Drinks, Pizza, and a Little Basketball

Nostalgic for the hours I used to spend in college dining halls debriefing a long organic chemistry lab session, planning the next Chinese Students Association event or discussing the misuse of Murphy's Law when describing catastrophic global events, I take great comfort in studying in cafes or catching a casual drink at low-key bars. Food and drinks are within reach and conversations are aplenty. However, it seemed just too perfect that I would find myself at a Wolverine friendly bar and pizza joint called the Brown Dog in the middle of Telluride to catch Game 3 of the NBA finals with my new patient safety friends.

In between sips (true sips because alcohol and high altitude could turn into a physiologic disaster), we would seamlessly transition from discussing the patient harm that results from unstandardized hand-offs to watching the Miami Heat claw their way towards a lead in the series against the Thunder. The true cherry on top was the mouth-watering smells of Detroit deep dish pizza that surrounded us. Because the University of Michigan atmosphere mixed with good pizza and beer seemed to be a winning combination for stimulating patient safety conversations and Miami Heat success, we recreated the magic for the rest of Miami's journey to become the 2012 NBA Champions. As I wistfully look back on my week in Telluride, especially as I suffer in the inhumane heat wave that has metaphorically encircled Southeast Michigan in an inescapable head-lock, I can’t help but intertwine patient safety and health care quality improvement with basketball.

Since becoming a basketball fan when the Miami Heat won the NBA Championship in 2006, my home team has really tried my patience. Like any health care quality nerd, I began to see health care connections in sports. The Miami Heat represented all of the negative characteristics of a poor performing health care system, primarily an organization that had seemingly lost its way (click here to read more about the Miami Heat and its failures as an HRO).

2010 represented a turning point. In a politically unwise and arrogantly publicized event, LeBron James was recruited to join Dwyane Wade and play for the Miami Heat. Chris Bosh of the Toronto Raptors also decided to move to warmer climates. Before I knew it, amidst the global antagonism directed towards Miami, a new sense of purpose had been injected into my home team: The Big Three had promised to fill their fingers with championship rings. While the rest of the world derided the team for its bombastic promises, I bought into the dream. With three superstars on the same team, as the Boston Celtics had proven in 2007, how could the Miami Heat fail?

Did the Miami Heat succeed in the 2011 NBA Finals? No. The Big Three was simply that, three basketball superstars who all happened to play on the same team. An optimist would say that The Big Three’s first season together was a string of small experiments (PDSA cycles) on how LeBron James, Dwyane Wade, and Chris Bosh would share the court together. But, what this looked like on TV was confusion and a total lack of coordination. The Big Three had their moments when they would each individually live up to their All-Star reputations, but these occurred in unpredictable and unreliable spurts. The Miami Heat haphazardly played its way into the 2011 NBA Finals and an entire season’s worth of bewilderment became obvious to the world as it was blown out by the Dallas Mavericks. I distinctly remember watching the team disintegrate into a group of headless chickens that did not seem to know what to do even when it possessed the ball.

In retrospect, the 2010-2011 season should not have come as a surprise to me. In assembling The Big Three, the Miami Heat committed the same mistake that many health care organizations make: attempting to achieve greatness through cultivating great parts. In a thought experiment to build the world’s greatest car by assembling the world’s greatest car parts, Dr. Don Berwick, former CMS Administrator and CEO of IHI, describes:

“Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence”… We’d connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.”

The basketball teams that want success to become an intrinsic characteristic of the team, invest and develop not just individual talent, but also create a reliable system of teamwork.

Examining the Miami Heat’s run for the 2012 NBA Championship, the Miami Heat has done just that: built on the talents of The Big Three and transformed into a high-functioning team. For those that continue to carry Miami Heat antagonism (I realize I am in the great minority being a Miami Heat fan), I’m not claiming perfection, but improvement. Although an abbreviated season, the Miami Heat discovered a rhythm of teamwork that allowed The Big Three to play together as a more unified front. The Miami Heat faced one of its first great tests in the second round of the playoffs against the Pacers. Chris Bosh was injured and out of the picture and the Miami Heat was shut out of Game 3, falling behind in the series 1-2. The Miami Heat of 2011 probably would have been knocked out of the NBA Finals running. But, the Miami Heat of 2012 readjusted and Udonis Haslem stepped up to the plate to fill in the gap that Chris Bosh left. The Miami Heat beat the Pacers 4-2.

