Issue No. 8
Patient Safety Forum Convenes an Unlikely Team to Address Health Care Challenges
Date: October 1, 2013
A former space shuttle commander. A nuclear engineer. A Ritz-Carlton executive. A pilot turned American hero. These experts were among the diverse group of presenters who convened for the Forum on Emerging Topics in Patient Safety, held Sept. 23-25 in Baltimore.
The inaugural event, presented by the Johns Hopkins Armstrong Institute for Patient Safety and Quality, in conjunction with the World Health Organization, drew international experts from a dozen different fields, such as education, government and sociology. Their goal: to learn what new, untapped lessons other industries hold for health care—especially patient safety—and to work together to accelerate the pace of improvement.
Keynote speaker Captain Chesley “Sully” Sullenberger, known for safely landing a disabled airliner in the Hudson River in 2009, challenged more than 200 clinicians, patient advocates, health care leaders and policymakers to consider what they could learn from aviation’s efforts to improve safety.
“Aviation wasn't nearly as safe 40 years ago, when I started, as it is now," Sullenberger said. It took a series of plane crashes and intense scrutiny by the media and public for airline leaders to make changes to improve passenger safety, he said.
Today, the industry has significantly improved its track record. Sullenberger attributed advancements in aviation to a sense of urgency for change among leaders, standardized work processes and environments, and systems designed to enhance safety. Sullenberger noted that airplanes have integrated systems, all working together, to ensure a safe flight. He contrasted this with intensive care units and operating rooms, which have numerous devices and technologies that operate independent of one another. In addition to checklists and teamwork skills, he said more safely designed systems are a key component of the aviation success story that needs health care leaders’ attention.
Peter Pronovost, director of the Armstrong Institute and senior vice president for patient safety and quality at Johns Hopkins Medicine, echoed Sullenberger’s call for more integrated systems in health care, as well as for standardized work processes and teamwork.
“Health care today comes from a team of experts, but it needs to come from an expert team,” said Pronovost, pointing to tensions between nurses and physicians as factors that could compromise patient safety. “Let’s move from a system that creates unnecessary competition among professionals and relies on the heroism of individuals operating within poorly designed systems to one that creates cooperation in an environment that supports safety.”
He emphasized that collaboration among all health care stakeholders, including medical device companies, regulators, policy makers, health care providers and consumers is necessary to reduce preventable patient harm—the third-leading cause of death in the United States.
During the three-day event, forum participants focused on designing safer systems of care delivery, accelerating the adoption of patient safety solutions and advancing the science of performance measurement. Breakout sessions featured nearly three dozen experts, including Bryan O’Connor, former space shuttle commander, and Patrick Conway, chief medical officer of the Centers for Medicare & Medicaid Services. In one session, Jill Guindon-Nasir, a Ritz-Carlton senior corporate director, and Melinda Sawyer, assistant director of patient safety at The Johns Hopkins Hospital, discussed employee engagement and culture change programs.
On the final day of the forum, attendees convened to discuss ways to implement potential solutions in a World Café format—structured, small-group discussions that allow participants to build on one another’s ideas and insights and gain a deeper understanding of the subject and issues involved.
One topic discussed was how health care could adapt and implement a peer-to-peer review system like that used by the nuclear power industry. While health care organizations are reviewed by regulatory and accrediting bodies, a confidential and voluntary peer assessment program could provide insights that enhance patient safety, according to Pronovost and Dan Hudson, risk and reliability engineer for the U.S. Nuclear Regulatory Commission.
Participants also considered how an organization modeled after the U.S. Securities and Exchange Commission (SEC) could be used to improve how data on the safety and quality of health care facilities are measured and reported. Just as the SEC provides investors with accurate data to evaluate potential investments,an SEC for health care could arm consumers with information to help them decide where to seek treatment.
Another World Café session gathered experts in implementation science, the study of how to put evidence-based solutions into practice. Shams Syed, program manager of the African Partnerships for Patient Safety, explained how this WHO program has spurred improvements in the safety of African hospitals through local and international partnerships.
Inspired by the success of adapting aviation-style checklists to reduce central line-associated blood stream infections, first at Johns Hopkins then across the country and internationally, the event organizers hope the forum will advance solutions to many patient safety challenges.
“In health care, we do have islands of excellence right now, but they’re in a sea of system failures,” Sullenberger said. “We need to make those islands bigger, and we need to have less water between them.”
To watch forum sessions, including Capt. Sullenberger’s talk, set up a log-in and password at http://www.hopkinssafetyforum.com/user-registration/.