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Transcript of Web-assisted Teleconference

Session 2: How Can States and Institutions Work Together to Create a Culture of Safety? Concrete Actions to Improve Patient Safety

Can You Minimize Health Care Costs by Improving Patient Safety?

This Web-assisted audio teleconference consisted of three sessions broadcast via the World Wide Web and telephone September 20, 30, and October 1, 2002. The program explored the business case for patient safety, how to overcome barriers, and practical solutions to help States and health care facilities improve patient safety. The User Liaison Program of the Agency for Health Care Research and Quality (AHRQ) developed and sponsored the program.

September 30 Transcript

Cindy DiBiasi: Good afternoon. Welcome to "Can You Minimize Health care Costs by Improving Patient Safety?" This is the second in a series of three Web-assisted audio conferences for state and local health policymakers sponsored by the User Liaison Program within AHRQ, the Agency for Healthcare Research and Quality at the U.S. Department of Health and Human Services.

My name is Cindy DiBiasi and I will be your moderator for today's session entitled How Can States and Facilities Work Together to Create a Culture of Safety? Concrete Actions to Improve Patient Safety. This is the second event of this Web-assisted audio conference series on overcoming barriers and launching practical solutions to improving patient safety. Why focus on patient safety in a time of budget crunches? Well, improving patient safety is not just a quality improvement strategy; it may also be a cost containment strategy. A patient's safety is directly related to the immediate crisis of workforce shortages, as we will discuss on our third call.

AHRQ, in its capacity as a Federal agency, is playing an important role in supporting research and providing policymakers with information and tools to improve patient safety. State and local policymakers also play an essential role in addressing patient safety. The goal of this series is to provide State and local policymakers and program administrators with insights regarding the business case for patient safety and methods to overcome barriers to launch practical solutions to help State and health care facilities improve patient safety.

Let me tell you about the calls on this Web-assisted audio conference series. On our first call on September 20, we discussed the business case for patient safety, the human and financial cost of errors, the potential cost savings from reducing errors and the cost and benefits of disclosing errors. Today's call is entitled "How Can States and Facilities Work Together to Create a Culture of Safety? Concrete Actions to Improve Patient Safety." We will explore the issues, opportunities, and strategies to create a culture of safety within health care institutions.

We will also be discussing ways in which Federal, State and local governments can help facilitate this effort. Panelists will share information about evidence-based practices, leadership initiatives and collaborative relationships between States and institutions. Then tomorrow, Tuesday, October 1, we will look at "What do workforce issues have to do with patient safety?"

Here we will examine the relationship between workforce issues and patient safety and specifically the link between health care shortages and medical errors. The call will highlight several State approaches to addressing workforce shortages and recent research findings on this topic.

Now I think we are ready to turn to the important matter of patient safety and as I said today we are going to take a look at concrete actions to improve it. Let me introduce you to today's panelists.

In the studio with me I have:

  • Marge Keyes, project officer for the Center for Quality Improvement and Patient Safety at AHRQ.
  • Julie Morath, nurses' executive and chief operating officer for Children's Hospitals and Clinics in Minneapolis.
  • Scott Williams, deputy director of the Utah Department of Health.

Welcome Marge, Julie and Scott.

Let's begin with Marge Keyes at the Center for Quality Improvement and Patient Safety at AHRQ. Marge, I know that AHRQ and the Joint Commission on Accreditation of Healthcare Organizations sponsored a conference last week on the business case for patient safety. In follow up to our call last week on this topic, what were some of the take-home messages from that conference?

Marge Keyes: Thanks, Cindy. There were about six general take-away practices. First, many attendees believe that the business case for patient safety has been made and are emphasizing patient safety as a part of their institution's core identity and mission. Others feel that patient safety has not been made as an important issue and that it doesn't show up in the profit and loss statements in their hospitals. Nonetheless, there seemed to be some general agreement that there are some patient safety improvements that are essentially budget neutral and they are low hanging fruit that can be easily implemented.

