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Making the Health Care System Safer: Closing Session

Third Annual Patient Safety Research Conference

Proceedings of the third annual patient safety research conference.

Closing Session

Gregg Meyer, M.D.
Agency for Healthcare Research and Quality (AHRQ)

Daniel Stryer, M.D.
Agency for Healthcare Research and Quality (AHRQ)

Daniel Stryer

My name is Dan Stryer and I direct the Center for Quality Improvement and Patient Safety at AHRQ. I'd like to welcome you to the closing session of the third annual Patient Safety Research Conference. It's a pleasure to introduce Dr. Gregg Meyer, who preceded me in my position. I'm looking forward to hearing his comments on how the patient safety initiative has played out. When he joined the agency about 7 years ago, he directed the Center for Quality Measurement and Improvement and patient safety wasn't even on the radar screen yet. There's been a metamorphosis since then. It will be interesting to hear some of his views on what he anticipated when the IOM report initially came out and how it's actually played out.

I need to thank a few people before turning the microphone over to Gregg. First, Deborah Queenan has done a fabulous job with this conference. It has been a pleasure to work with someone so professional; she's just been great throughout the process. In the spirit of continuous quality improvement, if you have any suggestions about this conference, please pass those suggestions along to Deborah or myself as soon as possible. We'll be having a debrief in the next few days. Anything you can pass along will be very much appreciated.

I would also like to thank a number of other people. The staff at Westat has really done a great job. In particular, at risk of forgetting a few people, I would like to thank Susan Rittenhouse, Vivian Chew, as well as additional AHRQ staff, Marge Keyes, Eileen Hogan, Ron Rabbu, Karen Migdail, Howard Holland, and Mary Rolston. Thank you to all of those individuals and thank you for coming here; we hope that it's been a valuable use of your time. Again, if you have ideas of how we can make it more valuable, please pass them along. Thank you.

Dr. Gregg Meyer

First, I personally want to thank all of the AHRQ staff and all of you who have been working so hard on patient safety here and those of you who have participated in this program. It's really an incredible pleasure to be here and actually see some of the twinkles in many peoples' eyes around this room start to produce some important results. I really thank Carolyn and Dan for their stewardship of what is a terrific program. I think you all have a lot of which to be proud.

When I was first asked to be the closing speaker here, it reminded me of one other time when I first began to work with AHRQ. I gave a speech in Russia when John Eisenberg asked me at the last minute to cover for him and be the closing speaker. He didn't tell me that it was after lunch. In addition to that, when I was originally invited, he did tell me that the speech was actually in Russia and that someone was going to have to translate it. He didn't tell me that I would have to pause often for the translator. I was accepting of all of those things. I was invited to the lunch, and it was a very typical kind of greasy meat and potatoes lunch. I thought that would be okay, that I would be able to get through that. Then they brought out the water for the lunch. They came out with these very unusual bottles of water and everyone started drinking the water. It turned out that they were pint bottles of vodka. When I got through most of my meal, they wanted me to have a toast with them and I said I would because I had to, of course. I was the guest of honor, so I had three or four bottles in front of me. I did my one toast and said I didn't think it was a good idea for me to have any more. Then the Minister of Health and all of his friends divided my bottles, finished them off, and slept through my talk.

I am aiming low to avoid disappointment, in the greatest of Air Force traditions. I'm hoping that I can at least keep you engaged for the next few minutes.

I think that where we go from here has changed a little bit. I think one thing that we all should feel responsible for is being able to answer the question that I think Carolyn posed to us the first morning, "What can we say we've done in 5 years?" The IOM report anniversary is coming up. What can we say that we've done? I will freely admit to you that I am of the Colin Powell School. I believe that optimism is a force multiplier and I'm optimistic about this. I know that many of you share a great deal of pessimism about how much we've been able to accomplish. It hasn't been as much as I would hope and certainly, as I think most of you would hope.

I think we have to keep in mind the reality illustrated on a slide from Naval Aviation. I can tell you that as an Air Force Colonel, it absolutely pains me to show a Naval Aviation slide. I think the point it makes is important. The slide shows how the Navy went ahead and made landing on a moving runway safe, which in Air Force lexicon is called "stupid." Nevertheless, they land on moving runways. What's important here isn't all of the little things that they did; it's the timeline on the bottom. It took 5 decades.