Improved teamwork was even seen off of the court. In the wake of the Miami Heat taking the lead in Game 3 against the Thunder, the drama that erupted in the media was when Kevin Durant of the Thunder was caught telling Dwyane Wade, "You're too small." Although the statistics of the team do back-up Kevin Durant's statement, LeBron James' response that the actual size of the players doesn't matter as long as they're fundamentally sound and play with the effort that helps that makes up that difference, rang true of the 2012 Miami Heat teamwork mantra. Just looking at the media coverage of the Miami Heat's journey to the championships, the words "we" and "team" are being used more frequently and coverage of the last game sings the praises of not just the Big Three, but also Mike Miller, Shane Battier, and Mario Chalmers--critical teammates who all contributed to the win.

So, what does this all mean for health care? The theme of the week at the Telluride Roundtable was communication. While we spent the day discussing the importance of communication facilitating successful teamwork, what we had in front of us in our after hours was an example of the incredible transformation of a basketball team that truly took teamwork to heart. So, as many of us are getting ready to apply for residency and are looking for residency programs and institutions that value patient safety, don't fall into the trap of optimizing health care by just optimizing individual parts, also consider what programs and institutions do to facilitate excellent interdisciplinary teamwork.

While the IHI Open School facilitates interdisciplinary communication by bringing health professions students of all disciplines out of their isolated silos together to discuss quality improvement and patient safety, what else can be done to improve interdisciplinary communication and hence create a reliable system of teamwork? I'd love to hear what you are doing at your institutions, so comment below and share your successes and challenges--perhaps some drinks and pizza will spark some health care quality improvement magic.

Why Hospitals Should Fly...

Isn't it appropriate that after 7hrs of flying and a 1.5hr windy car ride I find myself in Telluride, CO at an elevation of over 10,000ft to spend a week participating in the 8th Annual Telluride Interdisciplinary Patient Safety Roundtable?

My third year of medical school has been nothing short of transformative. While my classmates and I have grown tremendously in translating our theoretical knowledge into clinical skills, what has also grown is an increasing awareness of the plight of our patients. Many of our patients are already in a vulnerable position given their medical conditions. What does the health care system do to help them regain their health? We force them to navigate the rough seas of a fragmented health care system.

Out of frustration for one of my patient's experiences while on my Family Medicine clerkship, I wrote this welcome message that satirizes the typical patient experience in our current system:

Welcome aboard the US Health Care Cruise Line! Please take your time to explore all of the great features we have to offer on our entertainment Decks to take care of all of your medical needs, whether you need them or not! Here, our motto is “more is better,” so take this opportunity now to indulge away!

First, a brief message to our VIP guests: As the group of people with multiple health and social needs that are the true drivers of high health care costs, welcome! As you navigate this beautiful vessel outfitted with the latest most expensive technology and drugs, please keep the following in mind:

Primary care services are conveniently located on Decks 1 and 5. Deck 1 is only accessible via our exclusive Jet Ski coverage program. If you are not a Jet Ski member, we recommend you seek services at Deck 5. Deck 5 is only open three days a week in the afternoons. Both Decks have the friendliest of staff, but are only trained to address clinical questions.

Housing, childcare, utilities, legal, financial assistance and food services are available. With constantly evolving entertaining activities being offered through these agencies, we unfortunately do not have updated directions to reach them. But, if you wander around the ship long enough, you will surely find your way! These are some of our busiest services with the greatest demand, so please don’t be discouraged if we cannot address your needs. None of our passengers have suffered too greatly due to inaccessibility to these agencies.

24 Hr Care is available on Deck 9. You can access Deck 9 by any means. But, in exchange for this convenience, you will likely need to wait several hours before being seen. A 24 Hr All-You-Can-Eat Pizza Bar is also located on the same Deck to make waiting more tolerable.

Getting around the ship is most efficiently completed on foot as there are long staircases that connect most Decks. However, if this is difficult for you, please call the main office to arrange for transportation. We have a limited number of staff who can carry you to your desired destination. But, your height and weight may prevent you from taking advantage of this great service.

Specialty care services for diabetes, cancer, asthma, mental health, and hypertension are located in a gilded section of the ship. We are practicing cutting edge techniques that are so advanced that there is little literature available about them! Please don’t hesitate to let us know if you are having difficulties finding our specialty services. We would be happy to escort you there. Just be sure to bring your boarding passes, credit card statement that documents the purchase of this cruise, and any records of all of the experiences you have had here onboard. We do not have an electronic system connecting all of our services.

Lastly, drug and nutritional supplements must be purchased off of the ship, so you are encouraged to step off and explore our various stops. These islands are not very well-equipped, so please be flexible with the inconsistencies of what they have to offer.

Only the Captain is completely familiar with the ship and its services, but given how busy he is, he is unlikely to be able to help you navigate your stay. We are confident that you all are capable of coordinating your own cruise activities!

