely to report if there was a bad outcome for the patient.
- Protocol violations were reported most frequently, regardless of outcome.
The authors speculate that doctors’ unwillingness to report violations of protocol equal to their nursing or midwife colleagues may be a reflection of the perception that protocols “by many in the medical community (are viewed) as a threat to their professional autonomy”, and that doctors are reluctant to report a colleague as a reflection of “a professional culture in which what may be seen as whistle blowing is taboo.” Either way, the authors conclude that culture change within the NHS may first have to occur in order for incident reporting to deliver its true benefits.
The introduction of Evans and colleagues paper on incident reporting gives an excellent overview of the benefits these reports provide:
Incident reporting captures more contextual information about incidents and, when actively promoted within the clinical setting, it can detect more preventable adverse events than medical record review at a fraction of the cost. Near misses are rarely documented in medical records, yet occur more frequently than adverse events and provide valuable lessons in recovery mechanisms without the detrimental consequences of an adverse event. The subjective data provided by incident reporting enable hypothesis building and preventative strategies to be developed and tested. (See article for references).
An anonymous survey modified from Vincent et al J Eval Clin Pract 1999 was given to participants (186 doctors, 587 nurses both with >70% response rate) asking the following:
- Do you know if your hospital has an incident reporting system?
- If yes, do you know what form to use to submit a report?
- If yes, do you know how to access the reporting system?
- If yes, do you know how to submit a report?
- How often do you report 11 iatrogenic injuries (listed in Figure 2), and how often should these injuries be reported?
- Nineteen reasons as barriers to reporting were evaluated using a likert scale (listed in Table 2)
Results indicated that:
- Doctors and nurses were equally aware of an incident reporting system at their institutions, but nurses were significantly more likely to have filed a report (89.2% v 64.6% p<0.001). This may have to do with the fact that nurses also knew how to locate, and what to do with, a report to a significantly greater degree.
- Senior doctors were significantly less likely than their younger colleagues to have submitted a report.
- Both doctors and nurses completed reports most often for falls and least often for pressure sores.
Perceived barriers to reporting for doctors were: 1) Lack of feedback 2) Form took too long to complete and 3) Incident was perceived as too trivial. Barriers for nurses were: 1) Lack of feedback 2) Belief that there was no point in reporting near misses and 3) Forgetting to report when the ward was busy.
Of note in this study was that a poor reporting culture had less to do with the cultural environment and more to do with the functionality of the reporting system. Authors did note however, that the “poor reporting practices by doctors…probably reflects the prevailing deeply entrenched belief in medicine that only bad doctors make mistakes.” Authors conclude by highlighting the importance of sharing with staff the changes that are implemented as a result of the incidents reported.
Ravi Mahajan from the Division of Anaesthesia and Intensive Care at Queen’s Medical Centre in Nottingham, UK reviews how high reliability organizations, such as aviation and the rail industry, have been using incident reporting as a learning tool for improvement for some time yet that same well documented tool has not caught on in healthcare. According to Mahajan, the main reason to report incidents to improve patient safety, which is also well documented:
…is the belief that safety can improved by learning from incidents and near misses, rather than pretending that they have not happened.(5)
He states that leadership, larger governing bodies of healthcare and consumers are calling for the information incident reports provide in order to “better understand error and their contributing factors.” Mahajan highlights the World Health Organization (WHO) as having outlined guidelines for implementing effective reporting systems. Additional information on the WHO reporting guidelines can be found here.
What Mahajan also includes in his review is the need for a human factors approach to the analysis of medical errors, which considers the human component within the larger context of the health system. Instead of taking the quick and easy summation of an error as “someone’s fault”, a human factors approach takes into consideration all the events leading up to the error through a much larger lens, considering Reason’s “active and latent failures” mentioned earlier. All of this, he says, incorporated into the framework for analyzing critical incidents suggested by Vincent et al Br J Med 1998; (316) which takes into consideration the socio-technical pyramid discussed by Hurst and Ratcliffe and adapted to the clinical setting provides a structured approach for a meaningful root cause analysis of the error. The framework can found in Table 1 of Mahajan’s review.
Without meaningful feedback, however, Mahajan and others continue to point out the reports and the analysis are meaningless.
As we’ve mentioned, the road to high reliability starts with the formation of a just culture that supports the reporting of unsafe conditions, near misses and adverse events, in order to uncover those conditions within a system that make it prone to harm. It’s a simple statement–one that makes intuitive sense–so why then, has a reporting culture evaded medicine? The following authors weigh in on the how, what and why of incident reporting to show that any related growing pains are well worth the struggle in the best interest of our patients.
Please share references and information that will help raise our collective knowledge, and provide a road map for others seeking to build a reporting culture en route to high reliability. Our patients are depending on us to take this journey–
In this 2002 paper, Lucian Leape MD reiterates the recommendation of the Institute of Medicine’s To Err Is Human report, calling for the then controversial expansion of reporting around serious adverse events and medical errors. He also highlights that in order to stop the frequency of harm befalling patients, a greater understanding of the harm and its causes is needed “for the development of more effective methods of prevention (as) it seems evident that improved reporting of accidents and serious errors that do not cause harm (“close calls”) must be an essential part of any strategy to reduce injuries.”
Lucian describes the primary purpose of reporting these events is to learn from them, and the only way to learn is to first be aware the problem exists. Additional reasons to developing a robust internal reporting system according to Lucian include:
- Allows for monitoring of progress
- Allows lessons to be shared so others can avoid similar mishaps
- Holds everyone accountable
Table 2 in his report lists the characteristics of a successful reporting system along with an explanation. In brief, those characteristics are: 1) Non-punitive 2) Confidential 3) Independent 4) Expert analysis 5) Timely 6) Systems-oriented 7) Responsive
James Reason has been mentioned more than one time on this blog because of the focus we have on becoming a high reliability organization. Reason’s work in just culture and his in-depth research examining a person versus system’s approach to understanding medical error reinforces the need for a reporting culture in order to achieve high reliability. Reason writes:
Effective risk management depends crucially on establishing a reporting culture.(3) Without a detailed analysis of mishaps, incidents, near misses, and “free lessons,” we have no way of uncovering recurrent error traps or of knowing where the “edge” is until we fall over it…
…Trust is a key element of a reporting culture and this, in turn, requires the existence of a just culture–one possessing a collective understanding of where the line should be drawn between blameless and blameworthy actions.(5)
Reason’s explanation of a just culture is one in which error reporting is handled in a non-punitive manner, looking to understand active failures and latent conditions within a systems context. However, he recognizes that within the system, each individual remains accountable for their actions. In a high reliability organization, every individual is reminded of the value of incident reporting as the focus is put upon intentionally looking for anything that could result in harm.
Charles Vincent raises the point that incident reporting is only as effective as the measurement and patient safety programs that result from gathering the reports. As many agree, one of the reasons physicians give for failing to report is that having taken the time and emotional energy to do so, the report then sits without response or action. Vincent editorializes that:
…a functioning reporting system should no longer be equated with meaningful patient safety activity. Organisations must move towards active measurement and improvement programmes on a scale commensurate with the human and economic costs of unsafe, poor quality care.
The follow up on each report is reinforcement for the next incident to be reported. And it must be meaningful, productive feedback that rewards those who take the time and stick their neck out to share information.