If you watch the History Channel and look at the pictures of the USS Arizona and all of the old aircraft carriers, there is something different about them. What's different about them is that the airships ran right up and down the hull.

In the early 1950s, some engineer had the idea that tilting the airstrip at about 17° would get about a third more runway. It saved lives. It made a big difference. After that, they did some things like the NAMP, the maintenance program, so believe it or not, when you and I get on a plane, whether it's a military aircraft or a commercial aircraft, you expect that someone has a log of when the engine was serviced and how up-to-date all of the equipment is. That didn't exist. That was something that the Navy started. They started the idea of standard operating procedures. That's one of my favorite improvements because the way you landed on an aircraft carrier was perfectly predicted by one factor. It was how the person who taught you landed on an aircraft carrier. It sounds a little like medicine to me. We practice medicine the way the person who taught us practiced medicine.

The Navy figured out that although you learned it the way you were taught to do it, there is a right way to do it. There is a standard way that will produce the best possible outcome. It involves gunning the engines as soon as you feel the catch when you're landing and the way that you accelerate the engine with the catapult when you take off. It saved lives. They made this incredible leap in terms of making naval aviation safer. It took 5 decades.

When I go and speak to my board at Massachusetts General and Massachusetts General's Physician Organization and say that we're working on patient safety, they want to know what will be different next year. What will be better? How will it be measured? This is a very tough message. This is a commitment. I'm not saying that we shouldn't be making progress because they made steady progress over time. I am saying that this is not a quick fix. When someone says, "It's been 5 years. Why isn't it fixed yet?" I don't think anyone was saying that to the Navy in the 1950s. I don't think anyone was saying that to commercial aviation in the 1970s. I'm not saying we should cut ourselves a lot of slack, yet I think we have to keep in mind that this is a commitment. It will not be a real quick fix.

I think there are a few things really to celebrate that came out of the original research portfolio. I just pulled a few of these out and they are somewhat random thoughts. These things affect my life as a medical director of a very large group of physicians, the largest physician organization in New England. These things touch my life in a very direct way and came directly from the AHRQ program in which you all are participating.

  • One is the evidence report, Making Healthcare Safer, because it went to the NQF. It was translated by Chuck Denim and his team into a Leapfrog survey. This is something to which we have to respond. This was kind of a gleam in a few peoples' eyes about 4 years ago. Today, written into my contracts with payers is that we participate in this Leapfrog survey. That's not a bad timeline.
  • Another program I think has just as amazing potential, and I think it will be realized in short order as opposed to a long timeline, is the Patient Safety Improvement Corps. First, the notion that HHS and the VA were able to come together is neat enough on its own. An advantage beyond that, is having foot soldiers out there. I feel like I'm very lucky, I'm privileged because we actually have someone from Massachusetts General Hospital, Katie Brush, who is one of the PSIC folks this year. I think that's something that, in short order, will pay off for you.
  • WebM&M is another one. This is something that we use in our training programs. This was an idea that floated around for about 4 years before it found a home in the patient safety program. It's very much a homerun and it has exceeded many expectations.
  • Finally, Five Steps to Safer Health Care is the biggest no-brainer of the entire patient safety movement. This works. We put it on the back of our results letter that we send to patients, put signs up around the hospital. People understand this. It absolutely works and it's something that you can use today.

Yes, it's a commitment and it will take a long time, but we have some things to celebrate that have come out of it already. We have other areas where I think I've heard over the last couple of days where there has been considerable progress. Regarding the work on methods, there were many questions about data confidentiality, IRBs, and will you be able to do this research. I think many of those questions have been answered in the affirmative. I think there has been some progress there.

Regarding language, we were really talking about error and now people are focusing in on and talking about harm. I think that's a much stronger lexicon for us to adopt. We are trying to move that understanding beyond the urban hospital so it is terrific to see you who are rural grantees. This work touches beyond just a few privileged institutions with a history of working on this kind of area of research for a few years. I think there is more work needed in the multi-disciplinary teams. I wish I saw more groups where the engineers and physicians were presenting together. I think logistics may have made that difficult. I think that's something that really has risen out of this work.