Further discussion highlighted a number of issues that are critical to successfully move forward. They included aligning the facilities' culture with strategies for improving safety, creating a transparency for dialog about safety, ensuring CEO leadership and emphasizing that perceived risk can be overcome.

Attendees also highlighted a number of barriers. They included examining professional's roles and responsibilities in safety improvement, establishing better care management protocols, and incorporating safety guidelines into accreditation standards. Lastly they felt that we need to examine our payment systems and make sure that they are aligned to reward patient safety. We need to put in practice a national health care information infrastructure to facilitate investment in IT solutions and lastly we need more research to better document the specifics regarding patient safety.

Cindy DiBiasi: While AHRQ has conducted research to identify evidence-based practices to improve patient safety, can you describe this research?

Marge Keyes: Sure. I think the most well known and most recently published is a document called Making Health care Safer, a Critical Analysis of Patient Safety Practices. That was released in July of 2001. It is available at If you are interested in printing that out, it is a 650-page report that is accompanied by an executive summary. It includes patient safety practices, those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses and conditions. It incorporated 40 researchers with expertise in patient safety, evidence-based medicine, clinical medicine, nursing, and pharmacy. Plus it also included an advisory panel. It focuses primarily on hospital care but includes some nursing home and ambulatory care practices.

The selection of practices relied on inclusion criteria and structured evaluation of the evidence looking at the prevalence and severity of the problem, current use of the practice, evidence on advocacy or effectiveness, the practice's potential for harm, the cost for implementing the practice and other implementation issues.

Cindy DiBiasi: What were the top practices that were identified from this research?

Marge Keyes: I think on the slides that are being shown today, there is a list of 11 practices out of the 79 that were investigated. They fell into three major categories. First are medications such as perioperative use of beta-blockers to prevent heart attacks or MI's. Another category was procedures. For example, real-time ultrasound guidelines during central line insertion and lastly administrative practices. Looking at something like patients recalling or restating their informed consent somewhat like the aviation checklist or callbacks that are used on a regular basis in airplanes.

Cindy DiBiasi: What kind of response have you gotten to this report?

Marge Keyes: Well, some interesting responses. Actually, people are probably already aware that there were a couple of JAMA articles recently. A couple of the findings from those articles were that acceptance of a practice does not always rely on evidence from a randomized trial and reasonable judgment based on best available evidence may be an acceptable approach. But the authors of the report that we contracted with for production also wanted to emphasize in their article that their charge was to identify evidence-based safety practices. They also noted general insistence on evidence should not prevent implementation of practical low-risk understudy interventions that seem likely to work. Having said that, I think however we, we certainly need to be cautious how we move forward with that type of evidence and I think a perfect recent example is the hormone replacement therapy that was initially believed to be protective in nature and now with the recent clinical trial has been found to be somewhat harmful.

Cindy DiBiasi: I understand that AHRQ is currently exploring the creation of a patient safety improvement core. Can you tell us a little bit about that?

Marge Keyes: Sure. With the evolution of the patient safety movement and the focus on medical error and improving patient safety, we heard loud and clear from States that they were worried about a lot of pressure that would be put on them to investigate these types of things and they were very worried about not having the resources, that is the personnel or the dollars. So we are developing something called the Patient Safety Improvement Corps. It is to develop and maintain front line capacity for patient safety improvement at the community, regional and State level. We are expecting to have by 2004, technical assistance and trained individuals in ten States or health care organizations to help improve patient safety.

Cindy DiBiasi: What are some of the core issues that you expect the corps to cover?

Marge Keyes: In terms of its content and its courses, basically there was some agreement that the courses needed to be short and practical, useful. People that we had conversations with were not interested in going to courses that were very theoretically based and being involved in long academic programs. So they were very interested in information and courses that they could put to use immediately.