With these simple rules, I can guarantee that you will feel so overwhelmed by our top notch services that you will be wondering, “was it all really worth it?” Again, welcome aboard and enjoy your stay!

Despite sporadic episodes of safe, effective, patient-centered, efficient, timely, and equal care throughout my third year, our inconsistent ability to deliver high quality care has left me almost hopeless for the future of health care. But, what has reenergized my spirits was reading the book Why Hospitals Should Fly written by John Nance, a professional pilot and lawyer with a distinguished career in leading the patient safety movement. The book is a fictional narrative that follows a former CEO of a hospital, Dr. Will Jenkins, as he travels to a suburb of Denver, CO to visit the fictional St. Michael's Memorial Hospital. St. Michael's is THE ideal hospital that exudes quality not only in its basic processes and operations, but also in its culture. As Dr. Jenkins visits various departments in the hospital, the reader not only learns about the effectiveness of specific interventions to improve safety (i.e. multidisciplinary rounds, team huddles, checklists, etc.), but also indirectly gains insight to the process of implementation (probably the most difficult part of patient safety work).

When I finished reading the book, I felt like my head had been lifted up from the chaos of our current broken system. My head is now 10,000ft above sea level, the same elevation where aircraft passengers can safely use their electronic devices. While I'm forced to drink liters of water a day to ward off acute mountain sickness, perhaps it is necessary for me to be at the level where airplanes fly in order to better understand how to redesign our health care system to achieve high quality care. That is probably the reason why we are all here at Telluride, CO.

Stay tuned throughout this week as we dissect some of our health care system's greatest challenges. You can follow our thoughts here and on Twitter (#TPSER8). You can also take a look at Paul Levy's experience here at Telluride on his blog. Here's to a strong take-off tomorrow!

Focusing on Patient Safety in South Carolina

Susie Robinson & Amanda Hobbs, President and Vice President, Clemson University IHI Open School Chapter

The 5^th annual SC Patient Safety Symposium, held April 25 in Columbia, SC, proved to be a valuable experience for both of us! We learned a lot about patient safety and had the opportunity to her many leading experts in the field.

(We would first like to thank the South Carolina Hospital Association (SCHA) for sponsoring our attendance and for its constant support of the IHI Open School Chapters in the state of South Carolina.)

Here’s a rundown of our experience:

-          We kicked things off by meeting with leaders within the IHI Open School community, including the members of University of South Carolina’s IHI Open School Chapter and our two Southeast Regional Coordinators. 

-          As the Symposium began, we took front row seats and listened to Maureen Bisognano, CEO of the Institute of Healthcare Improvement.  She first recognized our state for the strides South Carolina has made in decreasing health disparities between populations, especially in Columbia.  Bisognano spoke briefly about the Triple Aim and recognized areas for health care improvement.  Bisognano then introduced Regina Holliday, a painter and patient advocate who painted representations of both the provider and patient perspective throughout the conference.

-          Next, Dr. Atul Gawande spoke about the future of Safe Surgery 2015, and the progress of South Carolina as a pilot state. 

-          After a short break, Dr. Eric Coleman from the University of Colorado spoke about the Care Transitions Program.

-          At lunch, the few students in attendance were recognized and the Lewis Blackman Patient Safety Awards were presented to honor deserving individuals from around the state. (The lunch, accompanied by the South  Carolina Philharmonic Orchestra, was delicious.)

-          As our day wrapped up, we were fortunate to spend some time talking with Maureen, Dr. Rick Foster, SCHA Vice President of Quality and Patient Safety, our IHI Open School Regional Coordinators, and patient advocate Helen Haskell (Lewis Blackman’s mother). 

We are grateful we had this opportunity through our involvement with IHI Open School!

IHI CEO Maureen Bisognano poses with faculty and students
at the 5^th Annual SC Patient Safety Symposium in Columbia, SC.

Former Hospital CEO Visits Chapter at University of Colorado

The University of Colorado IHI Open School Chapter, in collaboration with the Patient Safety Education Partnership, was proud last week to host Paul F. Levy, author and former CEO of Beth Israel Deaconess Medical Center.  

Levy related stories about reducing patient harm, transparency of clinical outcomes, and leadership in medicine. The 80 attendees included students and faculty from the schools of Medicine, Nursing, Pharmacy, Dental Medicine, and Public Health, as well as residents and staff from several area hospitals. 

All attendees received a copy of Levy’s new book “Goal Play,” provided by the Patient Safety Education Partnership, which you can learn more about at http://www.psepartnership.org/.  The Chapter continued the discussion this week through a deliberative dialogue that explored the potential benefits and drawbacks of several strategies for the improvement of patient safety.