We could potentially do many good things with the identification of populations at special risk. The bottom line is, I think, every manager or administrator is faced with making difficult decisions about where we can put our limited resources. It's very clear that if we can identify those patients who are higher risk and target our investments to solve their problems, we would do better.

I heard a lot over the last couple of days that will help me make decisions about on which patients and areas we should focus. The resource budget is clearly limited. I think the work on disclosure, again, is an area that has a very real impact. I think there have been some strides just in defining some legal issues. I learned everything I know about disclosure from the grantees who presented here over the last few years. That's been very helpful.

There are other areas where I would say we have progress. I think reporting is an area that fits in that category. We have a lot of work still to do on standard setting. I was hoping that we would be a little further in the vulcanization of reporting systems. There is still a lot of competition out there that hasn't exactly shaken out yet.

In the epidemiology of patient safety, I think we understand it well and I think there are many who would say, "If I never see another descriptive project on patient safety, it will be none too soon." We can have a moratorium on descriptive projects for 5 years and it will take us that long to implement what we already know here.

Transitions: I am very blessed in that I work in a health system with wonderful IT systems. Very bad things happen to our patients when they go outside of our system, when they go over to a rehab hospital that doesn't happen to be part of our system or they go home and get home care. Transition is an area where I think there is a lot more work to do. I think it's an area where I personally feel incredibly vulnerable being in a system with very strong IT systems.

IT implementation: I'm still hearing a lot about the barriers but am still not hearing as much as we need to about how we overcome them. Maybe the next phase with a greater focus on health information technology will allow us to start to address that question more.

I still believe regional collaboratives are a way to move things forward and a way that we can pull all of the stakeholders and get everyone pulling in the same direction. I think the parochial interests have made it difficult for collaboratives to reach their potential. I think there is a lot more work to be done.

This is part of the dilemma that we currently face. Take the schematic of medication administration from some of the work that we've done at Partners Healthcare System. We know that each one of the pieces here absolutely works. Research that you and your colleagues have done shows that these things work. That's very helpful. We really need to ask why we don't have it today. Part of it is the resources and standards. It's also putting these pieces together. We've done research on the pieces but we haven't done enough research on putting the pieces together. Maybe the next set of grants that will come from the RFA that was just released will allow us to do that. I think there's a lot of unfinished work and that's something that would clearly be helpful to us.

At the end of the day, you have to ask yourself, "What else could have been done to make health care safer with $165 million?" I posit there are a couple of options here. We could have provided complete coverage for 37,000 uninsured Americans at $4,500 each and that would be a good thing for that 37,000. It would do absolutely nothing for the 40 million who are uninsured. I'm not sure that that would have been the right way to do it. We could redo the IT platform in one major health care system because that is about the budget it would take to do the IT platform at Partners Healthcare. We could cover the implementation costs for electronic health records for about 13,000 physicians. Based on David Bates' research it takes $13,000 in year one costs per doctor to get these systems up and running. Electronic health records would be a wonderful thing, but will 13,000 doctors with that capability make health care safer? You could buy PDAs with free prescribing software for two-thirds of the physicians in America. Would that have been a useful thing? Where would the research come from to tell us what should go on those PDAs? I would say that we probably did much better with the $165 million than we would have done here.

I'm left with one more possibility, and I struggle with this. That is, we could buy 71 30-second spots during the Super Bowl to explain the five steps to safer health care. I would argue that that would really produce results. At one point John Eisenberg and I found that it was $2.4 million for a 30-second spot when we looked into it how much it would cost to do a couple of patient safety spots. We know the year before the military bought about half of them for recruiting ads. The Federal Government could actually buy them. We thought how well it would go over with the HHS administration that we want to spend $5 million on Super Bowl ads about safer health care. That's where that idea ended. I think that would have had some amazing impact. I think at the end of the day, the challenge is not that much different than it was a few years ago. I think what we have to work with has grown exponentially. The challenge is even clearer.

I think AHRQ's new mission lays down a gauntlet for all of you. That is that it's not just about doing research. You're responsible for improving the quality, safety, efficiency, and effectiveness of health care. I pulled Carolyn's quote from the other morning. You should be very proud that you are on the leading edge of AHRQ's new mission to translate research into practice. This is what's expected of you. It's not findings; it's the products. I think I'll play a little game with you and see if we can use it to illustrate why that's such a challenge.

