Only Twenty Percent There

By Edward D. Miller, M.D.

A few months ago, the American Hospital Association honored The Johns Hopkins Hospital with one of its coveted Quest for Quality prizes, citing a “strong leadership commitment to patient safety,” our openness on safety and error issues and our innovative efforts to eliminate potential mistakes.

This national award—the only one to an academic medical center—offers welcome affirmation of our three-year drive to make all parts of this medical system safety-centered. It recognizes the hard work of Richard “Chip” Davis and Peter Pronovost at the Center for Innovation in Quality Patient Care and the buy-in we have achieved from hundreds of doctors, nurses and administrators.

Yet I must confess the award in many respects is premature. We have a long road to travel before patient safety is front and center on every unit of Hopkins Medicine. Quite frankly, I think we’re only 20 percent of the way to our destination.

There are pockets of excellence—in the ICUs, in surgery, in the Children’s Center. Infection-control officer Trish Perl has done a superb job on catheter-related infections, bringing the rates for the various intensive care units down to near-zero. That task involved introducing evidence-based protocols, educating the medical staff to follow them and getting everyone invested in the program.

Still, the safety issue hasn’t fully taken root. That’s disappointing because I’m convinced everyone wins when a healthcare institution is safety-centric.

My counterparts around the country are surprised I’m so focused on safety initiatives. Many believe technology will solve the problem. Yet information technology, such as the physician order-entry system, is complex to implement, expensive and often proprietary. My guess is that IT can help eliminate about one-third of the mistakes; the rest will be up to those who staff our hospitals.

Yet when you look at where people who can effect change spend their time, it is usually on financial reports, budgets, patient census and other numbers affecting the bottom line. They allocate very little time to studying the complex processes involved in delivering care safely. That’s ironic because Chip and Peter have shown that when mistakes happen, most often it is the process that’s at fault.

The deeper I delve into this issue, the more I am convinced we have misplaced our priorities. Ensuring the safety of patients is every bit as important as the financials. Indeed, it can have a direct and positive impact on them. For instance, the Joint Commission on Accreditation of Healthcare Organizations recently mandated a “timeout” before surgery to confirm that the right patient is on the table, surgical sites are correctly marked and to go over a checklist of procedures. This is a simple yet powerful way to guard against blunders. It also can improve productivity.

On the first day that presurgical timeouts became official policy at Hopkins, we recorded the greatest number of on-time starts ever in the OR. Why? Because surgeons who previously had not shown up for preliminaries now had to be there early. As a result, we’re finishing each day’s work in the OR on time.

Similarly, our success in dramatically lowering catheter-related infections pays off for both the patient and the hospital. If a patient sails through an operation with no complications and a brief hospital stay, the patient is thrilled and we retain more of third-party payments.

Improved safety makes sense for everyone—and we can quantify that.

In the years ahead I see superlative patient care as an essential part of what sets us apart. This will happen if all of us start thinking: “What can we do that will differentiate Hopkins when it comes to ensuring a patient’s safety?”

Sweeping cultural change of this nature must start with senior management. We have to send word through the ranks that we’re serious about putting in place new safety procedures, and the emphasis on safety won’t fall off the radar screen. Protection of patients will remain at the top of our agenda.

This year, we have incorporated safety in our performance evaluations, tying safe outcomes to personal rewards. Each department must develop and implement its own safety program. We will measure progress and make budget decisions accordingly. We want chiefs and administrators spending time each day or week identifying the most critical areas where things could go wrong and coming up with solutions.

I know there will be resistance in some quarters. Change is never easy, especially for practitioners who have enormous confidence in the procedures they have gotten used to following. But safety must come first.

Yes, I’m pleased a prestigious national organization recognizes the progress we’ve made in reducing mistakes. At the same time, I’m frustrated at the slow pace of change. Every day without reforms puts patients at risk. We sacrifice productivity and efficiency, too.

I want us to be known as the safest hospital in America when it comes to protecting the patient. We can reach that goal if every one of us develops a sense of urgency. Safety is not just a priority here: It is the priority.