Creating safe environments is not a mystery. There are playbooks and a rigorous curriculum in safety science. High-performing, complex and high risk-industries build continuous improvement into their work processes, achieving nearly defect-free environments.
Somehow, this has eluded the U.S. health care industry. We’ve been aware of the scale of the problem for at least two decades, but as a society we have not achieved acceptable progress in almost any health setting. Medical error causes more than 250,000 deaths annually,
It’s not a question of not knowing what to do; it’s a question of not having enough pressure from purchasers or patients to overcome the resistance to change.
As an industry, health care has its own unique dynamic. Efforts at change encounter a resistant professional culture; insufficient education and training in the very fundamentals of patient safety and quality improvement; a perverse payment system; and a disempowered consumer base confronted with confusing and inconsistent safety data.
In reflecting upon September 17 as the first-ever World Patient Safety Day, two distinguished researchers have made the case for invigorated health services research around medical errors. This research-oriented moonshot would be helpful and we’d like to call for a moonshot of another kind as well. What we lack are enough dedicated and resolute leaders who will recognize, spread, sustain, and institutionalize the findings. Rigorous championship of patient safety reporting and diligent root cause analyses would take us from 'never events' to 'never repeated again' events. Given estimates of 100 million deaths globally from preventable medical error over the past 20 years, we say that a titanic societal jolt is in order.
What Doesn’t Work
Small experiments to prove that safety progress is possible for one problem, sometimes in one unit or practice at a time, has fed the research industry and produced enough academic publications to guarantee tenure to a multitude of aspiring thought leaders. Sadly, it is uncertain whether these hopeful reforms ever reach a broader audience of board members, C-suite leaders, patients, and purchasers. And, if the coach and internal champion leave a unit once attention shifts to other problem areas, the safety measurements return to baseline. No spread; no sustainability.
Other drops-in-the-bucket, though well-intentioned, include continuing education credits, coaching and training workshops, efforts to push safety reporting on staff and units, connecting safety with efficiency (a worthy tenet of Lean, which may seem to honor safety for the wrong reason). Dashboards, charts, and categorizations of errors can be interesting exercises, but if safety reporting and problem solving aren’t baked into the workflow of frontline operations, the data are meaningless.
Penalties and sanctions (and paying for performance efforts) have clearly not yet produced remarkable results.
What Must Change
1. Value-Based Purchasing
This requires real transparency of meaningful data on cost, quality, and safety that cannot be gamed. It requires payers and purchasers who will not be denied or deceived.
2. A Consumer Movement with Vigorous Advocacy
Health systems leaders — boards and executives — must be held accountable for safety. Until consumers and purchasers hold the leaders of health care institutions accountable for rapid and continuous processes toward safety, nothing will change. When design errors caused two Boeing 737 MAX 8s to crash in the past year, killing 346 people, nobody blamed the pilots. The accountability rested with the Boeing board of directors and the executives. Pilots refused to fly, and passengers refused to ride. And Boeing’s leadership accepted responsibility. They did not shift the blame to engineers or trainers.
3. Competition from New Players
Consolidation and mergers have created giant health systems that have neither lowered costs nor improved safety. However, powerful customer-centric companies that have dramatically disrupted transportation, communications, and retail are now pouring millions of dollars into developing health care services that meet consumer needs and preference. These disrupters will engage patients in their own diagnostic and treatment decisions that might provide simpler, faster, cheaper and more reliable care. Perhaps they will provide the jolt that legacy systems need.
- Creation of a National Patient Safety Authority
Systems achieve what they are designed to achieve. Most nations lack the infrastructure to monitor and ensure that our health systems are wired for safety. An airline or car manufacturer that doesn’t observe basic safety precautions and standards can pay stiff penalties. Health care needs an overarching authority with teeth to enforce rigorous safety science practices. In the U.S., models exist in the form of the Federal Aviation Administration, the National Highway Traffic Safety Administration, and the Food and Drug Administration, to name a few.
What Will Speed Progress
These are secondary considerations, but nevertheless useful if there is to be real progress in patient safety. We need:
- Informed, activated board members and consumers. Education, information, media coverage — whatever it takes.
- Useful measures for safety, and real transparency that isn’t gamed.
- Global trigger tools that are automated via credible, accurate electronic health records (EHRs).
- Infrastructure for continuous improvement, root cause analyses, etc.
- Patient-reported outcome measures (PROMS) of care.
- Culture change where frontline staff can safely report on safety problems and where an atmosphere of curiosity and discovery cause staff to pull for information and solutions.
- Better application of Lean principles for building safety improvements into the workflow at all levels of care.
- Improved EHRs, a critical element basic to workflow redesign and progress, and that allow for credible prediction and prevention of error.
In short, patient safety improvement requires a jolt, not incremental progress. Acceptable safety conditions will not result from doing the same things we’ve done for 20 years. It will come from significant new pressures that direct patients to systems and sites and innovations that guarantee safety.