You'll see a little video clip momentarily. This clip actually comes from my friend Helen Bevev from the National Health Service. If you've done this already, please don't participate and remain quiet. Otherwise, this is a little basketball game with two teams. There is a black team and a white team and they're just passing the ball around. I want you to count and tell me exactly how many passes the white players make to each other. It's about 30 seconds long.

The video shows the white team and black team passing the ball back and forth very quickly. All of you would have come up with a number of passes that the white team had to each other. You probably would have been within one or two; they pass back and forth very quickly. Most of you would not have noticed something else; and this has been widely tested with a wide range of audiences including people who are very smart like yourselves. Something else happened in the video, and all of you would miss it. The black team had another team member. Right in the middle of this video where they're passing the basketball around, a person in a gorilla suit walks out, beats his chest, and walks off. It ends up that 99 percent of the audience doesn't see the gorilla.

The point I want to make is that your job is to do great research. You also have to work with people like me because you'll be great about helping us try to be able to count the passes of the basketball and keep track of the data. All of that is very important, but at the end of the day, we have to answer this John Porter question, which many of you have seen. What are we doing for Americans? How has it changed? You missed the gorilla; so this is a mindfulness exercise. I'm just asking you to be mindful in the work that you do of how this will be translated. One thing that this raises for me is my change from someone who was primarily a researcher/funder to now being a recipient or a user.

This is best illustrated by the Hawthorne effect. If you're a researcher, you hate the Hawthorne effect. The Hawthorne effect absolutely ruins your studies because there is a secular trend and everyone improves and it wipes out any differences you may have had. I'm a user. I love the Hawthorne effect. The Hawthorne effect is what allows us to focus on a couple of little things and have a whole organization change. It's a different way of thinking.

I would even take it one step further. I don't know if any of you know Jeremy Bentham who was an English philosopher and was actually the head of University College in London. He got an interesting job from the King. The King went to Jeremy Bentham and said, "Design us a more efficient prison system." He came up with an idea for a prison system, and it was nothing radical or exciting. He said, "You should have a guardhouse in the center and have all of the cells arranged in a circle around the guardhouse." That's somewhat standard and seems to make sense. You can have many people being watched by one single guard. Then he said, "Then you build the guardhouse in a funny way that you can only actually get into the guardhouse via a ladder from underneath. You put louvers on the guardhouse." They didn't have one-way glass back then but they had wooden louvers on the guardhouse such that the guards could see out and the prisoners couldn't see back in. He said, "You have the guards sit in those guardhouses every single day for the first 3 or 4 weeks. You have a guard in every one of those guardhouses and they notice every little thing. After that, you have a guard in there half of the time. Then you have a guard in there about a quarter of the time. In the end, you'll get the same result because someone thinks they're being watched."

I can't watch everything that goes on in a big hospital with a wide array of physician's offices. It's impossible. I need a panoptic eye. That was Jeremy Bentham's design. I need to have people know we're paying attention. It's not what's right in front of our eyes. You need to work with us to make this happen. Embrace the Hawthorne effect.

When you heard Sister Mary Jean talk yesterday, she talked about perseverance, creativity, and integrity. That's what we need because as researchers, everyone wants to be pure. We're not striving for purity here. We're striving for safety. The mission has changed, and you're a very important part of that. Try to understand your users' needs. I need these things. I need to have some sort of balance between having pristine wonderful evidence and being able to move forward with projects. There is no randomized controlled trial that tells you whether certain aspects of aircrew training in military aviation save lives. There was not a randomized controlled trial of angling the decks on aircraft carriers. It wasn't there; but they did it.

We need your help to recognize we need to move forward on some of this now. What are the requirements for adopting internally within an organization versus trying to spread it? Measuring our success and knowing that a manager has a different need than an editor. With all due respect to the editors in the audience, I think you've had your day with this crowd. They've come to you; they've submitted their articles that they wanted published. That's great. I want them to focus more on people like me, people that are trying to make a hard decision because I think we need to make a shift there; high profile versus high impact. High profile things that we can do, things that are sexy and attract attention versus things that we face every day like transitions.