Pictured: University of Colorado IHI Open School
Chapter Steering Committee members Racheal Gilmer,
Josi Schwan,Betty Geer, Eric Wannamaker, and Dan Stoll; 
Paul Levy; Chapter Faculty Advisor Wendy Madigosky

Patient Safety in Iraq

I recently visited the Iraqi region of Kurdistan, both working with the International Federation of Medical Students' Association and arranging an interprofessional patient safety symposium for nursing- and medical students.

Iraqi Kurdistan is the northern region of Iraq with borders to Syria, Iran and Turkey. Given everything you hear in the media about Iraq and the war, I wasn't to sure what to expect, but what I did experience was a beautiful scenery, peaceful and friendly people and a well-functioning society.
The region has several nursing and medical schools, all fairly new and with a very international approach. The regional Minister of Health (a doctor) have been wanting to focus more on patient-doctor communication as well as patient safety, and it was on his request that we prepared the symposium covering these two topics. It was held on the afternoon on the 24th of April at the Ministry of Health.

We were not quite sure what issues the health professionals and students there had, so we started by asking some questions, and a lot of issues were raised. E.g: It is common to have consultations with up to 10 patients with the similar condition at the same time, not allowing much time to talk to the individual patient, hand hygiene, lack of guidelines, and a lack of educational resources, access to journals and evidence etc.

Based on this we chose to focus on practical tools, that the participants could use there and then, and that is one of the beauties of the IHI Open School courses. We took them through Patient Safety 101, and also introduced the "Check a Box-Save a life" campaign, and it generated a lot of interest. Some of the comments we got after the symposium were "I never thought I could do anything about safety myself" and "Why have we never heard about this checklist?". In other words, just keep up the good work in your campuses, it actually makes a difference.

- Jo Inge Myhre, medical student, University of Oslo

This is the Clinic that Will and Charlie Built...

I have officially become a groupie of the quality improvement in health care movement. Books sitting on my nightstand include: Pauline Chen's Final Exam, Super Crunchers by Ian Ayres, and How to Change the World by David Bornstein. I squealed like I had just sighted Brad Pitt when Atul Gawande's latest book, The Checklist Manifesto arrived at my door. Instead of simply saying that I need to clean my apartment, I specifically think that I need to "5S" my kitchen and desk. In order to stay fit and get rid of the belly fat I've grown since starting medical school, I am now in PDSA cycle 3 for a 30 minute exercise routine that I can reliably perform every day. The latest sign that I am a quality improvement junkie is my weekend pilgrimage to Mayo Clinic in Rochester, Minnesota.

This past weekend the AMSA Chapter at Mayo Clinic hosted a Patient Safety and Quality Care Conference at Mayo Clinic. The Mayo Clinic has not only been one of President Obama's shining examples of high quality care at low costs since he began his health reform push early last year, but has also consistently popped up during my experience at IHI as a health system that has truly embraced the IOM aim of patient-centeredness. Even though I'm buried underneath the dorsal columns of my central nervous system sequence, this was an opportunity I could not miss!



When I stepped off the plane in Rochester, I was abruptly greeted by a chilling gust of wind. But, that didn't deter me and like any good quality improvement groupie, I pressed on. From the moment my shuttle dropped me off in front of the Gonda Building and the Mayo Clinic greeters helped me out of the van, I knew I had arrived at what many say is the mecca of patient-centered care. It was difficult not to spend the weekend with my mouth agape.

Every aspect of the Mayo Clinic from its architecture and design, to the doctor-patient relationship, to Mayo's treatment of patient safety strongly embodies and reflects its mission: Mayo will provide the best care to every patient every day through integrated clinical practice, education and research. As Dr. Tom Viggiano, Dean of Mayo Medical School explained during his talk about Mayo Clinic's History, Culture and Professionalism Covenant, Mayo Clinic's mission stems from a remarkable story. A story about the work of Dr. William Worrall Mayo and his two sons, Drs. William and Charles Mayo.



Dr. William Worrall Mayo, born in England and a student of physicist John Dalton, arrived in Rochester as the Union army's examining surgeon. As his sons were growing up, William and Charles were intimately involved in their father's practice. They drove their father on patient rounds, attended medical society meetings, and even assisted their father in surgical procedures. This early exposure laid the foundations of medicine and patient care for the two brothers. Both William and Charles through consistent encouragement from their father attended medical school and both returned to Rochester to join their father's practice.