Cindy DiBiasi: OK. Marge, we are going to come back to you for more, but right now we are going to turn to Julie Morath, a nurse executive and chief operating officer for Children's Hospitals and Clinics in Minneapolis. To hear about Children's experiences creating a culture of safety within its hospital.

But first I would like to congratulate Julie for receiving one of the first John M. Eisenberg Patient Safety Awards for Individual Lifetime Achievement presented by the Joint Commission and the National Quality Forum. Julie was chosen to receive the award based on her successful work at Children's Hospital to introduce a culture of patient safety, to improve safety and the care of patients. Congratulations. You are much too young to have already received a lifetime achievement award.

Julie Morath: (Laughing) I appreciate you noting that.

Cindy DiBiasi: I am sure you will get another one. Let's talk about this patient safety manifesto. Where does it come from?

Julie Morath: First, a manifesto is a personal and public declaration of intent to act. 'Manifesto' wasn't a word I used in my regular vocabulary so I had to look it up. The Patient Safety Manifesto is a product of the Harvard Executive Sessions on Medical Accidents which convened health care leaders and leaders in research and the science of patient safety from 1997 to 2000. The manifesto provides a pathway for leadership actions in creating a culture of safety.

Cindy DiBiasi: According to the manifesto, there are seven things that need to be put into place within health care institutions to create a culture of safety. What are they?

Julie Morath: They are:

  1. Declaring patient safety an urgent problem and a priority at the board and the executive level.
  2. Accepting leadership responsibility for patient safety.
  3. Safety does not belong alone to those who give and receive care at the front line. It is also what we do in the boardroom and in the executive sessions. They are gaining new knowledge and tools from safety science and other industry in which failure is not an option.
  4. Ensuring accountability through plan and assignment.
  5. Confronting myths that are disabling as we begin to look at patient safety.
  6. Aligning external controls in the environment.
  7. Accelerating change.

Cindy DiBiasi: Let's talk about some of the barriers that get in the way of achieving these goals.

Julie Morath: One barrier that we found was overcoming cynicism. The patient safety was just another flavor of the month for the health care industry. Next was the fear of criticism and blame that the individual provider might have when there is greater transparency in talking about error and making a medical accident. There is also the fear of malpractice exposure and exposure and damage to the reputation of an organization when things don't go well.

We also had barriers of traditional myths in health care such as the myth of the perfect provider, the individual hero who is infallible, that harm is the inevitable by-product of technology. Another barrier is accounting and chasing rates is sufficient to create safety. Finally that safety is the problem of the front line providers alone. That we have these perfect systems and somehow they are messing them up and we all know that to be a myth.

Cindy DiBiasi: Some of these barriers appear to be pretty formidable. What specific tactics do we have that can break through the barriers?

Julie Morath: I think the first and the most important is the demonstration of leadership and the notion of reciprocal accountability. Patient safety is not about cautioning people to be more careful. Doctors, nurses, pharmacists are some of the most careful people on earth. But if to begin to accept the responsibility that leaders design and operate the systems in which care is given and received. So leadership and taking full responsibility for patient safety is the first strategy.

The second is creating a theoretical foundation, a softening of the culture. Bringing in new education, new knowledge to help reframe the issue of mistake making in medicine.

Third, we found very helpful is establishing a blameless report system and on surface this seems very simple but it is a very deep cultural intervention. Hardwiring patient safety into all aspects of the organization through a work plan, specific measures that are routinely reported to the board and back to the organization, hardwiring patient safety into job descriptions, expected competencies, training and incentives.

Cindy DiBiasi: Now of the seven factors in the Patient Safety Manifesto, is there one that deserves more emphasis than another? Where do you place the emphasis?

Julie Morath: I place the emphasis in two areas. The first is leadership. Patient safety at a local level will not be sustainable without the macro economics in place of the leadership of the organization.

The second is partnership. Our patients and families are part of the system, not just recipients of the care delivered. We need partnerships with our professional organizations, with our legal system, with those policymakers, and those who work in the legislative process.