Transitions are so ho-hum; the patient goes from the ICU to the ward, the ward to home, from home to a rehab or a nursing facility. It's a boring thing; but that's a huge vulnerability for us.

One thing I loved was the product café. I thought that was a wonderful idea. I don't know who came up with it; but it was terrific. It's not about reporting on findings. It's about products. It's a way that we have to think differently. One thing we try to do as researchers is we try to make what we did sound very difficult. "This was so hard. It was so hard for us to figure this out; but we did it." Einstein said it perfectly, "Beyond complexity lies simplicity." Think about the simplest message, the simplest change that could come from your work. That's what we need. Keep it very simple. What do we need to help this happen? We need to track the balance scorecard. We need to know how much these things cost. We need to engage the public.

I think we should be able to try to get more into the patient's experience of care and use what we learn as tools to tell people to think a little more about this. Then try to look at the incentives in the system. I would hope that all of you would have research on the business case embedded in your work. I think in retrospect, in designing this portfolio, we should have required everyone to have a business case piece to it. At the end of the day, I can try to wax poetic with my Board, but they want to know about return on investment. They need to know that information; and I understand why they need to know it. We need your help in doing that.

Your need technical assistance as change agents; and I recognize that that's not natural for some of you. I think the work that the coordinating center did that was presented earlier today about putting together a framework is absolutely terrific. That's what you need. You need tools that will help you take on this other role so that you can become a little more of an advocate; and that's not easy for you. I heard a term this morning I thought was terrific, "re-socializing researchers," pulling you out of your research and getting you back out there with people who are providing care on the frontlines. We need to do that. I think there has been some progress but there is still more work that needs to be done.

Transporting success to other settings: Probably the biggest fear that many of us here in the room have is that you heard about something wonderful that was done in this hospital or in this health care organization and say, "I would really love to do this where I am. Will it work? How do I do it? How do I get started?" I think that's where Don Berwick and the IHI were really ahead of the curve. They recognized that it's not about innovation; it's about spread. It won't hurt us if we have no innovation for a couple of years. It will hurt us badly if we have no spread for a couple of years.

Getting safety into the curriculum: One could argue that not only is patient safety not a blitzkrieg, it's a "sitzkrieg." It's a sitting war. The way you win that sitting war is you make the changes in the curriculum and you take a generational approach. I hope that's not what we fall back to here, but I think some of the work that took place in the dissemination grants is a great start. We need to pull those pieces together. You heard Carl Sirio give an impassioned plea for that today, to pull the educational piece, the research piece, and the clinical piece together.

One change that I think is wonderful to see is the relationship of researchers versus users. I would hope that this conference continues to become more of a user conference. That's not to say that the researchers aren't important. It's saying we have to get this stuff out there and show that we're adding value. This is a vision that I would hope that those of you particularly on the recipient side would agree with. We have to figure out how we'll provide this information to the public. The public trust will be violated in 2 months time. It's been 5 years since the IOM report, and if the answer to what did you do is not much, the public trust will be violated. I think there are things to celebrate and there are some real highlights here that we should be discussing more because they are positive stories.

It's a commitment. We need to continue to work on providing information to try to make it actionable. How do you make that information digestible in assessing what we need? I think some of the work that you have done in terms of looking at learners' needs and holding focus groups with users is terrific. Let's put it into action.

I would try to take one thing that Sister Mary Jean said a step further. When people ask me my goals at Massachusetts General in terms of quality and safety, I can summarize them in two very short statements. The first is, "Beat the VA." I want to beat the VA. It's not easy. That's not an easy goal. The second one is, "I want to be better than Home Depot." That's my goal.

The reason I want to be better than Home Depot is if you go to a Home Depot store, they have these signs up all over the place that say, "If this place isn't safe, let us know." When we were getting ready to move from Maryland to Boston, I was spending a lot of time in Home Depot trying to get things cleaned up around the house. My son went over to a ladder display in the Home Depot store in Silver Spring, Maryland and the ladders almost fell on him. I saw this sign that said, "Talk to a manager." I called the manager and said, "This ladder display almost fell on my son." He pulled out a pad of paper, wrote it down, and said, "Thank you." I thought I just wasted 5 minutes of my time and his and that was the end of it.