The tornado of 1883 that hit Rochester was a catalyst that led to the creation of Rochester's first hospital built in collaboration with the Sisters of Saint Francis. The Mayo family then became the physicians of the hospital and it was the brotherhood bond between William and Charles that was the first "team" that set the tone for the teamwork we see at Mayo Clinic today. As the hospital expanded and the fame of the brothers grew, it became necessary for William and Charles to pick physician partners to join the practice, expanding the team. In Dr. William Mayo's words, here is how teamwork was defined:

"As we grow in learning, we more justly appreciate our dependence upon each other. The sum-total of medical knowledge is now so great and wide-spreading that it would be futile for one man to attempt to acquire, or for any one man to assume that he has, even a good working knowledge of any large part of the whole. The very necessities of the case are driving practitioners into cooperation. The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary."

One such recruited partner in the team that proved to be influential in shaping Mayo Clinic, was Dr. Henry Plummer. Dr. Henry Plummer's ingenuity led him to design an easy, retrievable medical record system. This system gave each patient an ID number and the mode of transport for these records was a system of pipes. Dr. Plummer's innovation acknowledged the fundamental place that medical records had in research and advancing medical knowledge and the need for shared data between physicians to deliver the best care for patients. Dr. Plummer was also instrumental in bringing the Mayo vision of integrated care into reality with the construction of the first Mayo Clinic building (built in 1914), which housed clinical medicine departments, laboratories, and administration offices all under one roof.



As the years continue, additions and innovations to the Mayo Clinic all align with the traditions that Drs. William and Charles Mayo started. There is a Mother Goose rhyme called, "This is the house that Jack built..." Each successive stanza in the rhyme gets longer and longer as odd characteristics are added to the house that Jack built. The Mayo Clinic Model of Care we know and admire today is a result of a similar layering construction.

Though, from my weekend experience at Mayo Clinic, the foundations that Drs. William and Charles Mayo created are more than just a model of care, it's a tangible culture, or even a life force that allows the Mayo Clinic to thrive. The wholly understood value that the needs of the patient come first allow the Mayo Clinic to continually push the boundaries of improvement. The weekend was primarily focused on medical errors and the developed practices and systems at the Mayo Clinic to address patient safety and quality care. We heard from Dr. Stephen Swensen, Director of Quality at Mayo Clinic, Dr. Thor Sundt who is pioneering improvements in interprofessional teamwork in the surgical setting, Dr. Paula Santrach, Chair of Clinical Practice Quality Oversight Committee, Dr. Douglas Wood, Medical Director of the Quality Academy, Dr. Bob Cima on error analysis in surgery, and many many more who volunteered their time to not only share with us their approaches to medical error management, but true to the Mayo Clinic's culture of putting the patient's needs first were also frank about areas that needed improvement. If President Obama's shining beacon of clinical excellence continues to make improvements upon "the clinic that Will and Charlie built," then the rest of us certainly have lots to learn.



I've certainly learned a lot this weekend both through the stated curriculum in the conference agenda, but also through the hidden curriculum of taking in the culture of the Mayo Clinic. I may not be able to take back to the University of Michigan Mayo's unique electronic physician and patient tracking system or redesign all of the exam rooms at Michigan so that physicians are never talking down to their patients, but I can take a plank of Mayo's culture and lay it down as my foundation so that wherever I am, I can do my best to extend the clinic that Will and Charlie built.



A big thanks to Crystal Pruitt and Crystal Shen of Mayo Medical School who organized this enlightening conference. I look forward to more great opportunities to learn about patient safety and quality improvement from the great leaders at the Mayo Clinic.

"What Do I Need to Know for My Clerkships?": A Look at the Lucian Leape Institute Report on Medical Education

In the world of medical school, spring is a time of transitions. First year medical students are returning from spring break and gearing up for the last stretch of class before summer. Second year medical students are getting ready to buckle down and study for the USMLE Step 1 board exam (good luck to all!). Third year students are on their last clerkship rotations before becoming fourth year medical students. And fourth year medical students are holding their breath as Match Day approaches (this Thursday!). Like any time of transition there are a lot of questions about the future floating around. One of the most honest and interesting questions I have heard recently was from a second year student to a resident, "What do I need to know for my third year clerkships?"

This may sound like a strange question to those outside of the world of medicine. The third year of medical school should be a logical progression from the second year, right? Not exactly. Most medical schools in the United States are structured so that the first two years are spent predominantly in lecture. The first year covers the normal physiology, anatomy, and biochemistry of the body systems and the second year delves into pathology and pathophysiology. These years are marked by long hours in class and little, if any, patient interaction. With at most a two week gap after the USMLE Step 1 exam, third year medical students are then thrown into the hospital wards to learn how to apply the basic sciences into the practice of patient care. Are these new third year medical students ready to care for patients?