Cindy DiBiasi: Tell us a little bit about the Harvard Executive Sessions. How are Minnesota hospital leaders trying to replicate those?

Julie Morath: Well, the executive session really aims at three outcomes. The first is in the ideas and behavior of the members who are actually participating. That there is a change in insight. Second is challenging professionals outside of the confines of the group and the third is changing conventional wisdom about patient safety and health care.

In Minneapolis and St. Paul and Greater Minnesota, the health care leaders came together and agreed that we would not compete on the topic of patient safety; that this was an area of collective obligation. So we have been replicating the technology of the Harvard Executive Session. It includes health care leaders, the commissioner of health, policymakers, State and professional organization leaders as well as consumers and legal interests. We have created a safe container to open dialog about the cross currents in patient safety and identify areas for alignment in effective action.

Cindy DiBiasi: How can State officials engage hospital leaders and encourage facilities change?

Julie Morath:

  • The first thing is starting the dialog. I think we have a shared interest in the protection of the public. Often the level of analysis is the individual. As those who work in the regulatory environment, State officials begin to create a space for us to enter as a very candid and authentic dialog about the issues that are confronting us that will help.
  • Mutual education, learning together about patient safety and about what interventions are effective, learning what has been the experience in other States and other organizations and importing those into your own State.
  • Reviewing the regulatory experience. What is that about? Each State has a little different experience and it can either help support and enable patient safety or it can create a chilling effect. It is important to understand what those processes are and how they affect health care organizations.
  • Identifying common ground. What is our collective obligation? Then finding those paths that help close the gap and create a line of action.

Cindy DiBiasi: Julie, we are going to come back to you once we open this Web cast up to the audience. Next I would like to turn to Scott Williams, the deputy director of the Utah Department of Health. Scott just put his statewide patient safety program into effect one year ago in partnership with the Utah Hospital Association. Scott, how does a State determine its role in promoting patient safety?

Scott Williams: Well, I think you have to look around at the context that you are in. Every State is a little bit different in this regard which is why this really belongs at the State level at this point, I think. If you have had a really high-profile event that the media covered extensively, that is known to policymakers, elected officials, then you are going to be driven by that event to do something fairly quickly and that is just the cards you are dealt and you have to deal with that and move forward. If you have someone in your community or a group of people who have academic expertise that are really driving this, have strong opinions and credibility in the community about this, then you are going to have to rally around them to some extent.

There may be a legislator that really has had a personal experience with this and wants to push a bill through. You may or may not think a bill is needed but if that person is going to have involvement in this you are going to have to work around that kind of motivator.

Finally, different States have different regulatory environments. In the western States especially there is a fairly strong anti-regulatory feeling in a lot of State governments, so not that this really should be accomplished through regulation but the State tends to represent that part of the system and so the State's credibility and trust is really based on what their regulatory experience has been up to that point.

Finally, the relationship between the hospitals and the States and others kind of waxes and wanes around different issues. For example, a couple of years ago we had some very aggressive Medicaid fraud investigators who really damaged some relationships between providers and the State. It took us a while to sort of repair that relationship. Depending on where you are with that, it depends on how willing the industry is going to be to sit down with the State and move this forward.

Cindy DiBiasi: Obviously States have regulatory authority. But how can they use that as a tool for improved safety as opposed to being perceived by facilities as something that is punitive?

Scott Williams: I think States need to take a little bit different look at that. This all occurred, all that data that was collected in the IOM (Institute of Medicine) study occurred in the midst of a regulatory environment. So regulation clearly has not been enough to stop enough of these events from occurring. Certainly regulation has its place. So it is a little bit of a different kind of approach. What we have encouraged the industry to do is to use the government as a tool. Use the authority of the government as a tool for them to accomplish what they want to accomplish. An example of that is Julie talked a little about the hospitals in Minnesota coming together. In some States that is easier than others. You need a neutral place to do that because of the competitive environment that health care is.

