Only Twenty Percent There
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.
|By Edward D. Miller,
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
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
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
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
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,
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