The Lucian Leape Institute of the National Patient Safety Foundation says, "no." Just last week, the Lucian Leape Institute released its first of a series of reports on patient safety. The first report, titled: “Unmet Needs: Teaching Physicians to Provide Safe Patient Care,” finds that U.S. medical schools are not adequately teaching students how to provide safe patient care. Click here to read the report.

Although I have just 8 months of experience in the medical education system, I am not surprised by the conclusions of the report. A quick glance at the competencies tested in the USMLE Step 1 board exam that second year medical students ordinarily must pass before starting their third year clerkships will demonstrate the emphasis placed on the basic sciences of the body systems. While I don't disagree with the importance of understanding the basic sciences of the human body and disease processes, I agree with the Lucian Leape Institute report that there is a crucial dimension to patient care that is blatantly missing in an exam that signals that students are ready to be members of a patient care team.



The transition into a third year medical student is not easy: learning how the hospital operates, determining and establishing the medical student role on the care team, understanding and learning to anticipate the actions of the interns, residents, and attendings, and being prepared to answer any basic sciences question your attendings may ask you (a process called pimping). The third year is also an important learning opportunity. The more procedures and cases seen means a greater breadth of experience for future life-saving. Impressing your attendings is another facet to the third year of medical school. A good recommendation from attendings can go a long way in the residency application process. In the thick of all of that, medical students are probably too stressed to think about patient safety and definitely don't want to slow down the service just to ask "why?" when witnessing unsafe or needlessly complicated workflow processes. The chaos of third year makes asking questions about patient safety and quality improvement professional suicide.

So, how are medical students to learn the skills needed to deliver health care safely? The Lucian Leape Institute recommends restructuring medical education to include topics like safety science, human factors engineering, systems thinking, and the science of improvement into the basic science years of medical school. The report also recommends that medical students be given opportunities to develop interpersonal skills that include effective communication strategies for future interdisciplinary teamwork. In order to include these elements to medical training, faculty trained in patient safety and quality improvement who can model good patient safety behavior is essential. Unfortunately, most medical schools have not reached a critical capacity of faculty for training in patient safety and quality improvement to occur. Yet, from the student perspective, we can't wait another 10 years after the publication of the IOM "To Err is Human" report to reach that critical capacity.



Here at the University of Michigan, the few faculty we do have trained in patient safety and quality improvement are working hard to provide students with patient safety skills. In our first year of medical school, we've had a mandatory nurse shadowing experience and a sociocultural discussion case on medical errors to provide the first exposure to patient safety and effective teamwork. The University of Michigan also offers a second year two week elective on patient safety and a fourth year elective led by our very own, Dr. John Gosbee. At best, the University of Michigan has opportunities for students who seek to learn patient safety and quality improvement skills. This is a good start, but as the Lucian Leape Institute report would indicate, not enough. Patient safety needs to be prioritized formally from medical school through residency in order to make health care safer for all.

At the very least, concepts of patient safety and quality improvement should naturally become part of the answer to the question, "What do I need to know for my clerkships?"

Is patient safety a part of your curriculum? What do you think the best strategies are for making patient safety and quality improvement a bigger component to your health professions education and training?

Being Honest: Ducking Out from Under the Table

My adorable dog, May, has her flaws. Her bark and temper are infamous in our neighborhood. If the toy is not made of rubber, it will become an unrecognizable ball of mush within days. However, when it comes to going out to do her business, May almost never has accidents. On those rare occasions she makes a mistake, she slowly greets us with her head ducked down rather than her normal energy-filled charge when we arrive home.

We understand why these accidents happen. Most medical errors, as discussed in the IOM report, To Err is Human, are a result of poorly designed systems that do not give providers the best chance possible to care for patients in the way that they would like. May's accidents are also systems error. We only find a pool of pee in the house when we leave for a long period of time without allowing her to go out before we leave. May was not being negligent or purposefully filthy; the system she lives in simply does not allow her to successfully avoid these accidents. With these system constraints in mind, we do not blame her, but continue to work on scheduling improvements to prevent future occurrences.



Clinicians never want to intentionally harm their patients and are often emotionally impacted by a mistake. Similarly, as far as we can tell, May deeply regrets her accidents. Since she cannot use words to express her regret, she hides under the dining table and avoids eye contact as we clean up the mess until we say, "It's okay, May." Sometimes, she will even circle the "biohazard" zone slowly, as if admonishing herself. May's actions demonstrate her acknowledgment of the accident and we accept her apology--a courteous exchange that occurs between people all the time.

Medical malpractice is one of the few bipartisan goals of the current health reform battle. However, how to reform this messy process that is hard on all participants (physicians, hospitals, patients and families, and insurers) emotionally and financially is not as clear. Focusing on how to minimize costly lawsuits through caps on financial damages awarded to patients further complicates the fundamental courtesies that should occur when a mistake happens: acknowledgment, understanding, acceptance, and forgiveness.