They had an 800 number there and I wrote it down. A couple of week later, just for a laugh, I called the 800 number at Home Depot. I said, "I'm calling to tell you about something that happened in one of your Home Depot stores. There was this ladder display and it almost fell on my son." I got about that far into the story and they cut me off and said, "Did that happen in store number 463 in Silver Spring, Maryland?" I said, "Yes." They said, "There are 20 displays like that in stores around the country and we'll be changing them in the next month."

That's why I want to beat Home Depot. I think the patient's voice can really help us here. How do we get over the hump and move things into implementation? I think patients can help us out enormously. One of the simple things we can do is bring in the patient voice and ask them when we do the patient experience and care surveys that come out of research projects from AHRQ and the CAHPS® team. CAHPS® needs to ask patients questions about whether they had an opportunity to give feedback about safety. It's a simple question. We should embed it in there. It will help allow us to change things.

We will all have to struggle with this question over the next few years. When I ask people, they all tell me that the tsunami is coming. The tsunami of research results will crest and it will crest soon. I think the question for us is, will we be able to surf this thing or will it wipe us all out? Will we be crushed by all of this stuff that we should do and at the end of the day will people like me standing in front of boards with a fair amount of humiliation say, "We couldn't do it all"? Will the output be digestible? Will it be something that we can bite off and use? That's a very scary thing. All of you are a drop of water in that tsunami, but together you could overwhelm all of the users if you don't think about how to package things in a way that helps us.

The real challenge for us, where there has been a lot of talk in the conference and I think needs to be much more of a focus in the future is illustrated by what was allegedly said by Louis Pasteur on his deathbed where he was confronted by some of his junior colleagues. They said, "Louis, don't worry. We looked under the microscope and we think that you'll get better." He looked up at them and said, "It's not the seed; it's the soil." It's not the research products, it's not the innovations, it's not the interventions that all of you do; it's the culture that we put them into. It's the acceptability of them. It's how you can put them in front of a group of people and say, "We think this is worth our time, energy, and effort" because it has been said in several forums here, providers out there are working so hard. They don't have extra time. No matter how compelling a case you can make, they don't have time. We have to make it easy for them and we have to make sure their culture is ready to accept it. The best research can come out of your work but if people aren't ready to accept it, if the soil hasn't been prepared for it, the seed will not take. We need to talk more about how we prepare that soil.

In the end, all of this is local. I would ask all of you who are researchers to do two very simple things. First is make sure that you talk on a quarterly basis to someone like me, to a medical director, a chief medical officer, to a chief nurse, to someone in a leadership position in the organization. Tell them, "This is what I've done and this is what I've heard my colleagues around the country are doing." Just tell us about it. We desperately need to know. Many of you are becoming very quickly prophets in your own homeland. You're doing great work and nothing is happening in your organization. Why not? Just knock on the door. Just do it.

The second thing that I would ask you to do, and I'm allowed to say this now because I am no longer a Federal employee. All of you in larger organizations have lobbyists. You all have a Washington presence down here knocking on doors, talking to the people in your State capitols about how to improve reimbursement, and dealing with other issues like malpractice and other things around health care. Make sure that those people know what you're doing on safety. Make sure they know what your work is. Make sure that they know when they come to Washington they can say, "We were able to do this work because..." Have them make the case for this. I think we really need to make that more powerfully on the Hill as well. Please plug into your local system.

We're cranking the cycle. This is the old cycle of continuous improvement. We are now working on doing comparisons and process analyses, identifying opportunities, and interventions in process. One of the big interventions in process right now is health information technology, an important intervention that will help us crank this cycle. Recognize that this patient safety thing will be here for a while. Continue to work through the cycle.

I wrote a paper with John Eisenberg a few years ago. It said that patient safety is at the end of the beginning. I think this is a great place to declare that the beginning is over. The beginning is over because we've done some very wonderful research; but there is an awful lot more work to do. We are just beginning on this. Patient safety will not be over; but it's moving into a new phase. Part of that new phase will focus on things like health information technology. You built a foundation, the basic science of patient safety. Now we have to start framing it out. Health information technology will be one of the important sticks in that frame. There will be many others.

