Improving patient safety has long been a part of NQF's mission to advance high-quality healthcare. The wider healthcare community has embraced this idea as well – from the National Priorities Partnership to the National Quality Strategy, the nation's commitment to reducing harm and preventing medical errors is clear.
Each year, NQF recognizes outstanding individuals and programs dedicated to improving patient safety with the John M. Eisenberg Patient Safety and Quality Awards. The 2011 winners – representing diverse and innovative healthcare organizations and systems from across the country – epitomize what it means to put safety at the forefront of patient care. NQF asked the winners to share their thoughts on the importance of patient safety: what it means to inspire change, what challenges we still face, and why they are such advocates for quality improvement.
We invite you to learn about their stories.
Executive Vice President for Healthcare Quality Evaluation, The Joint Commission
Dr. Loeb was the recipient of the Eisenberg Honorary Lifetime Achievement Award in recognition of his extraordinary and sustained contributions to healthcare quality and patient safety. His work at The Joint Commission has resulted in thousands of hospitals and healthcare organizations realizing the importance of accurate, focused performance measurement in driving quality improvement, paving the way for federal performance measurement requirements that continue to be rolled out today.
What are the essential elements to building a culture focused on patient safety and quality? Why are these important?
Cultural changes designed to improve health care quality and reduce the risk of unintentional harm to patients cannot be mandated. Rather, such alterations in "business as usual" require organic changes within organizations, starting with leadership and progressing throughout the DNA of the facility. It is critical that healthcare delivery becomes a highly reliable system, much as has occurred in aviation and nuclear power. Such systems require three basic building blocks: leadership, the creation of a culture of safety – the triad of trust, report, and improve – and the use of effective process improvement tools, something The Joint Commission has called Robust Process Improvement.
What quality and safety challenges remain within our existing healthcare system? What steps can we take to overcome these challenges to help ensure safer, more effective care for all patients?
Unfortunately, our health care system remains highly fragmented and patients continue to be harmed each and every day. The challenges are enormous, but the rewards are greater. Systems of accountability must differentiate slips and lapses from intentional disregard of standardized systems and processes of care. There is a significant difference between promoting a blame-free culture and one that recognizes that certain acts, where intentional disregard for proper procedure have been identified, are not blame-free. Perhaps most importantly, listening carefully to the voice of the patient must be a critical component of any solution respecting the improvement of healthcare quality and patient safety.
What does winning the Eisenberg Award mean to you? What has inspired you and your organization to become such an advocate for patient safety and quality?
Receiving the Eisenberg Award is a humbling and unexpected honor. It is perhaps more impactful to me at this point in my life, having recently been diagnosed with cancer. John himself was the picture of dignity and humility as he dealt with a deadly disease. I can only hope that my disparate work on many aspects of healthcare quality and patient safety over the last three decades has helped others; now I am hoping that I too will be the beneficiary of what I have tried so hard to promote.
Executive Vice Chancellor for Health Affairs, The University of Texas System
Dr. Shine was the recipient of the Eisenberg Award for Individual Achievement for his multiple leadership roles that have helped to improve quality and safety in healthcare nationwide. As past president of the Institute of Medicine, Dr. Shine established the Quality of Care in America project, which led to the landmark reports, "To Err is Human" and "Crossing the Quality Chasm," and helped put safety and quality on the national agenda.
What are the essential elements to building a culture focused on patient safety and quality? Why are these important?
There are three elements: data, leadership, and communications. Data is critical to build a culture of safety – data can make staff aware of a problem. Without this awareness, it's hard to motivate staff to change and improve. Data is also critical to demonstrate whether quality and safety innovations actually work. Second is leadership. Clinical thought leaders are key – they are recognized as providing very good care, so they are models for other caregivers to emulate. Senior leadership must also make patient safety a major priority, and emphasize these priorities with all clinical staff. The last element is communications. Leadership and caregivers must pay close attention to the what, why, and when; the details are essential in order to carry out quality and safety initiatives. In addition, it's critical that you can communicate and demonstrate that quality and safety have actually improved. Once you see improvement on a smaller scale, you must figure out how to replicate this success in other areas of care. Scaling up safety and quality initiatives is a huge challenge.
What quality and safety challenges remain within our existing healthcare system? What steps can we take to overcome these challenges to help ensure safer, more effective care for all patients?
