Putting a structure to safety
Date: November 14, 2011
A lot of people might not be aware that when Mike Armstrong took over as chairman of the Johns Hopkins Medicine board of trustees, he made patient safety a top focus. He decreed that every meeting start off with something about patient safety. Partly because of his own experiences as a patient—though not bad experiences—he had that view of where potential errors could occur. You couldn’t slide that item down on the agenda, you couldn’t delete it, it had to be first, and he wanted the numbers. He insisted on getting sentinel events reports. He wanted to know everything that was going on with patient safety.
He was like a dog with a bone in his mouth. He would not let this issue go.
Mike understood that we needed to push patient safety out, not only to Bayview, but to Howard County General Hospital, Suburban, Sibley and All Children’s. The question was, What is the best mechanism to make that happen? We knew that the structure couldn’t just sit in the dean’s office or even the school of medicine. It had to encompass all of Johns Hopkins Medicine. We’ve done some successful patient safety and quality care improvement initiatives in pockets and silos—at different hospitals and at centers like the Center for Innovation in Quality Patient Care.
But the value comes into play when we can pull together all of those resources that are embedded in these silos so that we get synergies, so that we’re not duplicating efforts. For example, what we do to improve safety and quality and how we measure success at Hopkins Hospital should be applied not only at all of the other hospitals and ambulatory centers, but as we move toward more clinical integration, also at private doctors’ offices in the system.
We want to make sure that no matter where patients access our system, they receive the same level of quality care, the same level of safety. There’s no room for debating this point.
That’s where the Armstrong Institute for Patient Safety and Quality comes in. Mike and I have been talking ever since he put up money for the Anne and Mike Armstrong Education Building almost six years ago about what his next gift would be. It stood to reason with his passion that it would support patient safety.
In thinking about who would lead the institute, it was my view, and it was shared by Mike and others, that you can take patient safety only so far on the administrative level. You need a physician leader to drive it further. That is why we tapped Peter Pronovost to head the institute. No question, Peter has the international reputation in this area. We are and should be the leader in this field. The ability to coalesce our safety and quality groups will give us additional strength in the market and the world.
When I was a third-year medical student at the University of Rochester, I had a personal experience with a medical error that has stuck with me. I had gotten to know a young man who was a third-year graduate student going for his Ph.D. He had developed a lesion on his back. A surgeon had removed the lesion, but for some reason never sent it for a biopsy. It turned out to be a malignant melanoma.
Later, when I was doing a rotation in neurosurgery, he came in for a lesion on his brain. I remember that we had several talks in which he said he knew he was going to die and there was nothing he could do about it. We were the same age, yet he was going to die, and I was going on to earn my medical degree. I still think about him and how easily the outcome might have been different had the caregiver taken the simple step of sending that biopsy to pathology or if there had been a protocol in place to follow. I saw this as a preventable medical error.
I understand that there are going to be medical errors and, unfortunately, someone may die as a result. I can accept that only if we have standards and protocols in place across the system and they were followed. Anything short of that is unacceptable.