I'm always reminded when I hear about health information technology about one of the quotes from the Patient Safety Research Conference when we originally set the agenda for the RFAs for which many of you applied. One of the respondents started off his testimony by saying, "To err is human; but to really screw up you need a computer." We need to be mindful with all of the information technology and how it affects safety to avoid the Tower of Babel that we have between information systems. One thing I have difficulty arguing against is when my colleagues say, "When there's a paper record and it comes from across town, I can read it. When there's an electronic record and it comes from across town, maybe I can read it, maybe I can't." We need to solve that. Sister Mary Jean alluded to other systemic problems yesterday.

In the end, I would just ask you to keep up the commitment, to keep up this work, to be optimistic. I would say that cynicism is the harbor of a lazy mind. Do not be cynical about this. Just keep moving forward. Avoid being asked to set explicit goals. Dilbert's boss set a goal of zero disabling injuries. Last year our goal was 26 disabling injuries. In retrospect, that was a mistake; we had to injure nine employees to meet the goal. Dilbert's boss has an ingenious solution . I'm fond of saying that one reason I went to Massachusetts General and to Partners Healthcare System from Washington to Boston was so I could learn about bureaucracy. This is a wonderful bureaucratic approach. If you have an injury, fill out these forms immediately. These are resignation forms. If you cover the word "resignation" with your thumb, it's an injury report. We'll miss you. Keep on the job. Thank you.

Dr. Clancy

That was terrific, although I need to contradict you on one point. There is actually a randomized trial of resource management going on. I mention it not to make the point that I know something you don't, because I actually think you knew already, but more to make the point that it's in obstetrical care. The great experience I had a few months ago was speaking at the opening session of the annual meeting of the American College of OB-GYN where the president had decided to make patient safety his theme and his focus and it's his passion and commitment for this year. I gave an overview of what was going on with AHRQ and Lucian Leape gave a fabulous presentation. Then Ben Sachs from Beth Israel got up and described the study. He's a little embarrassed because he had hoped to present results and it's a randomized control trial being done in military and civilian hospitals. For obvious reasons, like Iraq, the enrollment in military hospitals has been a little bit behind schedule. Therefore, he doesn't have the results; he's only presenting an overview of the study and telling people the results are coming soon. The response from the audience was unanimous. People practically stormed the microphones. They weren't asking questions about the study design. They wanted to know when he would have the manuals ready because they want to do this. He had a very compelling video about some errors that had happened in his institution, but I was so impressed by the response. I think that is another reason for optimism.

Sister Mary Jean Ryan started this conference by inspiring all of us in reinforcing the idea that improving safety is both a destination and a journey. She also reminded us and inspired me personally by saying that while in many ways we'll need fundamental system reform before we can get to a system that's predictably and reliably safe, that doesn't free us at all from a moral obligation to do everything we can right now. I think there is a lot of optimism based on what I've seen at this meeting. At the opening of this conference, I asked all of you your opinion on whether you thought health care was safer. I would say the majority do think the health care system is safer now than it was 5 years ago. I then asked how many of you felt safer as patients in that same health care system. There were fewer hands then. I'll leave you to ponder that.

In keeping with the idea that this is a journey as well as a destination, I think we've seen at this meeting and from all of your ongoing work that we now have the beginnings of maps, tools, and a compass and we can begin to take off and really chart what we're doing. I was reflecting on a time right before the IOM report, shortly after the Boston Globe reporter was killed from an overdose of chemotherapy. At that time, Lucian Leape was quoted as saying, "There is a lot more activity but very little effort in trying to figure out if this activity is working."

I think what we now have in terms of a receptive soil or culture is that more and more people like Gregg are saying, "Tell me what I can do and tell me what evidence you have for why I know I can put any faith in this." That's not to say there aren't enough receptor sites, I want to reinforce his suggestion that you talk to people in the health care system or at the sharp end of health care as often as possible because you'll learn a lot. I think more and more people are saying, "How do we get there? Where is the manual? When will you have the products ready?" I was very excited by the products café. The fabulous thing about this meeting is that people have been walking up to me all of the time saying they think the meeting is wonderful. Thank you.