In a paper published in the NEJM in 2006, then Senators Hilary Clinton and Barack Obama discuss how to improve patient safety and the medical liability climate through open communication between physicians and patients. The paper cites that the most important factor in people's decisions to file lawsuits is not negligence, but ineffective communication between patients and providers: lawsuits occur when "unexpected adverse outcomes are met with a lack of empathy from physicians and a perceived or actual withholding of essential information."



For those of you who are Grey's Anatomy fans (click here to read a Grey's Anatomy Obsession confessional), episode 13 of season 6 titled, "State of Love and Trust," touches specifically on medical liability reform and being honest with patients. A patient, later discovered to have a form of cytochrome P450 that unexpectedly allows her to metabolize anesthesia faster than normal, wakes up from anesthesiology in the middle of her bowel surgery and is traumatized by the violence of surgery and the panicked yelling from the surgical team. Emotionally disturbed by the experience, the patient wishes to press charges against the hospital. Dr. Shepherd, interim Chief of Surgery, is deep in thought about the threat of a lawsuit on his first day as Chief, when Dr. Miranda Bailey talks to him about open communication between physicians and patients in situations of medical error (see clip above). By apologizing to the patient, Dr. Shepherd is acknowledging the mistake and the patient's concerns, is providing the patient with the opportunity to understand and accept the mistake, and is working with the patient to reach an agreement that allows both sides to accept the mistake and attempt to reach forgiveness.

As then Senators Clinton and Obama explain in the paper, open communication allows for improvements in patient safety. The proposed National Medical Error Disclosure and Compensation (MEDiC) Bill was based on model disclosure programs such as those in place at the University of Michigan Health System (Go Blue!) and the Veterans Affairs system. These programs have given both patients and physicians protection while successfully reducing administrative and legal costs for providers, insurers, and hospitals. Surveys from these successful programs have also showed greater trust in and satisfaction with health care providers. On the cost side, the disclosure programs have resulted in the filing of fewer malpractice suits, a reduction in litigation costs, accelerated provision of compensation to patients, and increases in the numbers of patients who are compensated.

It is a remarkable feat that the University of Michigan Health System has reduced litigation costs from $3 million to $1 million in four years with its disclosure program. Though isn't it ironic that at the heart of the solution to such a complex problem are the basic principles of being honest and communicating openly with patients?

Telling patients the truth at times may be harder, but it is the most respectful thing to do. My dog, May, would bark in agreement.

A Grey’s Take on To Err is Human

Hi, my name is Eva and I watch Grey’s Anatomy.

I started about three years ago with the hotly anticipated Season 2 Finale and have been addicted ever since. I have tried to stop and had hoped that a change in environment (back in school and no TV) would stop this unhealthy habit. But, I have been unsuccessful. In fact, I believe I have reached a new level of addiction.

At the end of every episode I watch, I have been able to extract a lesson to justify my time spent following the lives of the characters at Seattle Grace Hospital. I tell myself that these lessons learned will help me become a better doctor…

For example, episode 6 of Season 6 ("I Saw What I Saw"), in my eyes, is a clear case study on patient safety and systems thinking. Let me explain.

The system at Seattle Grace Hospital: The economy has shaken the foundations of Seattle Grace Hospital. Like leaders of hospitals around the country, the Chief of Surgery has had to make some tough decisions. A solution to some of the financial problems was a merger between Seattle Grace and Mercy West, a neighboring hospital. This led to staff cut-backs and an influx of new colleagues from Mercy West. The Mercy West additions were given no formal training to the ways of Seattle Grace. Caring for patients should be the same no matter where you are, right? Compounding this situation is the distrust and tension between the staff at Seattle Grace and the staff from Mercy West because they all anticipate more layoffs.

"Survival of the fittest" is everyone’s mentality. Everyone seeks to capitalize on the other’s weaknesses. In emergency situations, patients needing care are wheeled in and taken care of on a first come first serve basis. Patients are viewed as opportunities to shine. Everyone envies the surgical resident asked to assist on a patient with tough and difficult injuries. No one takes responsibility for the patients who don’t have “cool” conditions. The episode takes place just shortly after the merger of the two hospitals.

The case: Mrs. Becker and her son were just two of an influx of patients involved in a large fire at a hotel. Mrs. Becker presented with minor burns and her son appeared unscathed. Both Mrs. Becker and her son were very scared. After an initial hurried physical exam, Mrs. Becker and her son were left alone. She received treatment for her 2nd degree burns and morphine for her pain. By the end of the night, she suffered a pneumothorax (a collapsed lung) that was emergently treated with a cricothyrotomy, and then passed away due to respiratory distress followed by multiorgan failure. A disjointed “team” of seven residents (some of whose names many are still unfamiliar with) had attended to Mrs. Becker through the night.