Safety and quality are major issues for inpatient hospital services – recent data show some type of medical error may occur as often as one in three admissions, so there is still a significant problem. Leaders must emphasize that we must continue to improve, and that patient safety and quality is a work in progress. Further, we have not addressed these issues outside of inpatient settings – we need to extend our efforts to ambulatory, nursing homes, and assisted living facilities. Third, we must align reimbursement mechanisms so providers actually get reimbursed in a significant way for improving safety and quality. Early efforts in this regard have not been aggressive enough in reimbursing. Finally, we need to continue to improve methodology for improving quality and safety; what this means is increased use of systems engineering and other industrial strategies – some of which are being deployed – and applying them across institutions. These efforts are occurring in some places, but not at the level that they need to be at. Finally, we need to recognize achievement; awards like the Eisenberg Award are essential to doing that.
What does winning the Eisenberg Award mean to you? What has inspired you and your organization to become such an advocate for patient safety and quality?
When I was President of the Institute of Medicine, we were anxious to address quality of care in the United States. It became clear that if you talked about quality in an abstract way, healthcare professionals and the public wouldn't listen. Thanks to the leadership of Janet Corrigan and my colleagues, we identified that we could most effectively make these healthcare professionals and the public care about quality by focusing on medical errors and safety concerns. Doctors could not deny that they had seen errors in care and medication. When we announced that up to 99,000 people were dying each year from medical errors, we knew we had a compelling message. In my later positions, I was able to see whether such safety principles could be applied. I was able to put many of them into practice, especially here in Texas, where I work with a remarkable group of people; it truly is a team effort. On a personal note, John Eisenberg was a close friend and colleague of mine throughout my career, so winning this award is extremely significant to me.
Senior Vice President, Center for Hospital Innovation & Improvement, Society of Hospital Medicine
Dr. Maynard and the Society of Hospital Medicine were the recipients of the Eisenberg Award for Innovation and Patient Safety and Quality at the national level for the society's Mentored Implementation Program. The program helps to further frontline quality initiatives by employing quality improvement experts to serve as mentors and provide guidance to hospital teams. To date, mentors have been placed in over 300 hospitals across the United States and Canada.
What are the essential elements to building a culture focused on patient safety and quality? Why are these important?
The most essential elements are buy-in and demonstration of commitment from the very top of the organization on down. This means focusing upon and incentivizing quality and safety outcomes, as well as productivity. The commitment to standardize processes (even when it is not popular to do so) and support meaningful, actionable measurement and reporting (not just core measures, but more real-time measurement and feedback) make the difference between centers that really perform well versus those that talk a good game. A culture of safety certainly isn't built overnight, but it is palpable once it has been established. Establishing this culture requires the courage to make it a priority, setting expectations of your organization and always striving to do better.
What quality and safety challenges remain within our existing healthcare system? What steps can we take to overcome these challenges to help ensure safer, more effective care for all patients?
There is no shortage of challenges! Lack of coordination and communication, incentives that foster higher volume of care instead of better care, and a fragmented healthcare system that focuses on one segment of the health care continuum -- instead of across the continuum -- are among our greater challenges. For example, hospitals rely upon increasing volume as a strategy for driving up revenue. However, simultaneously, we are being told that readmissions need to be reduced and in fact, will not be paid for in the future. This creates a conundrum for hospitals that historically have figured a percentage of those readmissions into their financial models. Better measures, a continuing focus on patient-centered care across the continuum, and innovations in managing our most complex and resource intensive populations will help us overcome these challenges. Hospitalists can play a huge role in building the teamwork necessary for this.
What does winning the Eisenberg Award mean to you? What has inspired you and your organization to become such an advocate for patient safety and quality?
The award is a great honor for SHM and all the mentors and improvement teams involved. From the very start, SHM has understood that the best way to advocate for hospitalists is to unleash their potential as champions of patient safety and quality. The current and accelerating rate of health care expenditure are not sustainable. We are at a major cross roads. Either hospitalists and others in the health care team reduce costs through improved efficiency, coordination, quality, and safety, or cost reductions will take place in a far less attractive environment featuring indiscriminate cuts to much needed services. This lends a sense of urgency to our advocacy and quality improvement efforts, as the latter approach would impact the most vulnerable segments of our society in an unjust and disproportionate manner.