The work in progress is very exciting. In addition to Gregg's point about shifting the language from errors to harms, I think we have begun to develop a new language, so much so that I haven't heard aviation mentioned here very often. Early on, that was "the model" to use because they had it figured out and we didn't. Now, we're beginning to chart our own path. That doesn't mean we can't continue to learn from others, but that we have made a lot of progress. I've also noticed, and I'm sure some of you will notice on the way home, that it's been my impression that some airlines are beginning to emulate health care for service quality. I'll leave you to contemplate that on your journey home.

The other exciting thing here was seeing the interactions between users and researchers. I know that we inconvenienced some of you. I think it was worth it. I just saw so many people out talking to people in health care who are working on the frontlines, on the sharp end. It's just incredible to see and we need more of that. There has been incredible progress between the first year and the third year. People are very excited about their work. They're confident in what they're doing and so forth. It was wonderful to have the PSIC class here. I'm hoping that you all share my optimism and feel recharged. There is still quite a bit to do.

Some things we need from you. We are launching a new newsletter. We're very excited about that. Please share your work in progress with us. Even share information like we're working on this project and another hospital or organization wants to join with us. That's all very helpful information to share. It doesn't have to be multivariate analyses. We obviously and always remind you that we want to hear about forthcoming publications. Never forget which actors will need to act on your results. Sometimes that will be people like Gregg. Sometimes it will be people upstream who can actually influence policy. Sometimes it's not actually very clear. We may need to work on it together. There are times when we can actually help you make those interactions or connections with people in the health care system. Cynthia Palmer leads our Integrated Delivery System Research Network. She has been here because we actually work very closely with nine integrated delivery systems. They're looking for tools to implement in their systems and so forth. Remember her name; Cynthia Palmer.

A new wrinkle as we've moved forward which I think is both a challenge and an opportunity, and I've had a number of conversations with some of you about this, is the incredible enthusiasm right now for health information technology. I want you to know if you woke up any of my senior colleagues in the Department of Health and Human Services in the middle of the night and said, "Why are we doing anything about HIT?" they would say one thing, "Safety." It's very clear that they see its impact on safety. I know many of you are concerned that we may lose sight of the systems and culture piece. I want to remind you of the quote from the most recent report from the IOM, "We can't get to a reliably safe health care system without safe culture and improved information systems. They have to have both." You can help.

Gregg reinforced the notion of communicating with policymakers. I spoke to a group this morning that Senator Durenberger convened, some fairly senior folks in health care who want to learn about how Washington works. I noticed there was a panel in yesterday's meeting called, "Information Agents." In television shows and so forth, they might be called lobbyists. Lobbyists put information in front of people all of the time. Researchers save the information until they have a publication, and as a group, I think tend to be more modest in terms of sharing this. That's not how it works in business. It's not how it works in terms of sharing information. You all have an obligation and a responsibility to educate the policymakers who are frankly funding you on behalf of the taxpayers. If you need help or want advice about doing this, please let us know. This isn't about lobbying; this is about letting people know what really matters.

We know, all of us, that health information technology and the systems change in a culture of safety need to go hand in hand. They need to be linked. You don't need to tell us but you really do need to tell others who are really just as interested in having a safe health care system as all of us are. The House passed patient safety legislation last year. The Senate recently passed it by a kind of middle of the night voice vote by unanimous consent right before they went out for their summer recess. It's unclear whether that will be finally conferenced and their differences resolved before the end of this year but it's coming. Many of you will be prophets in your own land in a big way. Many people will be turning to you, but that will be another opportunity for you to educate people locally and the people who represent you about the importance of the work, about how much progress we've made, and that we need continued support to keep going.

Again, I want to reiterate Dan's thanks to Deborah Queenan, Dan Stryer, Kathy Crosson, Marge Keyes, the entire team, our colleagues at Westat and so forth for a fabulous conference and want to wish all of you safe travels on the way home. Remember, when you get on the plane, they're in charge, not you. Have a good trip. Thank you.

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Current as of July 2005
Internet Citation: Making the Health Care System Safer: Closing Session: Third Annual Patient Safety Research Conference. July 2005. Agency for Healthcare Research and Quality, Rockville, MD.


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