Another one is the public needs to know that this isn't just an internal industry effort. It lends credibility to the effort if there is an external watchdog; the entity that the public expects to make sure that their health care is safe is a part of this program. So we can actually add credibility as an endorser of it.

We can level the industry in terms of making sure that every body is obligated to do the same things so that every body experiences the same costs so that people aren't implementing patient safety measures completely dependent on whether they can outdo the cost competitiveness with the hospital down the street. Everyone is required to have the same kinds of things in place. Then the costs are all the same across the industry.

Sometimes unhelpful solutions come down the road from a policymaker or one particular part of the industry and I think we can as States, we can try to divert those through the political process into this more productive process of cooperativeness. We fund a lot of health care out of State health departments through the Medicaid program and we can create incentives to make sure that that is part of our funding.

If it comes down to it and there is a group of hospitals that want to move forward and some that are holding back, we can kind of be a little bit of a bad cop and say, "Well, if this doesn't all go forward together, if you don't do this together, then there will be regulations that you may not like." That has actually been effective in getting people to say, "Well, we had better do something that we control rather than something that is done to us.

Finally, if you just can't make it happen, if the groups can't come together, you can put regulation into effect to try to push it through, but in my view that is the last resort that you want to do because I think that doesn't lead to culture change which is really what patient safety is about.

Cindy DiBiasi: What are some of the barriers that the States face as regulators?

Scott Williams: I think the State has to be careful because we potentially can create an unsafe environment. One of the founding principles of patient safety is people have to feel safe in order to bring these issues forward. So if people feel like the State is going to be punitive in their response to these events or if people feel like there is going to be public disclosure and they are going to end up on the front page of the paper as soon as something occurs with no assistance, then they feel like this isn't a safe environment and they are going to conceal. So States have to be very careful how they approach that. I think we can impose unacceptable administrative burdens by just creating reporting requirements or a list of compliance issues that are costly to the hospitals or create redundancy and I think the hospitals or others will back away if they feel like we are just adding a lot of administrative work where they don't see the pay off on the other end in terms of really improving things.

Finally, I think we have to be careful, especially right now where we are still all kind of moving this forward together in making promises about things like cost containment. I know that was the subject of the last conference, or malpractice insurance premiums or a rapid decrease in errors because it is going to take time. If we promise those things as a condition of moving forward, I am not sure we know yet we can deliver those unless it is really a strong change on the internal side of the hospital.

Cindy DiBiasi: So what has Utah done to encourage facilities to change?

Scott Williams: Well, we decided to take what we thought was a fairly simple approach and we followed the IOM report fairly closely. The first thing we did, what we called kind of a booster to the IOM report, was we looked at our own data that was being reported by the hospitals and there is codes in the ICD system that allow you to say these are the things that probably represent medical errors in the hospital. We put a report together of what that data showed. We were very careful in making sure the limitations of that data were clear in the front of the report. But it kept the discussion going and it allowed us, the State, to step forward as an independent agent and say we have some data about this. Let's start there and look at that. So that report was a real kind of fulcrum for us to push this forward a little bit.

Then we worked with a task force the hospital association had created. They were already decided to create a task force, much to their credit. We joined that. We went to that and we said we really need you to help us develop these two tools for you to use. One was our Sentinel Event Reporting Rule that requires hospitals to report serious events. Another part of that is that it allows us to go in and have an arm's length review of their root cause analysis process to make sure it is thorough and credible. We don't sit in on the discussions because we don't want to have that kind of a chilling effect, but we meet with the convener and facilitator of the root cause analysis and we go through the process they went through and their conclusions to make sure we feel like they have taken it seriously and have responded at the adequate level.

Then we also wanted hospitals to all start working on an internal program. So we picked adverse drug events since that is the largest group of medical errors and we require every hospital in the State to have an adverse drug event prevention program. We haven't told them what that has to look like; we have just said it has to be evidence-based. It has to be implemented correctly and it has to be audited. But they get to pick the one they want. It could be very low tech or it could be very high tech, depending on the size and resources of the hospital.