The episode, filmed in the Rashomon style, retells the night from several vantage points to simulate the Chief of Surgery’s investigation on the death of Mrs. Becker. At the end of the interrogation, it was discovered that Dr. April Kepner had not completed Mrs. Becker's initial physical exam thoroughly. She missed the soot that had accumulated in Mrs. Becker's airway and lungs. The soot was the cause of Mrs. Becker's organ failure.

Leadership actions taken: Dr. April Kepner was fired for her negligence.

We are very quickly approaching the 10th anniversary of the Institute of Medicine’s (IOM) landmark patient safety report, To Err is Human: Building a Safer Health System. One of the most important messages of the report was that systems failures cause most injuries, not bad clinicians. Judging by the Chief's decision to fire Dr. April Kepner, he clearly has not read the report. Dr. Kepner was not a flawed or bad doctor, she was simply forced to operate in a bad system: She was not taught how to navigate the new hospital. She received no support from her colleagues. The process of admitting patients was chaotic and disorganized. Dr. Kepner and Mrs. Becker had no privacy. And communication between all of the physicians present was abysmal. Is it a surprise that Dr. Kepner would make such a simple mistake? I think it's a bigger surprise that more catastrophic mistakes didn't happen that day. Firing Dr. Kepner would not prevent a death like Mrs. Becker's death from happening again.

Dr. Shepherd has probably read To Err is Human. He understands that every system is designed to achieve the results that it gets. To prevent harm to patients, the Seattle Grace team needs to reduce the chaos and improve their work processes in order to fix the system. A point for those who swoon over Dr. McDreamy!

To have patient safety and systems thinking be major themes to an episode of a popular television show should be a good sign of progress in the field of quality improvement and patient safety, right?

Today's health care reform environment has thankfully showcased some of the many activities taking place at hospitals and professional societies to improve health care. Signs that quality improvement and patient safety are on the national radar have been allocation of funds in the Recovery Act towards comparative effectiveness research and reduction of hospital acquired infections. How to improve the quality of health care delivery while reducing costs has also reached the national scene (addressing overuse and underuse of health care). At a more local level, actions are being taken to reduce hospital acquired infections, reduce medication errors, and standardize safer and best practices (addressing misuse of health care). New accreditation standards and regulations such as no payment for "never events" adopted by the Centers for Medicare and Medicaid Services can also be taken as a sign of progress.

But, do I feel safer or sense the improvements made whenever I interact with the health care system? As this episode of Grey's Anatomy demonstrates, tangible and measurable progress is probably still not yet within our grasp.

Once we get there, this episode should be rewritten. Seattle Grace will be a shining example of the transformation of the culture of medicine. All of the characters would not be individual heroes searching for glory, but would support each other in order to deliver better care for their patients. The Chief and hospital leadership would not bury mistakes like Mrs. Becker's death, but would take the time to identify root causes of the error and fix the system. And every single person would critically evaluate and make improvements to the complex work processes of delivering health care.



The best indicator of progress in "Grey's speak" would be a scene where Dr. Cristina Yang pouts because she was not named as the resident who discovered and made the greatest number of improvements in the Department of Surgery, rather than the fits we see her in now whenever she is not named the most technically accomplished surgical resident.

I should probably take a few seconds to look up the medical term for severe addiction now...

World Health Day 2009

World Health Day is a global initiative led by the World Health Organization (WHO) and this year, World Health Day focuses on the safety of health facilities and the readiness of emergency workers in the face of disaster and emergencies. That's a WOOT for safety getting international recognition!

With sudden natural disasters such as the recent earthquake in Italy and the great tragedies of Hurricane Katrina, the earthquakes in Sichuan, and the tsunami that hit Southeast Asia all in recent memory, it is essential that health care facilities are both prepared to handle these crises and can handle things safely.

On the WHO World Health Day page, it says:

"This year, WHO and international partners are underscoring the importance of investing in health infrastructure that can withstand hazards and serve people in immediate need. They are also urging health facilities to implement systems to respond to internal emergencies, such as fires, and ensure the continuity of care."

While World Health Day 2009 focuses specifically on ensuring safety in an emergency context and ensuring health care facilities are prepared in light of emergencies, what kinds of patient safety and quality improvement interventions should be considered when designing safe and rapid response systems?

To read more about World Health Day 2009 background and activities, click here!

Also, take an IHI Open School Patient Safety Course to learn more about patient safety in hospital systems. Click here to start! What elements of the course are most important in an emergency setting?