Chief Executive Officer, Henry Ford Health System
Ms. Schlichting and the Henry Ford Health System were the recipients of the Eisenberg Award for Innovation in Patient Safety and Quality at the local level for the No Harm Campaign, designed to integrate harm-reduction interventions into a system-wide initiative to eliminate harm from the healthcare experience. Through increased reporting and studying of harm events, researching causality, identifying priorities, and redesigning care to eliminate harm, the No Harm Campaign has resulted in a 26 percent reduction in harm events and a 12 percent reduction in mortality across the Henry Ford Health System in a three-year period.
What are the essential elements to building a culture focused on patient safety and quality? Why are these important?
Quality and patient safety must be a top strategic priority, with significant discussion and leadership at the Board level. We must make decisions based on the impact on quality and patient safety, even when they require significant financial investment. We must make sure we are always doing the right thing for patients and employees to protect their safety, such as reporting the potential infection issue to patients and the press, even when there is relatively low risk. We must also encourage reporting and transparency of safety and quality issues.
What quality and safety challenges remain within our existing healthcare system? What steps can we take to overcome these challenges to help ensure safer, more effective care for all patients?
Safety and quality can be vastly improved in healthcare. We are far from six sigma performance in most quality categories. We need to listen much more effectively to our patients and families to ensure improvements in quality and safety. We also need to significantly improve health literacy, culturally sensitive care and basic communication with patients, families and caregivers – including language services – to achieve better outcomes. Quality metrics need to be as important as financial metrics for leadership performance evaluation.
What does winning the Eisenberg Award mean to you? What has inspired you and your organization to become such an advocate for patient safety and quality?
This award is very meaningful for our organization, because the No Harm Campaign has involved every business unit within our health system, was launched by our Board of Trustees and all of our Quality Committees within Henry Ford Health System, and has resulted in reduction in harm that is substantially better than national average performance. We are inspired by our commitment to providing the best possible care to our patients, their families and our team members. We included employee safety in the No Harm Campaign because we don't want any employee or physician to be harmed while caring for patients and are equally committed to their protection. We have also been inspired by the results – it has encouraged us to keep going and never be satisfied until we reach perfection. One patient, employee, or physician harmed is one too many!
Senior Vice President and Chief Medical Officer for Quality & Patient Safety, NewYork-Presbyterian Hospital
Dr. Lazar and NewYork-Presbyterian Hospital were the recipients of the Eisenberg Award for Innovation in Patient Safety and Quality at the local level for its Housestaff Quality Council initiative. Since 2008, the initiative has promoted greater housestaff participation in quality and patient safety initiatives by partnering with key constituencies to ensure processes and systems are in place to avoid medical errors in the hospital. The initiative has achieved positive results, including attaining greater than 90 percent compliance with medication reconciliation and reducing paper laboratory orders in favor of electronic orders by more than 70 percent.
What are the essential elements to building a culture focused on patient safety and quality? Why are these important?
Everything we do at NewYork-Presbyterian Hospital supports our core mission of putting patients first, and our highest priority is providing the safest and highest quality care. Incorporating multidisciplinary, innovative and pro-active residents and staff has been integral to the Hospital's quality and patient safety initiatives. Through the engagement of front line staff, the Hospital can fully understand and address quality and safety challenges impacting our patients. Key elements for NewYork-Presbyterian include leadership which has made quality and patient safety central to hospital operations, annual quality and safety goals which are reviewed regularly by senior leadership and allow for broad engagement from clinicians and staff, and a culture of learning and engaging front line staff.
What quality and safety challenges remain within our existing healthcare system? What steps can we take to overcome these challenges to help ensure safer, more effective care for all patients?
The challenges we face at our hospital include sustaining all the improvement in quality and safety that has occurred, while at the same time continually adding, or addressing new issues or requirements. We must maintain excellent quality and safety and at the same time, be sure we are using healthcare resources as efficiently as possible.
What does winning the Eisenberg Award mean to you? What has inspired you and your organization to become such an advocate for patient safety and quality?
We are continuously expanding our quality and patient safety program, and engaging all aspects of the hospital in that effort. Winning such a nationally recognized award for quality and patient safety sends the message to our entire team that their efforts are widely recognized. In particular, winning this award would not have been possible without our outstanding residents and the culture of teamwork that has become embedded in our institution and fostered by the Housestaff Quality Council. The Council is an example of how NewYork-Presbyterian successfully collaborates utilizing multi-disciplinary teams to deliver the safest and most compassionate care, leading to the best outcomes for our patients.