Then finally we have got a grant from AHRQ to evaluate the ICD reporting system to try to find out if it is really going to be a viable system over time to identify errors.

Cindy DiBiasi: Now how has Utah been able to work collaboratively with facilities in implementing these patient safety improvements?

Scott Williams: Well, several things helped us. I think the IOM report, probably more than any other document that has been released since I have been in medical practice, has created a huge amount of attention and momentum. It was a tremendous window of opportunity. It turned out that both the executive director and myself at the health department had had personal family experiences with medical errors during the year prior to the release of the IOM report. So there was tremendous receptivity in our agency when that report came out.

Also we had an advantage because where as many people were saying well, that is the data in the IOM report, we don't have data from our State, well, some of the data in the IOM report was from Utah. So people in Utah really couldn't say that and it allowed us to move past that fairly quickly.

We also had, our hospital association was ready to step forward and showed great leadership in saying we are going to take this seriously and a member of the IOM panel, Brent James, is in Utah and helped explain to people how that report got put together and why this was so important and that was tremendously helpful.

We decided we were going to move forward and the hospital industry knew that and we decided to move forward together, but they knew that if they dragged their feet or if things didn't proceed that we were going to move. So it created kind of this creative tension for us to do it together.

Then finally, in a sort of challenge to me, is we had to step back at some point and say we are going to let the hospitals take the lead on this. Even though we have been doing it together, this is their industry. They need to demonstrate to the public that they take this seriously. So we really tried to let the hospitals take all this work and say this is what we are going to do for the patients because we are worried. We had had to step back a little bit. Sometimes the State likes to flex its muscle and show look what we can do to make sure things work well. But we felt like it was appropriate for us to step back.

Then we didn't have these diverting events. We didn't have legislation that was ill conceived and we didn't have a high profile event so we had an environment where we could work a little bit more calmly without so much public attention.

Cindy DiBiasi: What has been Utah's approach to dealing with the media and disseminating public information on this issue because this can be a very touchy issue. We have been alluding to that all afternoon.

Scott Williams: And the hospitals were really worried about how this was going to play in the media and we had to be careful. We had a press conference together with the hospitals and the State when we started this program and we decided our message, our main message was going to be at that point that more errors is good. That the more errors we get reported, the better the system is going to be. So we tried to disabuse the public of the notion that this was going to result in declining numbers immediately. The first goal was to get the numbers up, to have more reported. So we immediately changed the perception of what we were trying to achieve.

We also tried to be clear whenever we talked to the media. That errors occur in multiple sites, hospitals, nursing homes, at home, in pharmacies. The hospitals are a convenient place to look at them first because hospitals are the easiest place to document them. It is not fair to hold up hospitals as the main, the only place that this is occurring. Eventually we are going to have to move in to these other areas.

We also tried to take the lead from the police departments who when there is a shooting by a police officer, immediately we all know what they are going to say. They are going to say, "We are going to do an internal affairs investigation, this officer is going to be taken off-line and we will have a report coming out about this." So that the public knows that these things happen, there is an immediate system that goes into place, and that we look at it and we report back. So we have gotten so used to that in police reporting that we don't, many communities still have concerns about their police departments, but most people believe that there is at least a process that if it isn't working well that it can be fixed to work well to address that kind of a problem.

One that I don't think we are quite up to yet but is important and we have talked about it and Julie mentioned it. This is more of an internal industry public relations strategies with patients is that you are an important part of this. We need you to be telling us when you think we are making errors. We need you to tell us this pill doesn't look like the pill they gave me yesterday. I think we need to really develop public information that isn't maybe through the media but through admissions offices and nursing units to make sure that patients know that we depend on them to help us do this.

Cindy DiBiasi: Like a shared responsibility?

Scott Williams: Exactly.

Cindy DiBiasi: Well, Scott we are going to come back to you in a moment. We are also going to open up the discussion for questions from our listening audience in a few moments.

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